Flaps in orthopaedics

Flaps in orthopaedicsFlaps in orthopaedics

Zameer AliZameer Ali

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Diagrammatic Diagrammatic representation of cross representation of cross section skinsection skin

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Skin grafting and Skin grafting and classificationclassification

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Classification on basis of Classification on basis of thicknessthickness

Split thickness skin graftingSplit thickness skin grafting

Full thickness skin grafting Full thickness skin grafting

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Diagramatic Diagramatic representation of skinrepresentation of skin

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Species of origin

Species of origin 1. Autologous (Auto) graft 2. Homologous (Homo, Allo) graft 3. Heterologous (Hetero. Xeno) graft

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STSG (Thierish graft)STSG (Thierish graft)

It usually contains epidermis and part of It usually contains epidermis and part of dermis.dermis.

Thickness ranges from .01 (very thin) Thickness ranges from .01 (very thin) to .016 intermediate thickness) to .020 to .016 intermediate thickness) to .020 (thick graft) (thick graft)

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Split thickness skin Split thickness skin grafting grafting

STSG are useful for early resurfacing STSG are useful for early resurfacing following burns ,immediate coverage of following burns ,immediate coverage of traumatic defects or surgical excision traumatic defects or surgical excision defect especially when area is too wide defect especially when area is too wide to use full thickness graft and to use full thickness graft and replacement of defect caused by full replacement of defect caused by full thickness graft is quite large thickness graft is quite large

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When vascularity of recipient area is When vascularity of recipient area is doubtful STSG is more likely to take than doubtful STSG is more likely to take than full thickness graft full thickness graft

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Split thickness graft may be used as a Split thickness graft may be used as a definitive treatment in areas where definitive treatment in areas where durability of skin and function of durability of skin and function of underlying structures are not of prime underlying structures are not of prime consideration consideration

Otherwise it must be used temporary to Otherwise it must be used temporary to be later replaced by a more suitable type be later replaced by a more suitable type of graft of graft

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STSGSTSG

STSG STSG

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When free skin grafts are to be obtained, When free skin grafts are to be obtained, it is well to remember that "the thinner the it is well to remember that "the thinner the graft, the better the take," and yet when graft, the better the take," and yet when the graft is expected to be permanent, the graft is expected to be permanent, "the thicker the graft, the better the "the thicker the graft, the better the functionfunction

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." A thick graft is better able to withstand ." A thick graft is better able to withstand friction and constant use than a thin one friction and constant use than a thin one and will contract only about 10%; a thin and will contract only about 10%; a thin graft may contract 50% to 75%. graft may contract 50% to 75%.

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Sites from which to obtain full-thickness skin Sites from which to obtain full-thickness skin grafts. Groin or medial aspect of arm is grafts. Groin or medial aspect of arm is preferable preferable

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STSG wolfe STSG wolfe graftgraft

1) considerable 1) considerable secondary contractionsecondary contraction

2) may develop 2) may develop pigmentation later onpigmentation later on

3)Epidermis +partial 3)Epidermis +partial dermis dermis

4)No need to cover 4)No need to cover donor sitedonor site

5) Quicker healing of 5) Quicker healing of donor site donor site

Little Little contraction/shrinkagecontraction/shrinkage

usually Little /no usually Little /no pigmentationpigmentation

Epidermis + whole of Epidermis + whole of dermisdermis

Donor site to be Donor site to be covered by STSG covered by STSG

Lesser healing of donor Lesser healing of donor site site

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Factors affecting uptake Factors affecting uptake of graftof graft

1. Recipient site capable for producing capillary bud. 2. Approximation between the graft

and recipient site (: No hematomaor infection)

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3. Immobilisation during the phase of grafting 6. Subsequent behavior of free graft

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No take No take

1. Compact bone 2. Bare cartilage 3. Bare tendon 4. Heavily irradiation of tissue

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A. Take

1. Fat, fascia. 2. Muscle, tendon sheath. 3. Periosteum. Perichondrium, Cancellous bone

tissue

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Instruments for taking Instruments for taking graftgraft

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Humby knifeHumby knife

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Taking STSGTaking STSG

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Graft taking with weck Graft taking with weck knifeknife

Technique of Technique of removing split-removing split-thickness skin graft thickness skin graft from flexor surface from flexor surface above elbow with above elbow with Weck knife.Weck knife.

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Reese dermatome Reese dermatome

Large area of skin is Large area of skin is removed by adhering removed by adhering to tape mounted on to tape mounted on drumdrum

Thickness is Thickness is measured by measured by shimmer that shimmer that measures distance measures distance between drum and between drum and blade blade

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Reese deramtomeReese deramtome

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Pneumatic dermatome Pneumatic dermatome

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meshermesher

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Skin flaps Skin flaps

Skin flaps are Skin flaps are composed of skin composed of skin and subcutaneous and subcutaneous tissue temporarily tissue temporarily attached by attached by vascularized pedicle vascularized pedicle to donor site to donor site

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Filletted graft from injured Filletted graft from injured finger finger

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Classification

l. Due to blood supply 1. Random pattern flap 2. Axial pattern flap

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Types of skin flapsTypes of skin flaps

Random pattern flaps Random pattern flaps Axial flaps Axial flaps Island flapsIsland flaps

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Axial flapAxial flap

Limited by available Limited by available vesselsvessels

Based on direct Based on direct cutaneous vesselscutaneous vessels

Random flap at distal Random flap at distal tiptip

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Axial flapAxial flap

Axial pattern flaps allow a safe length-to-Axial pattern flaps allow a safe length-to-width ratio of at least 3:1, the possibility width ratio of at least 3:1, the possibility of covering either the dorsal or palmar of covering either the dorsal or palmar surface, and a sufficiently long pedicle to surface, and a sufficiently long pedicle to allow arm and hand movement. Because allow arm and hand movement. Because such flaps usually do not require a delay such flaps usually do not require a delay in detachment of one end, they are useful in detachment of one end, they are useful for coverage of acute hand injuries. for coverage of acute hand injuries.

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Random pattern flapRandom pattern flap

Most commonMost common Based on subdermal plexusBased on subdermal plexus UnpredictableUnpredictable Length:width of 3:1 or 4:1 Length:width of 3:1 or 4:1

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Random pattern flapRandom pattern flap

A randomn pattern flap is one perfused A randomn pattern flap is one perfused by musculocutaneous arteries located in by musculocutaneous arteries located in pedicle of flap and connected to dermal pedicle of flap and connected to dermal and subdermal plexus and subdermal plexus

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Due to site of flap

1. Local flap 2. Distant flap

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Flap coverage can be used in the primary Flap coverage can be used in the primary closure of a hand wound or in a closure of a hand wound or in a secondary procedure to replace scars, secondary procedure to replace scars, skin of poor quality, or necrotic skin. skin of poor quality, or necrotic skin.

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flap can be obtained locally or from a flap can be obtained locally or from a distant part. If the area to be covered is distant part. If the area to be covered is small, a local flap may be indicated, small, a local flap may be indicated,

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Local flap (thenar flap) Local flap (thenar flap)

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Tests for flap circulationTests for flap circulation

Blanch test (Capillary circulation returns Blanch test (Capillary circulation returns within 4 seconds after blanching if more within 4 seconds after blanching if more time is consumed suggestive of vascular time is consumed suggestive of vascular insufficiencyinsufficiency

However above test gives no clue about However above test gives no clue about venous drainage venous drainage

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Flourescein test Flourescein test

The flourscein test is accurate method of The flourscein test is accurate method of evaluating skin flap circulationevaluating skin flap circulation

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Flap survivalFlap survival

increased width of increased width of base would increasebase would increase surviving length butsurviving length but feeding vessels have feeding vessels have same perfusion same perfusion

pressurepressure

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Principles of skin flap Principles of skin flap surgerysurgery

1) The recipient and 1) The recipient and donor area must be donor area must be brought in position brought in position and an over sized and an over sized pattern is applied pattern is applied

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2 ) local flaps are preferred because 2 ) local flaps are preferred because they provide similar texture and cololr they provide similar texture and cololr charecteristicscharecteristics

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3) Axial pattern flaps based on specific 3) Axial pattern flaps based on specific arterio venous system are better than arterio venous system are better than random pattern flapsrandom pattern flaps

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4) elderely patients are not good 4) elderely patients are not good candidates for large flaps because of candidates for large flaps because of arteriosclerotic changes arteriosclerotic changes

5) the flap should not be subjected to 5) the flap should not be subjected to kinking or pressure ( dressing over flap kinking or pressure ( dressing over flap should be avoided )should be avoided )

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6) Hematoma formation jeoparadizes flap 6) Hematoma formation jeoparadizes flap Complette haemostasis ,use of suction Complette haemostasis ,use of suction

drainage and delay of flap transfer when drainage and delay of flap transfer when haemostasis is doubtful will reduce haemostasis is doubtful will reduce hematoma formation hematoma formation

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7) transfer should be delayed when 7) transfer should be delayed when adequate vascularity of flap is doubtful adequate vascularity of flap is doubtful

When transfering a flap from distance When transfering a flap from distance raw area produced by raising flap must raw area produced by raising flap must be eleminated this is achieved by be eleminated this is achieved by

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A) bringing donor area and recipient area A) bringing donor area and recipient area close close

B) immediate application of STSGB) immediate application of STSG C) forming hinge flap adjacent to C) forming hinge flap adjacent to

recipient area .recipient area .

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Flap separation should be delayed till Flap separation should be delayed till 2121stst day once vascularization of flap at day once vascularization of flap at recipient area is doubtful.recipient area is doubtful.

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Flaps should not be Flaps should not be in tensionin tension

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Delay of flaps Delay of flaps

Instead of raising and immediately Instead of raising and immediately transferring flaps ,transferring flaps ,

flaps may be partially divided in stages flaps may be partially divided in stages before transferring before transferring

This will increase vascularity and ensure This will increase vascularity and ensure survival of flap survival of flap

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Local flaps may be designated as Local flaps may be designated as 1 advancement, 1 advancement, 2 rotation 2 rotation 3 translation3 translation 4 transposition types. 4 transposition types.

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Skin to be used for a local flap should not Skin to be used for a local flap should not be damaged, since necrosis may occur. be damaged, since necrosis may occur. Developing a local skin flap requires Developing a local skin flap requires undermining and minimal tension on the undermining and minimal tension on the flap. flap.

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Advancement flapAdvancement flap

Use of an advancement flap involves Use of an advancement flap involves mobilizing a small flap of skin to cover an mobilizing a small flap of skin to cover an adjacent defect without using a skin graft adjacent defect without using a skin graft for the donor defect. for the donor defect.

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These are used to cover fingertip These are used to cover fingertip amputations.amputations.

Rotation flaps are raised on a curved Rotation flaps are raised on a curved radius with undermining of the flap and radius with undermining of the flap and closed under modest tension without a closed under modest tension without a skin-grafted donor defect skin-grafted donor defect

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Translation flaps Translation flaps

Translation flaps usually are rectangular Translation flaps usually are rectangular and are used to close an adjacent defect. and are used to close an adjacent defect. The flap is moved around a pedicle base The flap is moved around a pedicle base and is closed without tension. Translation and is closed without tension. Translation flaps require a skin graft for the donor flaps require a skin graft for the donor site site

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Translation flap Translation flap raised from skin in raised from skin in continuity with area continuity with area of skin loss. Donor of skin loss. Donor area is covered by area is covered by graft.graft.

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Transposition flapsTransposition flaps

Transposition flaps usually are moved Transposition flaps usually are moved across an adjacent area of normal skin to across an adjacent area of normal skin to close an adjacent defect without tension. close an adjacent defect without tension. Skin grafting at the donor site is Skin grafting at the donor site is necessary ... necessary ...

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The advantages of a local flap over one The advantages of a local flap over one from a distant part are that the involved from a distant part are that the involved part is not tied to the distant donor and part is not tied to the distant donor and that in many instances finger motions that in many instances finger motions may continuemay continue

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Flag flapFlag flap

"Flag flap." "Flag flap." A,A, Skin can Skin can be moved over distance be moved over distance to palmar surface or to to palmar surface or to neighboring digit. neighboring digit. B,B, "Flagstaff" contains the "Flagstaff" contains the pedicle consisting of pedicle consisting of dorsal vein, dorsal dorsal vein, dorsal branch of digital artery, branch of digital artery, and dorsal branch of and dorsal branch of digital nerve digital nerve

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dorsoulnar thumb flap dorsoulnar thumb flap

The circulation to the dorsoulnar side of the The circulation to the dorsoulnar side of the hand and thumb has been further hand and thumb has been further elucidated by Brunelli et al., leading to elucidated by Brunelli et al., leading to the development of the dorsoulnar thumb the development of the dorsoulnar thumb flap flap

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dorsoulnar thumb flap dorsoulnar thumb flap

Dorsoulnar flap Dorsoulnar flap harvested from inner harvested from inner side of thumb side of thumb metacarpophalangeametacarpophalangeal area reaches distal l area reaches distal area of thumb area of thumb

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CROSS-FINGER FLAPSCROSS-FINGER FLAPS

CROSS-FINGER FLAPSCROSS-FINGER FLAPS useful for useful for covering a defect of the skin and other covering a defect of the skin and other soft tissues on the volar surface of the soft tissues on the volar surface of the finger when tendons and neurovascular finger when tendons and neurovascular structures are exposed and a small structures are exposed and a small amount of subcutaneous fat is needed. amount of subcutaneous fat is needed.

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CROSS-FINGER FLAPSCROSS-FINGER FLAPS

They also are useful for some They also are useful for some amputations of the thumb These grafts amputations of the thumb These grafts are best avoided in patients over 50 are best avoided in patients over 50 years of age, in hands with arthritic years of age, in hands with arthritic changes or a tendency to finger stiffness changes or a tendency to finger stiffness for some other reason, or if local infection for some other reason, or if local infection is present is present

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Cross-finger flap.Cross-finger flap.

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Cross-finger flap.Cross-finger flap.

Cross-finger flap. Cross-finger flap. Laterally based pedicle Laterally based pedicle flap has been raised flap has been raised from middle finger and from middle finger and has been applied to has been applied to distal pad of index. distal pad of index. donor finger and bridge donor finger and bridge between two fingers between two fingers have been covered with have been covered with split-thickness skin graft split-thickness skin graft

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Principles of three types Principles of three types of local flapsof local flaps

. In each type, defect to be covered is . In each type, defect to be covered is converted into triangular one. Flap may converted into triangular one. Flap may be rotated be rotated

or transposed or both.or transposed or both. Defect created by transposing flap must Defect created by transposing flap must

be covered with split-thickness graft. be covered with split-thickness graft.

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Flap rotating about a pivot point - Rotation - Transposition : Rhomboid flap - Z-Plasty

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Skin coverage by pedicle method Skin coverage by pedicle method provides a well vascularized cover for provides a well vascularized cover for underlying vital structures with minimum underlying vital structures with minimum scaring relaxing all tissues within the part scaring relaxing all tissues within the part and improving local blood supply and and improving local blood supply and nutrition nutrition

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Flaps withstand wear and tear of rough Flaps withstand wear and tear of rough usage as soon as nerve supply returns to usage as soon as nerve supply returns to themthem

A skin flap is best method of resurfacing A skin flap is best method of resurfacing palm of hand and volar surface of fingers palm of hand and volar surface of fingers

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Axial pattern flap Axial pattern flap

An axial pattern flap (arterial flap ) An axial pattern flap (arterial flap ) contains at least one specific direct contains at least one specific direct cutaneous artery within its longitudinal cutaneous artery within its longitudinal axis axis

Artery lies in subcutaneous layer just Artery lies in subcutaneous layer just superficial to muscular fascia therefore superficial to muscular fascia therefore flap thickness should include flap thickness should include subcutaneous fat and deep fascia subcutaneous fat and deep fascia

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Axial pattern flaps Axial pattern flaps

ExamplesExamples Deltopectoral flap Deltopectoral flap Hypo gastric flap Hypo gastric flap Superficial inferior epigastric flap Superficial inferior epigastric flap Groin flap Groin flap Superficial circumflex iliac artery flap Superficial circumflex iliac artery flap

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Abdominal flapsAbdominal flaps

Traditionally, flaps from the abdomen Traditionally, flaps from the abdomen have been used as tubed pedicle flaps or have been used as tubed pedicle flaps or as direct flaps. as direct flaps.

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Axial pattern abdominal Axial pattern abdominal flapsflaps

The tubed pedicle technique requires the The tubed pedicle technique requires the formation of a bipedicle tube and 6 formation of a bipedicle tube and 6 weeks of maturation followed by weeks of maturation followed by detachment of one end of the tube to be detachment of one end of the tube to be applied to the hand, followed by another applied to the hand, followed by another 3 to 6 weeks before the flap is completely 3 to 6 weeks before the flap is completely detached and "inset" into the defect. detached and "inset" into the defect.

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Abdominal flapsAbdominal flaps

The direct abdominal flaps typically are The direct abdominal flaps typically are limited in their length-to-width ratio limited in their length-to-width ratio because of the random circulation. It because of the random circulation. It rarely is safe to use such a flap with a rarely is safe to use such a flap with a length-to-width ratio that varies length-to-width ratio that varies significantly from 1:1. significantly from 1:1.

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A random pattern A random pattern abdominal flapabdominal flap

A random pattern abdominal flap to be A random pattern abdominal flap to be applied to the hand should have its base applied to the hand should have its base either distal, toward the superficial either distal, toward the superficial epigastric vessels, usually on the same epigastric vessels, usually on the same side as the affected hand, or proximal, side as the affected hand, or proximal, above the umbilicus toward the above the umbilicus toward the thoracoepigastric vessels, usually on the thoracoepigastric vessels, usually on the opposite side opposite side

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The flaps above the umbilicus should not The flaps above the umbilicus should not be used in a patient with a "barrel chest" be used in a patient with a "barrel chest" with chronic lung disease.. with chronic lung disease..

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Lower abdominal flap Lower abdominal flap may be made may be made narrower in relation narrower in relation to its length if it to its length if it contains superficial contains superficial circumflex iliac artery circumflex iliac artery and vein (lower right) and vein (lower right) or superficial or superficial epigastric artery and epigastric artery and vein. vein.

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Abdominal flaps obtained from areas Abdominal flaps obtained from areas above the umbilicus usually avoid the fat above the umbilicus usually avoid the fat "storage areas." If the flap is obtained "storage areas." If the flap is obtained from the infraumbilical area, the recipient from the infraumbilical area, the recipient grafted area usually increases in bulk, grafted area usually increases in bulk, since the infraumbilical area skin adds fatsince the infraumbilical area skin adds fat

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AFTERTREATMENTAFTERTREATMENT

The flap should be inspected almost The flap should be inspected almost hourly during the first 48 hours for hourly during the first 48 hours for circulatory compromise produced by circulatory compromise produced by tension or torsion or for the development tension or torsion or for the development of a hematoma. of a hematoma.

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Sutures that appear to be too tight should Sutures that appear to be too tight should be removed because the pressure they be removed because the pressure they apply on the flap may be sufficient to apply on the flap may be sufficient to produce ischemia. produce ischemia.

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If an area becomes necrotic, it should be If an area becomes necrotic, it should be excised and covered with a split skin excised and covered with a split skin graft. Gross infection from necrosis or graft. Gross infection from necrosis or hematoma usually results in failure. hematoma usually results in failure.

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The area should be redressed frequently The area should be redressed frequently to avoid offensive odor and reduce the to avoid offensive odor and reduce the chance of infection. Usually the flap can chance of infection. Usually the flap can be safely detached after 3 weeks. In be safely detached after 3 weeks. In children this can be reduced to 2 weeks.children this can be reduced to 2 weeks.

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Groin Pedicle FlapGroin Pedicle Flap

the iliofemoral (groin) flap, popularized by the iliofemoral (groin) flap, popularized by McGregor, was widely used in reparative McGregor, was widely used in reparative and reconstructive surgery of the upper and reconstructive surgery of the upper extremity. extremity.

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Advantages of the groin flap include (1) Advantages of the groin flap include (1) its location in an area sparse in hair, (2) its location in an area sparse in hair, (2) minimal donor site morbidity, (3) multiple minimal donor site morbidity, (3) multiple arteriovenous supply, (4) potential for arteriovenous supply, (4) potential for incorporating bone with the overlying skin incorporating bone with the overlying skin flap even when used as a pedicle flap, flap even when used as a pedicle flap, and (5) potentially large size. and (5) potentially large size.

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Disadvantages include (1) problems with Disadvantages include (1) problems with color matching, (2) possibility of damage color matching, (2) possibility of damage to vessels from previous inguinal surgery, to vessels from previous inguinal surgery, and (3) thickness of the flap in obese and (3) thickness of the flap in obese patientspatients

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The groin pedicle flap usually receives its The groin pedicle flap usually receives its arterial supply from the superficial arterial supply from the superficial circumflex iliac branch of the femoral circumflex iliac branch of the femoral artery. Its venous drainage is through the artery. Its venous drainage is through the superficial inferior epigastric and superficial inferior epigastric and superficial circumflex iliac veins. superficial circumflex iliac veins.

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Hypogastric (Superficial Hypogastric (Superficial Epigastric) FlapEpigastric) Flap

it has proved extremely useful for it has proved extremely useful for coverage of the hand and forearm. Its coverage of the hand and forearm. Its arteriovenous pedicle consists of the arteriovenous pedicle consists of the superficial epigastric artery and vein The superficial epigastric artery and vein The axis of the flap usually is oriented in a axis of the flap usually is oriented in a superolateral direction, with the base superolateral direction, with the base near the inguinal ligament centered at near the inguinal ligament centered at about the midpoint of the ligament. about the midpoint of the ligament.

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Flaps measuring up to 18 cm long × 7 cm Flaps measuring up to 18 cm long × 7 cm wide have been used. Its advantages wide have been used. Its advantages and disadvantages are similar to those and disadvantages are similar to those described for the described for the groin pedicle flap. .

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Usually a bone graft cannot be Usually a bone graft cannot be incorporated into the skin flap. During incorporated into the skin flap. During preoperative planning it is important to preoperative planning it is important to examine the abdomen on the affected examine the abdomen on the affected side for the presence of previous surgical side for the presence of previous surgical or traumatic scars that might have or traumatic scars that might have damaged the arterial supply. damaged the arterial supply.

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Island flap Island flap

The island flap has pedicle devoid of skin The island flap has pedicle devoid of skin and consists of nutrient artery and vein and consists of nutrient artery and vein

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filleted graftfilleted graft

A filleted graft is a flap of tissue A filleted graft is a flap of tissue fashioned from a nearby part, usually a fashioned from a nearby part, usually a finger, from which the bone has been finger, from which the bone has been removed but in which one or more removed but in which one or more neurovascular bundles have been neurovascular bundles have been retained. retained.

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filleted graftfilleted graft

In the hand such a graft is indicated only In the hand such a graft is indicated only when deep tissues such as tendons, when deep tissues such as tendons, nerves, and joints are exposed and when nerves, and joints are exposed and when a nearby damaged finger is to be a nearby damaged finger is to be sacrificed because it is not salvageable; it sacrificed because it is not salvageable; it is never used at the expense of a is never used at the expense of a salvageable, useful part. salvageable, useful part.

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Thank you……..Thank you……..

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Date post:	01-Jun-2015
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Flaps in orthopaedics

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