Definition : A flap is a unit of tissue that is transferred from

donor site to recipient site while maintaining its own blood supply.

Term “Flap” : Originated from the 16th century Dutch word

“FLAPPE” which means “anything that hung broad and loose, fastened only by one side”.

BASED ON LOCATION OF DONOR SITE

LOCAL FLAP: Flap transferred from an area adjacent to the

defect.

DISTANT FLAP : Flap transferred from an

noncontiguous anatomic site.

CLASSIFICATION OF LOCAL FLAP

LOCAL FLAPS

Random flaps

• Based on the rich sub -dermal vascular plexus of the skin.

• Most of the local flap are random flaps.

• length : breadth ratio of up to 3 : 1 in the face.

Axial flaps

• Derive their blood supply from a direct cutaneous artery or named blood vessel .

• Examples :Nasolabial flap (angular artery) , Forehead flap(supratrochlear artery).

• The surviving length of an axial pattern flap is entirely related to the length of the included artery.

Type I: one vascular pedicleType II: dominant pedicle (s) + minor pediclesType III: two dominant pediclesType IV: Segmental vascular pediclesType V: dominant pedicle + secondary segmental pedicles

Based on vascular pedicle typesIn muscles

Mathes and Nahai (1979)

3. Based on composition

Skin (cutaneous)Visceral ( colon, omentum)Muscle Mucosal

CompositeFasciocutaneous Myocutaneous Osseocutaneous Tendocutaneous Sensory/innervated flaps Osseo-myo-cutaneous

Local / Regional flaps – Goals (Kinnerw & Jeter)

1. Adequate color match2. Adequate thickness – avoid protrusions or

deficiencies3. Preservation of clinically perceivable sensory

innervation4. Sufficient laxity – avoid retraction or deranged

function5. Resultant suture lines of either primary or

secondary defects are restricted to anatomic units and fall within natural skin lines.

FLAP MODIFICATION

Modifications and refinements in both technique and design of flaps have been used for the optimal result in reconstructive surgery. Important modifications are :

1. Flap delay.2. Tissue expansion.

1. DELAY PHENOMENON

It can be defined as “ preliminary surgical intervention wherein a portion of the vascular supply to a flap is divided before definitive elevation and transfer of the flap”.

2. TISSUE EXPANSION

1957 : Neumann is credited with the first modern report of this technique.

1976 : Radovan further described the use of this technique for breast reconstruction.

Advantages : 1. Reconstruction with tissue of a similar colour and

texture to that of the donor defect. 2. Reconstruction with sensate skin containing skin

appendages.3. Limited donor-site deformity.

Planning and design of local flap

• Facial defects most common– Trauma– Skin malignancies

• Treatment– secondary healing– skin graft– local flaps

Advancement flaps

flap moves in a straight path without any lateral movement into the primary defect.(Burrows Triangle’s)

sites – forehead, brow, cheek.

Single advancement flap:movement is entirely in one direction.

Advancement Flaps

Burrow’s triangle at the base of the flap

Bilateral advancement flap:

When large tissue is required.Same technique & principle.

used: forehead, mustache area

and posterior neck.

variant of bilateral advancement flap

Useful fordefects at the periphery of the face around the nasal ala and upper lip

dog–ear almost always forms Disadvantages:number of scars- created with the three limbs and Burow’s triangle and with the three point closure

A to T flap:

V-y advancement flap: (Herbert flap)

A V shaped flap is moved into a defect with primary closure of the donor area leaving a final Y shaped suture line. 

It is pedicled from the underlying subcutaneous tissue rather than the surrounding skin.

Ideal for Lesion in the cheek and alar base

Panthographic expansion:

variation of the advancement

instead of the flap being advanced as a rectangle, the limbs of the flap are designed at 120º with back cuts at the bottom so that it looks like an inverted tumbler.

The flap is then advanced so that the donor site closes primarily. This technique is particularly useful on the cheek and neck.

Bipedicle Advancement Flap

Pivot flaps:

Derives its name from the pivot point at the base of the flap as well as its arc of rotation .

When flap moves laterally into the primary defect - transposition flap when it is rotated into the defect - rotation flap

Pivot point

Is the axis around which the transfer takes place. Flap is designed so that the distance from the pivot point to each part of the flap before transfer is atleast equal to the distance to be expected after transfer

pivot point is on the side of the flap away from the direction of movement of the flap.

Rotation flaps: it is semicircular flap that rotates about a pivot point to fill the defect.

Place the arc closest to the defect higher than the defect itself, to reach the most distal point of the defect

Should be 5-8 times the width of the defect

Simple rotation flap

Ideally suited on a convex surfacecheekSubmandibular area

Classic form - a rectangle or near square which is raised and moved laterally into a triangular defect

In a correctly designed flap, the distance from the pivot point to A equals the distance to B and the transfer is carried without tension

sites of choice retroauricular area submandibular area perioral area for upper and lower lip reconstructions.scalp

Transposition flaps

A

B

not to rotate more than 90º

More acute –less dog ear

Transposition flap

Limberg’s flap:

combination of flap rotation and transposition

Disadvantages:Excess tension

Anatomic landmark displacement because the tissue used to resurface the rhomboid defect is borrowed from single area.

Rotation pucker at Point C

Best in temple region between the eyebrows and anterior hair line

BD=DE=EFEF at angle of 60º &Parallel to one side

Limberg’s flap

Dufourmental flap:

variation of a rhomboid flap

Need not convert into 60º rhomboid

Such flaps are designed for closure of square & rectangular defects.

Adv: less closure tension

Disadv: rotation puckering at point C

Bilobed flap: First by Esser in 1918popularized by Zimany

reconstruct nasal and facial defects and even full thickness cheek defects.

Tension free closure of original and secondary defects.

90º is the optimal angle between the first and second flap

Maximum distortion occurs around the flap bases and the second donor lobe closure sites

Disadvantages: Rotation pucker

Interpolation flaps:

An interpolation flap is from a nearby, but not immediately adjacent donor Site and transposed either above or below the intervening skin to the Recipient defect

Types:

Cutaneous: requires two stage procedure but more reliableSubcutaneous Island

Ex: Median forehead flapNasolabial flap

Nasolabial flap:

Sushruta in 600 BCpopularized by Esser and Ganzer

reconstruction of facial skin defects of the upper lip, nose and cheek following extirpation of skin cancers.

superiorly based nasolabial flap- closure of the oro antral fistulae.

The bilateral inferiorly based nasolabial flap has utility in the reconstruction of the anterior defects of the floor of the mouth.

Defect in the anterior face, nose and upper lip, floor of the mouth OAF

Inferiorly based Superiorly based

For reconstruction in the anterior floor of the mouth

Case photos-Nasolabial flap

Forehead flaps• The forehead flap is an axial flap used to reconstruct

defects below the level of the eyes..• The most commonly raised forehead flap is the cutaneous axial median forehead flap, based on the

supratrochlear artery.• It can be raised and transposed to reconstruct areas

in the upper medial cheek region and the lower half of the nose and alar rim

• If a radial forearm flap fails in the mouth and an immediate, reliable 'lifeboat' is required; the forehead flap may be quickly raised to get the surgeon out of trouble!

Forehead flap: McGregor.

Blood supply superficial temporal artery and posterior auricular artery.

Hemiforehead flap or total forehead flap

Advantages:

Near to the oral cavityHairlessTissue is firm and holds sutures wellExcellent blood supplyThin and suitable for intraoral lining

Disadvantages:

Noticeable donor defectNeed to divide the pedicle and close the oral fistula at a second operationBleeding Flap necrosis can occur

Glabellar Flap

- Axial pattern flap- Based on supra-trochlear artery

uses:-nasal reconstruction-cheek defects

disadvantages:-donor site morbidity-limited amount of tissue

Temporalis flap:

Golovine in 1898

Temporoparietal fascia - superficial temporal artery

Temporalis muscle - anterior and posterior deep temporal br. Max. art

Type III

Uses: • Useful for obliterating skull base, maxillofacial and

orbital defects. • It is also used in cranialisation procedure• Reanimation of the face• Used to close CSF leaks & dural tears secondary to

trauma & cancer surgeries.• Used for midface augmentation for hypoplasia

secondary to trauma & congenital anomalies.

Advantages:• Close to the oral cavity• Good arc of rotation• Reliable and well tolerated• Thin flap• Problems from the loss of muscle function are

minimalDisadvantages:• Cosmetic deformity in donor site• Traction paresis of Facial nerve

Temporalis flap

•Ideal for Aged patient

•Defects of 4x4 to 6x7 cm.

•based laterally

•It involves lower cheek and upper neck

•useful, well tolerated flap for closing cheek defects with or without an associated neck dissection.

•maxillary artery, vein and their branches-blood supply

Cervicofacial flap:

Postoperative Care

• Pain reliever• Wound care• antibiotic ointment• Sutures removed at 5-7 days• Revision if required - 6 months

Complications

• Infection• Dehiscence• Vascular insufficiency due to

• Mechanical tension• Kinking• compression

• Hematoma/seroma

• Failure/necrosis

PREVENTION OF FLAP NECROSIS

Important steps to prevent necrosis :

1.Avoiding tension by prior establishing pivot point or using planning in reverse if local flap is jumping over intact skin .

2. Planning the flap with a margin of reserve is an additional way in which tension can be avoided.

3.Avoding kinking particularly at the base of the flap.

4.In random flap proper length: breadth ratio should be maintained .

PREVENTION OF FLAP NECROSIS

5.In axial flap , length does not extend recognized safe length.

6.Proper plane for flap elevation for raising flap.

7. No compression at pedicle

8.Using delay principal when it was considered inadequate .

9.Avoiding infection : prevention of hematoma and avoidance of raw area .