PRINSIP DASAR DAN

RANDOM FLAP
Putra Haqiqie Adnantama Lubis
Caroline Dewi

Pembimbing :
Dr. Lisa Hasibuan dr., SpBP-RE (K)
 RECONSTRUCTIVE LADDER
DEFINITION

• Flap: Segment of tissue that is transferred with its

own blood supply.
• Pedicle: Base of flap that contains blood supply.
• Pedicled flap: Remains attached to native vascular
supply
• Free flap: Fully detached from vascular supply
and reconnected to recipient vessels using
microvascular technique.
ANATOMY
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)
CORMACK AND LAMBERTY CLASSIFICATION
OF FASCIOCUTANEOUS FLAPS
CLASSIFICATION BY MANIPULATION

• A discussion of classification of flaps would be incomplete

without mention of the different types of flap manipulation
that can occur prior to harvest. First, tissue that is desired for a
planned flap can undergo tissue expansion. An expanded flap
allows for greater reach and coverage and can minimize the
donor site defect.
• Furthermore, the mechanical force of stretching tissues has
also been shown to enhance tissue
neovascularity, and the accompanying thinning of the flap can
be an additional bonus in reconstruction.
• In situations where there is concern for the ultimate perfusion
of the flap, flap delay can be employed.
• A delayed flap is one in which a preliminary surgical stage is
planned to partially raise the flap and divide a
portion of the blood supply, delivering a sublethal ischemic
insult that stimulates vessel dilation,
ischemic preconditioning, and neovascularization.
• This allows for axialization of blood flow and
conditioning of the flap tissues to lower oxygen levels in
anticipation of flap transfer at a second stage
 INDICATION

• Covering recipient beds that have poor vascularity  tibia, ankle,

heel
• Covering vital structures  bare bone, cartilage, tendon, nerve
• Reconstructing the full thickness of the eyelids, lips, ears, nose, and
cheeks
• Padding body prominences necessary to operate through the wound
at a later date to repair underlying structures
 DISADVANTAGES

• Bulky in appearance
• May carry hair into non hairbearing areas
• May require multiple operations with long
periods of hospitalization
 SIZE AND LOCATION OF THE FLAP

• Grcatcr length-to-width ratio:

(1) By outlining the flap so large axial blood vessels (or multiple arteries and veins) will pass
into the base
(2) By selecting the donor site in an area such as the head and neck region with
its excellent vascularity
(3) By developing the flap in stages {i.e., delaying the flap) to encourage an increased
circulation in its longitudinal axis
 FLAP DESIGN AND APPLICATION

• Assesing the defect

• Diagnosis of defect, underlying causes, and
reconstructive requerements
• What tissue are missing, precise measurement of
shapae and size include 3D size
• Wound bed should be debride from necrotic material,
granulation tissue and scarred tissue
• In onkologi, clear margins must be defined well
• If there are no adequate recipient vessels near the
defect, consideration to vein graft or create AV loop
from regional blood supply source
• Selection and Management of Donor site
• Local tissue will often provide better color match and
appearance but may be limited
depending on the location of the wound
• Attempt to minimize residual
donor site deformity
• Pedicle considerations
• Concerning pedicle length, the surgeon should
consider the ergonomic constraints of microsurgical vessel
anastomosis. Free tissue transfer can be made
significantly easier with slight slack in the pedicle for creation
of a tension-free anastomosis

• Manipulation of Donor Site Tissue

• site and Content Selection
• First consider the skin surrounding the defect. Color match,
texture, thickness, and special characteristics such as hair
growth should be taken
• Design the flap to be slightly larger than the defect for
adequate skin coverage
• For complex reconstructions of the head and neck, lining may
berequired in addition to external skin coverage. Mucosal
lining can be fashioned from skin, skin graft, mucosa, or raw
muscle surface, which will mucosalize with time
• Management of the Donor Site
• Attempts should be made to minimize donor site deformity as much as possible.
Consider the consequences of scar contracture such as decreased range of motion and
pain. When possible, orient incisions within resting skin tension lines. Contour
deformity may be considered cosmetic;
• Functional loss from muscle or nerve transfer must be contemplated preoperatively
anddiscussed with the patient
• Revision of donor site deformities should be offered when a functional problem exists
and a solution is apparen
 STAGING
RECONSTRUCTION IN
COMPLEX DEFECTS

• Prefabrication of a flap involves transferring a

vascular pedicle into a desired block of tissue, then
waiting
8 weeks for spontaneous neovascularization, thus
creating a new vascular territory not previously found
in nature.
• After maturation, the neovascularized tissue is
transferred based on the implanted pedicle.
This technique has been used to provide thin axial
flaps and to transfer tissue with enhanced color and
texture match
 OPTIONS IN CASE OF FLAP
COMPROMISE

• In pedicled or free flaps, inadequate arterial flow is usually recognized early and
may be the result of poor flap design or pedicle kinking. In a free flap, the arterial
insufficiency represents thrombosis of the new anastomosis until proven otherwise.
• Venous insufficiency of a flap is more common and the onset more insidious than
that of arterial insufficiency
• Numerous methods have been described to improve flap survival in the case of
venous congestion. First, the surgeon should attempt to release insetting sutures
causing tension or kinking. The flap may be pricked with a needle serially to reduce
the venous burden. Deepithelialization of a portion of the flap, or removal of the
nail plate in the case of a digit, with periodic application of heparin solution may
increase venous outflow. Use of Hirudo medicinalis or medicinal leeches can
ensure ongoing flap outflow until venous microanastomoses form. Finally,
augmenting outflow by cannulation of a vein with an angiocatheter and periodically
draining the flap may be useful
Monitoring of the
flap
Color

Warmth and turgor

Assess blanching

Capillary refill time

24
 Complications
• Seroma formation
• Hematoma formation
• Superficial skin necrosis
• Wound separation with eventual partial and/or
complete flap loss
• Fat necrosis
• Donor site infection
25
 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;

26
 Ny. Yani Kusmayaningsih, 47 th (14/8/1972)
1759909 / NHI
`` Consultant dr. Irra Rubianti W., SpB, SpBP-RE(K)

Diagnosis
• Wound dehisens regio temporoparietal post CTR

Treatment
- Craniectomy debridement (NC), tutup defek dengan scalp flap scoring galea
 Agung Mustofa. 13th. 1767792
1759909 / NHI
`` Consultant Dr. dr. Hardi Siswo, SpBP-RE(K)

Diagnosis
• Kontraktur difuse dan hypertrophic scar regio axila sinistra ec burn injury

Treatment
• Release kontraktur dan eksisi hypertrophic scar, tutup defek dengan transpositional flap dan STSG
 Child Nofal Isnan/M/ 5 months old (06/08/2019)
0001815554/BPJS
Consultant dr. Irra Rubianti W., SpB, SpBP-RE (K)
Consult from Neurosurgery - Kemuning 5

D/
• Multiple chronic ulcer at parietal post meningoencephalocele resection
• Post VP shunt due to acute hydrocephalus
• Hypoalbuminemia (improvement)
T/
• Pro joint op with Neurosurgeon (ND + wound explore – dura) + defect closure with flap
 Nn. Ayu Puspita Sari, 10 th (3/9/09) 0001784008 / BPJS
DPJP dr. Irra Rubianti, SpB, SpBP-RE(K)
Outpatient

D/
• Ankle contracture post burn injury
• Left poplitea defect post release contracture + defect closure with transpositional flap post
ND dan STSG
T/
• Pro release contracture ankle and defect closure with flap
 Tn. Nana Helisyah, 38th (08/10/1981)
0001807578 / BPJS
DPJP Dr. dr. Lisa Hasibuan SpBP-RE(K)

Diagnosis:

• Deep dermal-full thickness burn 4% TBSA wiith 1.5 % raw surface due to high voltage electric

burn at extremitas superior bilateral and extremitas inferior dextra post ND + right below elbow

amputation + STSG

Tatalaksana

• Pro Abdominal Flap

16/01/20 (Pre Op)
16/01/20 (Intra Op)
 Nn. Risma, 19th (06/11/00)
0001807936 / BPJS
DPJP dr. Rani Septrina, SpBP-RE
Admitted 17/1/19, Kem 2 Bed 4.6

Diagnosis:

• Open skin degloving a.r ekstremitas inferior sinistra dengan bone exposed (tibia)

• Open fracture 1/3 medial tibia post OREF

Tatalaksana

• Tutup bone exposed dengan soleous flap + STSG

28/1/20 (Pre Op)
TERIMA KASIH