Random Flap

Grabb 7th Ed
Ribka Theodora
History
• Knowledge of the anatomy of the cutaneous arteries and veins is
fundamental to the design of skin flaps and incisions. Although
detailed studies of these vessels were performed by Manchot,
Spalteholz, Pieri, Esser,S and Salmon. They were published in either
German, Italian, or French. In the English-speaking world, little
attention was paid to the precise anatomy of the cutaneous vessels so
that surgeons designed skin flaps randomly on whatever vessels
happened to be in the area, assigning rigid length-to-breath ratios to
the flaps.
Introduction
• Skin and subcutaneous tissue was initially elevated as "random“
pattern flaps either from a site adjacent to the wound or from a
distant site.
• The term "random" really means that the surgeon does not know for
sure if there is enough longitudinally oriented (axial) vessels to keep
the flap alive.
• Any flap requires an adequate blood supply after transfer to survive.
"Random" cutaneous flaps are based on unnamed smaller vessels. It
was observed historically that the ratio of flap length to width was a
critical variable for flap survival. A base-to length ratio of 1:1 is usually
safe.
Introduction
• These restrictions limit their reliability for use with large defects.
When utilized appropriately, however, random flaps can be reliable
first choices for coverage of smaller defects throughout the body.
• Due to unpredictable circulation, these flaps often went on to partial
or complete necrosis. This era of flap surgery required adherence to
length and width ratios in hopes of maintaining adequate vascularity
for flap survival. "Delay“ techniques were also utilized to augment the
vascular supply.
Delay Phenomenon
This is most commonly achieved by interrupting a portion of the
normal blood supply to the flap without transferring the flap from its
native position. The associated sublethal ischemia result in
(1) opening of "choke" vessels that are normally closed allowing blood
flow into the ischemic region of the flap,
(2) reorientation of the vessels within the £lap to a more longitudinal
pattern
(3) sprouting of new vessels within the flap through angiogenesis, and
perhaps via vasculogenesis.
• Vessels within the flap also respond to the stress of delay by
increasing in caliber. Most surgeons find it prudent to delay a flap for
at least 7 days to 3 weeks prior to final transfer, thereby permitting a
maturation of the process of neovascularization.
• Incorporating a planned delay can significantly improve the chances
of complete survival of a large random pattern cutaneous flap/ as in
patients with an impaired microcirculation (e.g., smokers and
diabetics). Furthermore, delay is always considered if a flap
demonstrates signs of ischemia or venous congestion after elevation.
In such cases the procedure is best performed in a staged manner,
following a period of delay.
• The connections between adjacent cutaneous arteries are either by
true anastomoses, without change in caliber, or by sreduced-caliber
choke anastomotic vessels (Figure 4.3).
• The latter are plentiful in the integument (skin and subcutaneous
tissues) and may be important in regulating the blood flow to the
intact skin (Figure 4.1C).
• These choke vessels play an important role in skin flap survival,
where, like resistors in an electrical circuit, they provide an initial
resistance to blood flow between the base and the tip of the flap.
Although some dilatation of the choke vessels occurs because of the
relaxation of sympathetic tone, the major effect is seen between 48
and 72 hours after surgery. This is due to an active process resulting in
hypertrophy and hyperplasia of the elements of the vessel wall and a
permanent increase in diameter of its lumen.
• Lastly, a planned surgical delay requires appropriate staging. In these
cases intermediate coverage of critical structures may be required to
bridge the gap between surgeries. If at all possible, the resection or
exposure of any critical structures such as bone, tendon, nerve, or
vessels should be delayed till the final coverage is ready. This is not
always possible, especially in traumatic wounds. In these cases a
delay procedure may not be possible and another flap is chosen.