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Dr.
Sidra memon
Definition:
Vascularized block of tissue, mobilized
from it’s donor site & transferred to another
location, adjacent or remote, for
reconstructive purposes.
Difference b/w graft & flap
Pathophysiology:
Uses:
Orientation of elective incisions:
 Skin lines:
- Relaxed skin tension lines

(RSTLs)-----parallel to natural skin
wrinkles(rhytids) & perpendicular to
underlying muscle fibers.
- lines of maximum extensibility (LME)-----

lie perpendicular to RSTLs & parallel to
underlying muscle fibers.
Orientation of elective incisions
cont….
 The best orientation of incision can be
judged by:
- knowledge of direction of pull of
underlying muscles.
- Making incision parallel to RSTLs.
- Incision perpendicular to LMEs.
- Incision parallel to direction of hair
growth.
- Pinch test: skin on either side of
incision is pinched
If it makes transverse fold without distortion
if oriented correctly.
If sigmoid shape fold forms, it is oriented
incorrectly.
Principles of flap surgery:
Principles of flap surgery cont….
Principles of flap surgery cont….
Classification:
1. Composition:
 Cutaneous
 fascial
 muscle only
 osseous
 fasciocutaneous
 musculocutaneous
 osseocutaneous
2. Contiguity:
 local
 regional
 distant (pedicled / free flap)
 island
3. Circulation:
 random
 axial (direct; fasciocutaneous; musculocutaneous; venous)
Classification cont….
4. Contour:
 advancement
 pivot
 transposition
 interpolation
5. Conditioning:
 delaying the flap
Classification cont….
1. Circulation:
1. Circulation cont….
A. Random flaps:
• No directional blood supply.
• Maximum length : breadth ratio of 1:1 in
lower extremity, as it has relatively poor
blood supply.
• It an be increased to 6:1 in face a it has
good blood supply.
B. Axial pattern flap:
• vascular supply if nothing else, must be
correctly identified & protected to ensure flap
viability.
•
 Direct
 Fasciocutaneous
 Musculocutaneous
 Venous
1. Circulation cont…..
B. Axial pattern flap cont….
1. Direct:
•contains at least 1 direct cutaneous branch
blood supply along its longitudinal axis.
• can include a random segment in their distal
portion after the artery peters out.
•E.g.:
• Groin flap ---------- Sup: circumflex
iliac vessels.
• Deltopectoral ---------- Perforating vessels
flap of int: mammary art:
2.Fasciocutaneous:
•Based on vessels running either
within or near the fascia
•This system predominates in limbs.
•Classified by:
•Cormack & lamberty
•Mathes & Nahai classification
2.Fasciocutaneous flap cont….
Cormack & lamberty
Type A: lower leg super flaps.
Type B: scapular/parascapular flaps; perforator based
fasciocutaneous flap of lower leg.
Type C: Radial forearm flap; lateral arm flap.
Type D: RFF raised with segment of radius; LAF raised with
segment of humerus.
Mathes & Nahai classification:
Groin flap,
SIEA, DMAF
Scapular & parascapular,

PIA, Lateral arm flap
Median forehead,
nasolabial, anterolateral
thigh flap
TYPE A:
TYPE B:
TYPE C:
1. Circulation cont…
3.Musculocutaneous flaps:
•Based on perforators that reach skin through muscle.
•Musculoskeletal system predominates on the torso.
•Classification by Mathes & Nahai (1981):
3. Musculocutaneous flaps cont…..
,abductor digiti minimi
,trapezius
,rectus
abdominis ,pectoral
is minor
,extensors & long flexors o
,tibialis anterior
3.Musculocutaneous flaps cont…..
-Segmental flap
-Neurotized- Functional muscle flaps
-Sensory flap
-Distally based flap
-Vascularized bone
-Tissue expansion
-Free flaps
-Perforator flaps
-Prefabricated flaps
-Combined flaps
Segmental Flap:
•Type 3 specially gluteus maximus ideally suited for this
flap design due to it’s dual blood supply. (muscle is
splitted, leaving half of it attached to it’s origin, insertion
& nerve supply. The other half can then be elevated as
transposition flap)
•Can be used for type 1 & 2.
•Type 5 because of their blood supply, have ability to
be split & taken as smaller flaps based on main or
secondary circulation.
•Type 4 in particular requires elevation as segmental
flap, as entire flap cannot survive based on single
segmental vascular pedicle. (superior part of Sartorius
muscle for groin vessel coverage)
Distally based Flap:
•Based on minor pedicles located opposite
to the base of standard flap.
•Entire muscle will not survive after division
of dominant pedicle, so only part of muscle
is elevated on specific identified minor
pedicle.
•Main problem: venous drainage
•Survival by surgical delay and elevation of
extremity to allow for postural drainage.
•E.g. medial hemisoleus (reversed based
flap) for ankle coverage & distal third
defects of lower extremity.
Neurotized – Functional muscle flaps:
•Muscle flap may be used to provide motor
function at the site of reconstruction.
•Requires preservation of both dominant
vascular pedicle & motor nerve.
•E.g. latissimui dorsi muscle in the biceps
region and gracilis.
•For maintaining effective muscle function,
the muscle must be inset so that its resting
length & tension is same as it was at donor
site.
Sensory Flap:
•Sensory innervation of cutaneous islands after transfer is unpredictable.
•Musculocutaneous flap may be designed to include sensory nerve to cutaneous
portion of flap.
•If nerve divided, then neurorrhaphies can be performed.
•Division of sensory nerves must be performed appropriately to avoid neuroma
formation.
•Indications for sensory reconstruction in flaps should be individualized as sensory
return is not a functional requirement in all territories of body.
Vascularized bone Flap:
•Vascular connections b/w bone and
muscle are generally observed at the
muscle-bone interface.
•If these connections are preserved, it is
possible to elevate a segment of
vascularized bone with flap.
•E.g. a segment of 6th rib with pectoralis
major muscle; segment of iliac bone with
internal oblique muscle (Deep circumflex
iliac artery flap)
•Serafin classification:
a)Endosteal (blood supply directly enters
bone, via nutrient foramen)
b)Periosteal (circumscribes bone within
periosteum to eventually reach bone
indirectly)
Tissue expansion:
•Rarely used because of surgical staging
difficulties & risk of complications.
•Insertion of a tissue expander beneath a
musculocutaneous flap allows for an
increase in skin island dimensions &
assists in donor site closure.
•More commonly used in preparation of
fasciocutaneous advancement flaps.
•Can be utilized to increase the useable
skin island in a latissimus
musculocutaneous flap & allow for primary
closure of the defect.
•Breast reconstruction: tissue expander
increases the dimensions of both the
remaining skin envelope and associated
overlying pectoralis major muscle.
Free Flaps:
•Natural extension of axially based muscle
& musculocutaneous flaps.
•Pedicled flaps are limited by their arc of
rotation.
•Reasons for using muscles as free flaps:
To overcome limited regional options
such as in distal tibial and foot defects.
Volume of defect is larger than regional
tissues can reconstruct.
When functional deficits from utilizing the
regional muscle supply may limit the
outcome, nonessential distant muscle can
be utilized to provide a functional outcome.
For infections or prosthetic coverage,
when flap re-elevation is likely, even when
local, fasciocutaneous coverage can be
performed.
1. Circulation
cont….
Perforator Flaps:
•Vessels can be meticulously dissected from
surrounding muscle to produce a direct
cutaneous perforator flap.
•Are cutaneous flaps.
•Problem of anatomic variability to these
cutaneous perforators is greater when not
following known muscle territories.
•While technically challenging, may decrease
some of the functional morbidity associated with
harvesting of muscles & overlying muscle fascia
in myocutaneous flap harvest.
•Widely used for breast reconstruction.
Prefabricated Flap:
•Represents future of flap based
reconstruction.
•Goal: To provide all missing components
of a given defect by positioning support,
lining and coverage tissues in preplanned
positions and allowing them to vascularize
prior to transfer and minimize donor site
morbidity.
•In larger defects, there is no one flap that
can provide all these missing layers.
•The use of thin flaps with the pre-grafting
of autologous or bio-engineered structural
elements such as bone & cartilage and the
creation of new vascular bundles in desired
donor sites.
Combined Flaps:
•Used when large tissue is required (more
than single flap can provide) or multiple
tissue types are required in a complex
position or orientation.
•Conjoined or chimeric flaps.
•Either attached by a common vascular
supply or are directly attached, each with
it’s own blood supply.
•Conjoined flaps: individual flaps with their
own vascular territory but attached by a
soft tissue bridge to form a larger flap with
multiple vascular territories being
incorporated.
e.g. bridging of an extended myocutaneous
latissimus flap with superficial inferior
epigastric flap.
Combined Flaps:
•Chimeric flaps: individual flaps, fully
separated from each other but linked
together by common source vessel. E.g.
i.subscapular flap with variety of tissues
from bone to skin, either taken as separate
flaps or in multiple combinations.
ii.Anterolateral thigh chimeric flaps:
perforater based, since islands of tissue
can be created on each perforator branch
that emanates from source supply of lateral
circumflex femoral vessels.
•Fabricated chimeric flaps: flaps attached
to each other by microanastomosis, either
at branch points or at distal (flow-through)
end to create a hybrid flap.
4. Venous flaps:
•Based on venous rather than arterial
pedicles.
•Mechanism of perfusion not completely
understood.
•Many venous flaps have small arteries
running alongside them.
•Tend to become congested post-
operatively.
•Survival inconsistent, not universally
accepted.
•E.g.: saphenous flap (for reconstruction
of knee defects)
4. Venous flaps:
•Classified by Thatte & Thatte:
•Modifying the type 3 arterialized
venous flap by restricting direct
arteriovenous shunting can
improve survival rates by
redistributing blood to the
periphery of flap.
4. Venous flaps:
Arterialized saphenous
venous flow-through flap
for managing the RFFF
donor site
2. Contiguity:
2. Contiguity cont…..
A. Local flap:
B. Regional flap:
C. Distant flap:
D. Island flap:
Flap consisting of skin &

subcutaneous tissue with pedicle
made up of nutrient vessels only.
4. Contour:
(Movement required for flap to fill desired defect)
 Advancement flap
 Transposition flap
 Interpolation flap
 Pivot flap
4. Contour cont….
A. Advancement flaps:
(no rotational or lateral movement
applied, relies on skin elasticity
to stretch and fill defect)
- Simple
- Modified
- V-Y advancement
- Keystone
- Bipedicled
4. Contour cont….
A. Advancement flaps cont……
-Simple:(single pedicle advancement

flap)
Rely on skin elasticity.
-Modified: (single pedicle advancement

flap)
Incorporate one of the following at flap’s
base to increase advancement.
•Counter incision
•Excision of burrow’s triangle
•Z-plasty
4. Contour cont….
-V-Y advancement flap:

•Incised along their cutaneous borders.
•Advance skin on each side of v-shaped
incision to close wound with Y-shaped closure.
•This technique allows most patients to regain
sensation and two-point discrimination in
fingertip.
•Blood supply-----from deep tissues through a
subcutaneous pedicle.
•Modifications: Horn flaps & oblique v-y flaps.
4. Contour cont….
-Bipedicled:
•Receive blood supply from both
ends, so less prone to necrosis.
•Designed to curve parallel to
defect, allowing flap transposition
with less tension.
•E.g.: von langenbeck
mucoperiosteal flap (for cleft
palate repair)
4. Contour cont….
-Keystone: (bipedicled)
Type I (simple keystone)
Type II (division of deep fascia +/- skin graft of donor site
Type III (double opposing flaps
Type IV (undermining of upto 12-2/3 of flap)
•Trapezoidal flaps-----closes elliptical defects.

•Two v-y flaps end to side
•Designed to straddle longitudinal structures (sup
nerves, veins which are incorporated into the flap)
•Blunt dissection to deep fascia preserves perforators &
subcutaneous veins.
•Lateral deep fascial margin can be incised for increased
mobilization.
•Extremes of donor site are closed as v-y
advancements, which produces transverse laxity in the
flap.
4. Contour cont…..
D. Pivot flaps:
•transport skin to an adjacent area while
rotating the skin about its pedicle (blood
supply).
•There are four types of pivotal
flaps: rotation, transposition,
interpolated, bilobed & island.
•All pivotal flaps are moved toward the
defect by pivoting the flap around a fixed
point at the base of the pedicle. Except
for island flaps skeletonized to the level
of their nutrient vessels, the greater the
pivot, the shorter is the effective length of
the flap.
D. Pivot flaps:
•Pivoting a flap with a cutaneous pedicle 45°

from its in situ position reduces the effective
length 5%.
•A 90° and 180° pivot reduces effective length
by 15% and 40%, respectively.
•The reduction in effective length must be
accounted for when pivotal flaps are designed
so that greater pivoting requires a longer design
of the flap.
•As the flap turns in an arc around its relatively
fixed pivotal point, redundant tissue, known as
a standing cutaneous deformity (dog ear),
develops at the base.
D. Pivot flaps:
•Similar to effective length, there is a

positive correlation between the degree of
pivoting and the size of the standing
cutaneous deformity.
•The greater the pivot of the flap, the larger
the deformity that occurs.
•Thus, increasing the flap’s pivot will:
1) change the flap’s shape
2)Shorten the effective length
3) Increase wound closure tension
4) Deform the flap’s base by development
of a standing cutaneous deformity.
•To limit these restricting factors, a flap’s
arc of pivot should not exceed 90°
whenever possible.
B. Pivot flap cont…..
1. Rotation flaps:
•Rotate adjacent tissue into the
defect.
•Donor site can generally be
closed primarily.
•Flap circumference should be
5-8 times the width of defect.
•Used on scalp for hair-bearing
reconstruction.
•Back-cut at flap’s base can be
directed towards or away from
defect.
•In reality, many flaps have
elements of both transposition
& rotation, and may be best
described as PIVOT FLAPS.
4. Contour cont:

2. Transposition flap:
flap is moved into adjacent

defect, leaving a secondary
defect that must be closed by
another method.
Donor site can be closed
primarily.
Are rectangular or square &
turn laterally to reach the defect
4. Contour cont….
2. Transposition flap cont….
Includes RHOMBOID FLAP (limberg flap)
-Relies on looseness of adjacent skin to
transfer.
 DUFOURMENTEL FLAP
(Both are similar in concept but vary in

geometry, they are designed to leave the
donor site scar parallel to relaxed skin
tension lines)
3. Interpolation flaps:
•Raised from local but not
adjacent skin.
•Pedicle is passed either over or
under an intervening skin bridge
to recipient defect.
•E.g.: thenar flap for finger tip; lip
switch (abbe) flap.
3. Interpolation flaps cont….
4. Bilobed flaps:
•Consists of 2 transposition flaps with
single base.
•1st flap------transpositioned into original
defect.
•2nd flap-----transposed into secondary
defect (donor site of the 1st flap).
•The remaining defect made by 2nd flap can
be closed primarily (it is designed to lie
parallel to relaxed skin tension lines).
•Esser:
1st flap----at 90° to defect
2nd flap----at 90° to 1st flap.
•Zitelli modification:
45° angles, resulting in smaller
dog ears.
5. Island flaps:
•uses an island of skin that is
detached from its epidermal and
dermal attachments while retaining its
vascular supply from an underlying
pedicle to repair a cutaneous defect.
Homodigital island flap

Crane principle:
 Transforms an ungraftable bed into a graftable one.
 1st stage-------flap is placed into defect.
 2nd stage------flap is replaced in its original position (after sufficient time has
passed to allow vascular ingrowth into the flap from the recipient site)
 This leaves a segment of subcutaneous tissue in the defect, which can now
accept skin graft.
5. Conditioning:
• Involves delaying the flap.
• Any preoperative maneuver resulting in increased flap survival.
• Delay, expansion, prefabrication, prelamination.
• Mechanism remains incompletely understood.
• Theories:
 Increased axiality of blood flow (removal of blood flow from periphery of
random flap promotes development of axial blood supply)
 Tolerance to ischemia (cells become accustomed to hypoxia after initial
delay procedure; therefore less tissue necrosis after second surgery)
5. Conditioning:
 Sympathectomy vasodilation theory
(dividing sympathetic fibers at the
borders of flap results in vasodilation &
improved blood supply)
 Intraflap shunting hypothesis
(Sympathectomy dilates arteriovenous
anastomosis, resulting in increased non
nutritive blood flow bypassing capillary
bed; greater length of flap will survive at
second stage as there are fewer
sympathetic fibers to cut & therefore
less of a reduction in nutritive blood
flow)
5. Conditioning:
 Hyperadrenergic state:
i. Surgery results in inc: tissue concentrations of
vasoconstrictors, such as epinephrine &
norepinephrine.
ii. After initial delay procedure, the resultant
reduction in blood supply is not sufficient to
produce tissue necrosis (the level of
vasoconstrictor substances return to normal
before the second procedure)
iii. Second procedure produces another rise in
vasoconstrictor substances (this rise is smaller
than it would be if flap were elevated without
prior delay procedure)
iv. The flap is therefore less likely to undergo
distal necrosis after delay procedure.
 Unifying theory (incorporates elements of all
above theories)
Plasty techniques:
1. Z-plasty:
• Involves transposition of two interdigitating
triangular-shaped flaps, without tension to
use lateral skin to produce gain in length
along the direction of the common limb of
the Z.
• Can be used to:
 Inc: length of area of tissue or scar.
 Break up a straight-line scar.
 Realign a scar (changing direction of
cosmetically unfavorable scars)
• Degree of elongation of longitudinal axis of
Z- plasty is directly related to the angles of
its constituent flaps.
 30°--------25% elongation.
 45°--------50% elongation.
 60°--------75% elongation.
 75°--------100% elongation.
 90°--------125% elongation.
Plasty techniques cont…..
1. Z-plasty cont…..
1. Z-plasty cont….
• Gain in length are estimates; true value
depends on local tissue elasticity and
tension.
• 60° angle commonly used as they
lengthen without undue tension.
• Angles of both flaps need not be equal
and can be designed to suit local tissue
requirements; however all 3 limbs
should be of equal length.
1. Z-plasty cont…..
• When designing a Z-plasty to realign a scar:
a) Mark the desired direction of new scar.
b) Draw the central limb of Z-plasty along the
original scar.
c) Draw lateral limbs of Z-plasty from the ends
of central limb, to the limbs drawn in (a).
d) 2 patterns will be available, one with wide
angle at apex of flap, another with narrow
angles.
e) Select the one with narrow angles as they
transpose better.
1. Z-plasty:
2. five-flap technique:
•Also called jumping man flap.
•Two opposing z-plasties with a V-Y advancement
in center.
• flaps originally in ABCDE configuration, end as
BACED.
• used to release contractures of 1st web space &
epicanthal folds.
3. four-flap plasty:
• Two interdependent Z-plasties.
• Can be designed with different angles.
• Two outer flaps become inner flaps after
transposition.
• Two inner flaps become outer flaps after
transposition.
• the flaps originally in ABCD configuration, end
as CADB.
4. W-plasty:
•Used to break scar line and improve its

aesthetics.
• unlike Z-plasty does not lengthen tissue.
•If possible one of the limbs of W- plasty should
lie parallel to RSTLs, so half of resultant scar lies
parallel to them.
•Using template ensures each wound edge
interdigitates easily.
• technique discards normal tissue, which may be
a disadvantage in certain areas.
Factors affecting flap survival:
Postoperative flap monitoring:
Postoperative flap monitoring
cont….
Postoperative flap monitoring
cont….
Complications:
Causes of flap failure:
Reconstructive ladder:
Reconstructive ladder cont…..
Scapular flap:

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Dr.

- Relaxed skin tension lines

- lines of maximum extensibility (LME)-----

Scapular & parascapular,

,abductor digiti minimi

Flap consisting of skin &

-Simple:(single pedicle advancement

-Modified: (single pedicle advancement

-V-Y advancement flap:

•Trapezoidal flaps-----closes elliptical defects.

•Pivoting a flap with a cutaneous pedicle 45°

•Similar to effective length, there is a

B. Pivot flap cont…..

flap is moved into adjacent

(Both are similar in concept but vary in

Homodigital island flap

•Used to break scar line and improve its

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