Brrtish Journal of Plastic Surgery (1996), 49.

119-122
G 1996 The British Association of Plastic Surgeons

Early division of pedicled flaps using a simple device: a new technique

A. George, D. Cunha-Gomes and R. L. Thatte

Department of Plustic and Reconstructive Surgery, Lokmanya Tilak Municipal General Hospital
and Lokmanya Tilak Medical College, Sion, Bombay, India

SUMMA R Y. A simple occlusion clamp with screws used to achieve early division of two-staged, distant pedicled
flaps is presented. The device is applied to the bridge of a distant flap on the 5th postoperative day and is
gradually tightened. It was used on 20 consecutive pedicled flaps in 20 patients: 5 abdominal flaps, 4 superficial
external pudendal artery @EPA) flaps, 9 cross leg flaps, 1 groin flap and 1 medial arm flap. In 17 patients, the
flaps were divided successfully between the 9th to the 14th day (Mean: 10 days). The device was removed in
3 patients when ischaemic changes became apparent; their flaps however survived completely and were divided
after a longer interval. The principles on which the device works, the technique, feasibility, and advantages of
using the device for early flap division are discussed.

The conventional two-staged flap continues to be a
safe and effective workhorse for a very large number
of plastic surgical units all over the world. The two-
stage pedicle flap, in fact, is also a safe option in
many challenging situations where a microvascular
transfer might be theoretically feasible but is risky or
when such a flap has failed on an earlier occasion.
Various attempts have been made to divide pedicle
flaps earlier than the conventional three week inter-
val.‘-’ However, a simple, safe and easily reproduc-
ible technique for routine early division of pedicle
transfers has not been developed. We have evolved a
technique that can be routinely applied in clinical
cases to achieve early division of pedicle flaps by
reducing the blood flow across the flap in a controlled
fashion, always remaining within physiologically
tolerable limits as monitored by clinical parameters.
The device and technique
The device consists of two identical opposing ‘V’
shaped plates made of stainless steel (Fig. 1). The
apex of the ‘V’ or the cutting edge is 2 mm in width.
One of the plates has a groove in the edge which
facilitates division without anaesthesia at the bedside
of the patient. The plates are applied on either side
of the bridge of the flap pedicle. They are held
together by a screw and nut system.
The device is put across the bridge of the flap on
the 5th postoperative day (Fig. 2). The screws are
tightened by l-2 mm at 12-hourly intervals from the
5th postoperative day onwards so that the entire
thickness of the flap is gradually compressed. By the
10th day, on fully tightening the device, the plates
almost completely oppose each other, leaving a deep
linear groove in the flap. In all the cases the flaps
appeared fully viable and ready for division in the
ward. Minimal dermal bleed is easily controlled with
a dressing. The flaps were trimmed and inset later on
a convenient theatre day.
Patients
The device was used on 20 patients of ages ranging
from 5 to 37 years (Table 1). The flaps on which the
device was used were: 5 abdominal flaps, 4 superficial
external pudendal artery (SEPA) flaps, 9 cross leg
flaps, 1 groin flap and 1 medial arm flap.
The flaps in this series were periodically monitored
by observing their colour, feeling their temperature
and looking for the presence of oedema. When in
doubt, their vascularity was assessed by a pin prick.
It was decided that if at any stage the flaps appeared
to be compromised, based on the above criteria, the
device would be removed and conventional delay and
division techniques would be used thereafter. This
occurred in 3 cases (Table 1). However, no com-
plications or necrosis were observed in any of the
20 flaps.
Case report
A 22-year-old female was referred to our Unit 2 months
following a high voltage electrical burn to her left knee.
The exit wound was on the left heel and had not produced
any morbidity. The wound was circular in shape with an
approximate diameter of 10 cm and the patella bereft of
periosteum was seen in its floor. The knee joint was exposed.
The area needed flap cover. A muscle flap was not con-
sidered because the calf appeared very thin. Other local
flaps were not considered because of the nature of the injury.
Instead a transverse cross leg fasciocutaneous flap of
appropriate dimensions was harvested from the opposite
calf in its upper two thirds and sutured to the defect. The
occlusion device was applied on the 5th day (Fig. 2) and
the flap detached in the ward on the 11th day and sub-
sequently inset in the operating theatre on the 13th day
(Fig. 3). The patient was reviewed in our outpatient clinic

119
 120
Fig. 1
Figure 1-A line diagram of the assembled device (above). The upper plate with a slit at the apex (below). Figure
to the bridge segment on the 5th postoperative day.
for 3 months during which she regained almost full range
of motion of her left knee joint.
Results
The device was used on 20 consecutive flaps in 20
patients (Table 1). 8 flaps were divided on the 9th
postoperative day, 4 on the 10th day, 2 on the 1lth
day, 1 on the 12th day, 1 on the 13th day and 1 on
the 14th day. The mean day of division was around
the 10th day (N= 17 out of 20).
In 3 cases the device had to be removed. In the
first two cases there was rim discolouration of the flap
on the 9th day, while in the third case there was
marked oedema of the distal part of the flap. In all
3 cases the flaps were divided after 21 days. No loss
of flap occurred. 3 flaps out of 17 on which the clamp
was successfully used were oedematous at the time
of division and therefore the insetting was deferred.
All 3 flaps settled down within 2 weeks after early
division.
Follow-up times ranged from 1 month to 8 months.
All 20 flaps have settled well.
Discussion
The term “delayed transfer” in pedicle flaps was
introduced by Blair in 1921 to describe the prelimi-
nary stages in which the safety of a skin flap is
increased by gradually reducing its blood suppl~.~
This nomenclature was subsequently shortened to a
single word, “delay”.
Theoretically, a unipedicled flap can be considered
as a bipedicled flap after it is inset into a defect
because the end that is inset becomes the other pedicle
of the flap (after its neovascularisation). Applying
the device on the bridge of the flap on the 5th day
and gradually tightening it would work as a continu-
ous controlled delay process, probably stimulating
the rate of neovascularisation from the area of the
inset and thus enhancing flap viability.
British Journal of Plastic Surgery
Fig. 2
2-The device applied
The survival of a flap following ligation of its
pedicle has been studied in detail by numerous
authors.*-I2 Gatti et al. reported 100% survival of
tube pedicles when divided after 4 days in experimen-
tal conditions.* In another study when only the artery
was ligated following an experimental microvascular
free flap transfer, full survival occurred provided this
was done on the 4th day. lo When only the vein was
specifically ligated on the 3rd day, in a series of rat
abdominal flaps, severe swelling resulted which how-
ever subsided over the next 7 days and the flaps
survived in toto.12 However, it is only after 7 days
that both the artery and the vein can be safely ligated
with full survival of free flaps in pigs.” The appli-
cation and gradual tightening of the device at the
base of the flap on the 5th postoperative day and the
division on the 10th day (as done in 13 cases) seems
logical as this incorporates the above ideas, albeit
slowly and probably more physiologically.
It should be noted that in all experimental situ-
ations, the wound bed is ideal and obviously the
neovascularisation takes place without any hin-
derance. However, in clinical situations the wound
bed is usually far from ideal due to a variety of
factors such as infection or potentially devascularised
structures in the bed (as seen in our cases). In clinical
practice, the situation may be compounded by the
“zone of trauma” and by an incomplete inset of the
flap. The time required for adequate neovascularis-
ation may thus be greater in these circumstances. We
decided therefore to obtain division only by the 10th
day as compared to the 8th day in experimental
situations. Our aim was to evolve a simple technique
that could routinely be applied to pedicled flaps in a
clinical setting, thus reducing the considerable physi-
cal inconvenience associated with distant flaps.
Numerous authors have managed to achieve early
division of pedicled flaps between the 6th to the 14th
postoperative day. Kislov and Kelly tested cross
finger flaps on the 7th postoperative day by applying
a rubber band tourniquet. Depending on the circu-
lation of the flaps, they divided 53 flaps between the
Table 1 Patients

Six Dc1v Day of

(lxhi device J%
NUl?W ((m) rrpplied division

I. YM 13/M Adherent scar over M3 Inf. based 18x7 5 12 Good 8

forearm, non union abdominal flap
#RU.
2. ML 15/M Exposed MPJ, little SEPA flap 5x4 5 9 Good
finger
3. RP 5/F Gustilo IIIb #TF, L3 Cross Leg Flap 15x9 5 9 Good
4. YC 30/M Palmar contracture Groin flap 12x7 5 9 Oedema of flap, delayed inset
48 h after division
5. ss 30/M Gustilo IIIb, #TF, M3 Cross leg FC 12x9 5 Device removed Rim discolouration. Division
flap 21st day. No loss of flap
6. MH 15/M Degloving injury SEPA flap 15x12 5 9 Oedema of flap, delayed inset
dorsum of hand and 48 h after division
fingers
I. GM 26/F Soft tissue defect over Cross leg flap 16x11 5 II Good 4
knee
8. SB 13/M Degloving injury Inf. based abd. 12x9 5 IO Good 4
forearm flap
9. AM 28/M Exposed tibia M3 Cross leg flap 15x 12 5 9 Good 5
without periosteum
10. TS 14/M Degloving injury wrist Sup. based abd. 8x9 5 10 Good 5
with exposed tendons flap
II. SP 24/M Gustilo IIIb #TF, M3 Cross leg flap 15x9 5 Y Oedema of flap delayed inset by 3
48 hours
12. ST 6/F Exposed tendo achillis Sup. based cross 12x8 5 9 Good 4
leg flap
13. MK 20/M I st web contracture SEPA flap 8x4 5 Device removed Oedema of flap. Division 21st 8
day
14. BN 30/M Gustilo IIIb #TF, L3 Cross leg flap 15x12 5 Y Good 3
15. BS 28/M Contour defect rt. Rt. Medial arm 16x7 5 II Good 3
temporal region flap
16. RT 27/M Degloving injury rt. Abdominal flap 12 x 10 5 14 Good 6
elbow
17. RB 18/F Gustilo IIIb #TF, L3 Sup. based cross 14x12 5 10 Good 2
leg flap
18. SK 21/M Exposed tendons SEPA flap 14x17 5 Device removed Rim discolouration. Division 3
dorsum hand 21st day
19. AP 25/M Adherent scar over Cross leg flap 18x14 5 IO Good 1
tibia, Non union #TF
20. PA 37/M Degloving injury Abdominal flap 15x 11 5 13 Good 1
dorsum wrist

Key: TF: Tibia-fibula: RU: Radius-ulna; #: Fracture; MPJ: Metacarpo-phalangal joint; M3: Middle third; L3: Lower third; FC: Fasciocutaneous
122 British Journal of Plastic Surgery

cation is easy and the use of expensive monitoring

gadgetry is avoided, thus facilitating routine clinical
use in all types of flaps and in various locations with
or without incorporating a distal fascial extension.
This technique also reduces inconvenience to patients
and allows early discharge from the ward,
substantially cutting down costs.

Acknowledgements
The authors wish to thank Mr Parshuram Pangerkar and Mr
Bapat for the illustrations and Mrs S. Chandrashekar for her help
in typing this manuscript.

References
Fig. 3
1. Kislov R, Kelly AP. Cross finger flaps in digital injuries with
Figure 3-Postoperative photograph following flap division and notes on Kirschner wire fixation. Plast Reconstr Surg 1960;
insetting. 25: 312222.
2. Smith JW. Clinical experience with the vermilion bordered lip
7th to the 16th day, losing only one flap in their flap. Plast Reconstr Surg 1961; 27: 527-43.
3. Klingenstrom P, Nylen B. Timing of transfer of tubed pedicles
series.’ Smith divided vermilion lip flaps as early as and cross-flaps. Plast Reconstr Surg 1966; 37: l-12.
the 6th postoperative day.’ Klingenstrom and Nylen 4. Furnas DW, Lamb RC, Achauer BM, Turpin IM, Black KS.
divided selected cases of tube pedicle flaps, cross leg A pair of five-day flaps: early division of distant pedicle
flaps and cross finger flaps between the 7th and after serial cross-clamping and observations with oxymetry
the 14th postoperative day.3 Furnas et al. reported 2 and flurometry. Ann Plast Surg 1985; 15: 262-7.
5. Thatte RL, Yelikar AD, Chhajlani P, Thatte MR. Successful
cases (groin flap and cross leg flap) which were detachment of cross-leg fasciocutaneous flaps on the tenth
divided on the 5th day using a procedure of cross day: a report of 10 cases. Br J Plast Surg 1986; 39: 491-7.
clamping with “rubber shod bowel clamps” causing 6. Govila A. Extracorporeal tissue transfer for intra-oral recon-
intermittent periods of ischaemia. They monitored structions. Br J Plast Surg 1992; 45: 388890.
7. Tauxe WN, Simons JN, Lipscomb PR, Hamamoto K.
these flaps with transcutaneous oximetry and Determination of vascular status of pedicled skin flaps by
fluorometry, thus deciding the time of division.4 use of radioactive pertechnetate (99mTc). Surg Gynecol
Thatte et al. reported a series of 10 fasciocutaneous Obstet 1970; 130: 87-93.
cross leg flaps divided on the 10th day using a 8. Gatti JE, LaRossa D, Brousseau DA, Silverman DG.
technique of incorporating a distal fascial extension Assessment of neovascularization and timing of flap div-
ision. Plast Reconstr Surg 1984; 73: 396-402.
in the transferred flap.5 Govila noted that a soft 9. Milton SH. The effect of “delay” on the survival of experimen-
plastic clamp could be used to train extracorporeal tal pedicled skin flaps. Br J Plast Surg 1969; 22: 24452.
flaps and allow early division of their pedicles.6 Tauxe 10. Tsur H, Daniller A, Strauch B. Neovascularization of skin
et al. used radioactive pertechnetate clearance studies flaps: route and timing. Plast Reconstr Surg 1980; 66: 85590.
11. Black MJM, Chait L, O’Brien BMcC, Sykes PJ, Sharzer LA.
on tube pedicles and divided them on the 10th day.7 How soon may the axial vessels of a surviving free flap be
Gatti et al., using fluorometry studies, divided 2 cross safely ligated: a study in pigs. Br J Plast Surg 1978;
leg flaps on the 1lth day and 1 groin flap on the 14th 31: 29559.
day.* They provide a useful review of previous 12. Nakajima T. How soon do venous drainage channels develop
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Surg 1978; 31: 300-8.
suggested sophisticated monitoring aids that can be
used to deduce the correct time for safe early division:
thermometry, photoplethysmography, laser photom-
etry, perfusion fluorometry, oximeter probes, isotope The Authors
scanning and laser doppler flowmetry. While all these Alexander George MS MCh, Chief Resident
tests have proved excellent as laboratory tools for Dean Cunha-Gomes MS, Senior Resident
assessing flap physiology, they have not gained uni- Ravin L. Thatte MS, Honorary Professor and Head
versal acceptance as routine clinical procedures.
Department of Plastic and Reconstructive Surgery, Lokmanya
In this context, we feel that our clinical method is Tilak Municipal General Hospital & Medical College, Sion,
reliable, reproducible, simple and safe. In addition to Bombay (Mumbai) 400 022, India.
this, the device can be used on a variety of pedicle
flaps. In case of doubt, the removal of the device Correspondence to: Dr Ravin L. Thatte, 46, Shirish, 187, Veer
Savarkar Marg, Bombay (Mumbai) 400 016, India.
prevents unnecessary flap necrosis. Also, the device
is extremely easy to fabricate and is inexpensive Paper received 24 May 1995.
(Rupees 350/ 7 pounds sterling). Its clinical appli- Accepted 16 August 1995, after revision.