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Surgiacl flaps

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Subervised by: Dr.Mohammed Khudher Presented by : Muhanad Khames Zahrra Abduljaleel Faihaa Amer
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Page 1: Surgiacl flaps

Subervised by: Dr.Mohammed Khudher

Presented by : Muhanad Khames

Zahrra Abduljaleel

Faihaa Amer

Page 2: Surgiacl flaps

A flap is a unit of tissue that is transferred from

one site (donor site) to another (recipient site)

while maintaining its own blood supply.

Flaps come in many different shapes and forms.

They range from simple advancements of skin

to composites of many different types of tissue.

These composites need not consist only of soft

tissue. They may include skin, muscle, bone,

fat, or fascia.

Page 3: Surgiacl flaps

The term flap originated in the 16th century

from the Dutch word flappe, meaning

something that hung broad and loose,

fastened only by one side. The history of flap

surgery dates as far back as 600 BC, when

Sushruta Samita described nasal

reconstruction using a cheek flap. The origins

of forehead rhinoplasty may be traced back

to approximately 1440 AD in India. Some

reports suggest flap surgeries were being

performed before the birth of Christ.

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Page 5: Surgiacl flaps

The surgical procedures described during

the early years involved the use of pivotal

flaps, which transport skin to an adjacent

area while rotating the skin about its

pedicle (blood supply). The French were

the first to describe advancement flaps,

which transfer skin from an adjacent area

without rotation. Distant pedicle flaps,

which transfer tissue to a remote site,

also were reported in Italian literature

during the Renaissance period.

Page 6: Surgiacl flaps

1- Replace tissue loss due to trauma or surgical

.excision

2-Provide skin coverage through which surgery

.can be carried on latter

.3-Provide padding over bony prominences

4-Bring in better blood supply to poorly

.vascularized bed

5-Improve sensation to an area (sensate flap).

6-Bring in speialized tissue for reconstruction

such as bone or functioning muscle.

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1. Enable rapid reconstruction.

2.Good colour and texture.

3.Has a reliable and adequate blood

supply.

4. More adaptable to weight

bearing.

Page 8: Surgiacl flaps

The microcirvculatory system of skin is composed of

:

1-Superfacial plexus in the superfacial dermal

papillae in the papillary dermis.

* Supplies the more metabolically active epiderms by

means of diffusion.

2-Deep vascular plexus at the junction of

subcutaneous fat and reticular dermis.

* Physiologic factor affecting flap survival :

1- Blood supply to the flap through its base.

2- Formation of new vascular channels between the

flap and the recipient bed.

3- Perfusion pressure of the supplying blood

vessels.

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Page 10: Surgiacl flaps

*Can be based on (five ‘C’ s)

1- Congruity

2- Configuration

3- Components

4- Circulation

5- Conditioning

Page 11: Surgiacl flaps

Local – immediately adjacent to defect.

Regional – moved from adjacent region.

Distant – moved from remote anatomic

area.

Pedicled – moved with intact tissue bridge

for support.

Islanded – no intact skin but moved under

the skin for non contiguous defects.

Page 12: Surgiacl flaps

Local flaps are flaps that are located adjacent to the defect.

They may be contiguous to the defect or a small

amount of tissue may separate the flap from the defect.

The surrounding tissue is transferred to repair the defect

and therefore the flap tends to be similar in color and tex-

ture, and the thickness can often be tailored to the needs

of the defect.

Local flaps are created by freeing a layer of tissue and then

stretching the freed layer to fill a defect.

Page 13: Surgiacl flaps

:Advantages

Best local cosmetic tissue match.

Often a simple procedure.

Local or regional anaesthesia option.

Disadvantages :

Possible local tissue shortage.

Scarring may exacerbate the condition.

Surgeon may compromise local resection.

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LOCAL FLAP

BLOOD SUPPLY

METHOD OF MOVEMENT

COMPOSITION

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Local flaps can be classified based on their blood supply

Random flaps Axial flaps

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Page 17: Surgiacl flaps

Rotation flaps provide the ability to mobilize

large areas of tissue with a wide vascular base

for reconstruction. The name rotation flap

refers to the vector of motion of the flap,

which is curved or rotational, and the

procedure involving these flaps can be thought

of as the closure of a triangular defect by

rotating adjacent skin around a rotation

point(or fulcrum) into the defect.

Page 18: Surgiacl flaps

Indication

1-Commonly used for coverage of sacral pressure

sores. This type of flap can cover wounds of

various sizes.

2-After excisional surgery.

*Rotation flaps are particularly useful when the

proposed donor site of the flap is the lateral

aspect of the face. These flaps are advantageous

because they have a particularly wide base and

thus an excellent blood supply. Their

disadvantage is that they require relatively

extensive cutting beyond the defect to develop

the flap.

Page 19: Surgiacl flaps

A: 3*3 cm skin defect of

medial cheek.

Page 20: Surgiacl flaps

Rotation flap designed for

repair

Page 21: Surgiacl flaps

Flap in place. Standing cutaneous

deformity excised parallel to melolabial

crease

Page 22: Surgiacl flaps

The rectangular flap is rotated on a pivot point.

The more the flap is rotated, the shorter the

flap becomes. Most commnly used in head and

neck

Transposition flaps have the following

advantages:

1: They accomplish redistribution and

redirection of tension.

2:They tend to be smaller in size than

advancement and rotation flaps.

3:Resultant scars are geometric broken lines that

may be less conspicuous and tend to be easy to

hide.

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Reconstruction of total upper eyelid defect with lower lid

transposition. Illustration of planned reconstruction of an upper

eyelid defect with lower lid transposition.

Page 24: Surgiacl flaps
Page 25: Surgiacl flaps

Interpolation flap – the flap rotates about a

pivot point into a nearby but not adjacent

defect, with the pedicle passing above or below

a skin bridge.

E.g. median forehead flap, thenar flap

Page 26: Surgiacl flaps

Advancement flaps can be used at any location

on the cheek. As with the rotation flap, the

advancement flap can be of any size. It is best

to use natural lines, even if they diverge away

from the defect, because this will still give a

.better and more natural cosmetic end result

No rotational or lateral movement is applied.

E.g. rectangular advancement, V-Y advancement

etc.

Page 27: Surgiacl flaps

Create a triangular-shaped flap with the base of the flap at the cut edge of the skin where the amputation occurred. It should be as wide as the greatest width of the amputation

Skin incisions are made through the full thickness of the skin.

Advance the flap over the defected area and suture it to the nail bed.

Place corner stitches to avoid interference with the blood supply to the corners. Convert the V-shaped defect into a final Y-shaped wound

The V-Y pedicle plasty technique allows most patients to regain sensation and two-point discrimination in the fingertip.

The cosmetic results are usually excellent, with good contour and fingertip padding is preserved

Page 28: Surgiacl flaps

A-skin defect of alar groove. V–Y island subcutaneous tissue

pedicle advancement flap designed for repair

B-Flap incised and advanced on nasalis muscle

Page 29: Surgiacl flaps

(C) Flap in place.

(D) 4 months’ postoperative

Page 30: Surgiacl flaps

A rhombus is classically defined as an oblique-

angled equilateral parallelogram, whereas a

rhomboid differs in that it has uneven adjacent

sides. The term rhomboid is frequently used in

facial reconstruction literature to mean either

rhombus like or to describe one of the popular

transposition flaps used to repair rhombus-

shaped defects. Specially designed transposition

flaps for rhombic shaped defects.Defect must

have 60 and 120 angles.

Page 31: Surgiacl flaps

(A) Melanoma in situ right temple.

(B,C) Lesion excised. Limberg flap designed

for repair of 2*2 cm defect.

(D,E) Dufourmentel flap designed

and transferred to defect.

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Page 33: Surgiacl flaps

Z-plasty is one of many techniques for

scar revision and camouflage. Z-plasty

is a type of transposition flap that

incorporates qualities of advancement

and rotation flaps into its design.

USES

1-Lengthning of scar

2-Changing direction of scar into more

favorable one

3-Interrupt scar linearity

Page 34: Surgiacl flaps

Regional flaps are located at a significant

distance from the donor site. Because of

this distance, the flap usually has its own

blood supply in the form of a named

vessel. Advantages of a regional flap are

that post-operative care and monitoring

are much less intense compared with a free

flap; they are usually quicker than a free

flap; large amounts of skin and/or muscle

can be obtained; and if free flap surgical

expertise is not available, regional flaps

can provide a favorable result.

Page 35: Surgiacl flaps

There are several potential disadvantages of

regional flaps. The first and perhaps the most

important is the arc of rotation of the flap.

The ability to use a particular regional flap

will be dependent on the reach of the flap

based on its arc of rotation. The reliability of

regional flaps is improved when the flap can

reach the defect and the inset is performed

without tension. Other disadvantages for

regional flap are that the skin color match

and texture may be slightly different found at

the recipient site

Page 36: Surgiacl flaps

Pectoralis major muscle flap (with or without

skin).

Deltopectoral flap

Submental artery island

Supraclavicular artery island flap

Temporalis flap

Sternocleidomastoid flap

Scalping Flap

Trapezius flap

Paramedian forehead flap

Palatal Island Flap

Page 37: Surgiacl flaps

Indications

*Soft tissue reconstruction of the neck and

hypopharynx

*Pharyngocutaneous fistulas

*Backup” flap

Circulation

Septocutaneously: Randomly through skin perforators

from the internal mamary artery.

Constituents

Fasciocutaneous: Skin and fascia overlying the chest

and shoulder.

Conformation:The skin island is oriented to the shape

of the defect. The flap can be tubed for pharyngeal

reconstruction.

Page 38: Surgiacl flaps

Clinical Case: A young female patient aged 21

years presented with severe RTA trauma of

middle and lower vertical thirds of the face

who has admitted to maxillofacial Surgery

Department, Ramadi Teaching Hospital, Anbar

Province, Iraq.

Page 39: Surgiacl flaps

The skin paddle of deltopectoral flap allowed

the reconstruction of the lower lip, submental

region, and submandibular region. The flap was

marked preoperatively and the outline of the

flap was extended laterally to simulate the

resultant defect. The incision was extended 1

cm below the clavicle parallel to the lateral

border of the pectoralis muscle. The inferior of

the flap was 2 cmabove the nipple and parallel

to the clavicle. The 2 lines of incisions were

joined laterally on right arm.

Page 40: Surgiacl flaps

K-wire was inserted to maintain mandibular

bonecontinuity and prevent collapse of missed

segment of mandibularThe flap was elevated

with the deep fascia of the pectoralismuscle,

and dissection was performed inferiomedially,

the flap wasraised till the sternal border. After

preparation of recipient site, theflap was

rotated to the defect in a tension-free manner

and was sutured with 3/0 silk suture.

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Page 42: Surgiacl flaps

The first description of the pectoralis major

flap for head and neck reconstruction was by

Ayrian in 1978. The fol-lowing year he

published his work in the Journal of Plastic

and Reconstruction Surgery. Since the

description of this flap, its use quickly became

widespread and within a short time it held the

positionas the flap of choice in head and neck

reconstruction.

*Based upon the pectoral branch of the

thoracoacromial artery off the second portion

of axillary artery.

*Able to handle 90% of virtually all head and

neck defect.

Page 43: Surgiacl flaps

ADVANTAGE:

1-The location of the donor site as it relates to

the head and neck makes this flap a great option

for reconstructing defects in this region. The

harvest of the flap can be carried out with the

patient in a supine position. i.e., in the same

position as the ablative head and neck

operation.The potential for a two-team

approach is also available. although the surgical

field would be slightly crowded.One of the

greatest advantages of the pectoralis major

myocutaneous flap is the quality and quantity of

tissue that can be harvested. The pectoralis

maior mus-cle enables the closure of a

multitude of defects in the head and neck.

Page 44: Surgiacl flaps

2-More durable blood supply

3-Defect at the donor site can be closed

primarily.

4-Provide bulk tissue to cover large defect.

DISADVANTAGE:

1-The main disadvantage is that the pectoralis

major flapis a pedicle flap and therefore its use

in reconstruction of head and neck defects is

limited to sites within the arc of rotation of the

flap. Equally, some of the reasons that make

this flap good option for reconstruction will also

Be potential downsides in certain cases. When

the defectsite demands a thin and pliable flap,

this may not be themost ideal flap.

Page 45: Surgiacl flaps

2-In cases where the flap is used as a

myocutaneous flap with the skin island used to

reconstruct a skin defect in the head and neck,

there is often a very distinct color mismatch. In

males there may also be a significant a mount

of hair growth on the skin component of the

flap that may become bother some to patients

depending on the site of the reconstruction.

Page 46: Surgiacl flaps
Page 47: Surgiacl flaps
Page 48: Surgiacl flaps

The trapezius flap can be used to reconstruct numerous defects in the head and neck regionranging from defects in the oral cavity, resurfacing of various sites in the neck, and coverage of mandibular and temporal defects.

ANATOMY:

The trapezius muscle is a triangular muscle that covers the back of the neck and shoulder region and extends inferiorly in the back. It arises from the medial third of the superior nuchal line of the occipital bone.

The actions of the trapezius muscle can be divided based on the region, the upper region elevates the shoulder,

Page 49: Surgiacl flaps

the middle retracts the scapula and aids in the

abduction of the upper extremity, and the lower

portion aids in the depression of the scapula.

*blood supply from four sources: the transverse

cervical artery, the dorsal scapular artery, the

intercostal perforators lying just off the midline,

and the branches from the occipital artery.

The blood supply to the trapezius muscle and

overlying skin is primarily from the superficial and

deep descending branches of the transverse

cervical artery, as well as the occipital artery.

Page 50: Surgiacl flaps

Mutter 1842, Originally described as

superior based cutaneous flap.

ADVANTAGES:

1- Flap is versatile

2- Regionality of flap

3- Strong vascular security

4- Supplies considerable bulk

5- Arc of rotation 90 - 180 degree

6- One stage procedure

7- Minimum deficit at donor area

Page 51: Surgiacl flaps

DISADVANTAGES

1-Venous system difficult to preserve

2-Vascular supply in general difficult to preserve

Can present with excessive bulk

3-Cannot be easily tubed

4-Moderate shoulder drop postoperativer

Page 52: Surgiacl flaps

(A) Preoperative defect in the submental

region.(B) Marking of the dorsal scapular artery

and flap planning on the back.

Page 53: Surgiacl flaps

(C) Elevated flap as an island flap. (D)

Postoperative 3 months.

Page 54: Surgiacl flaps

Indications

1- all soft tissue defects of the oral cavity and

neck

2- Restoration of facial contours after

parotidectomy, prevention of Frey’s

Syndrome

3- Esophageal and tracheal defects

4- Backup flap

Circulation

Axially and myocutaneously by the thyrocervical

trunk and the occipital superior thyroid,

external carotid, the superficial cervical

suprascapular, and transverse cervical artery.

Page 55: Surgiacl flaps
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Page 57: Surgiacl flaps

Indications

Facial and nasal sof tissue defects.

Circulation

Axial by the supratrochlear artery

Constituents

Fasciocutaneous: Skin and fascia overlying the

forehead.

Conditioning

* Delay and subsequent two-stage

reconstruction is possible.

* Tissue expansion can be performed for large

facial defects.

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