Surgical flaps in plastic surgery

SURGICALFLAPSIN
PLASTICSURGERY
Compiled By: - Dr Joginder Singh, Resident
Under Guidance: - Dr Ashok Kumar, Associate
Professor
SPMC, Bikaner

◦ A surgical flap consists of tissue that is moved from one part of the
body to another with a vascular pedicle to maintain blood supply.
◦ A skin graft is a segment of dermis and epidermis that is separated
from its blood supply and donor site and transplanted to another
recipient site on the body.
2Dept of Surgery, SPMC

Skin Grafts
◦ Can be Autograft, allograft, homograft, heterograft
◦ Partial thickness skin grafts/ Thiersch graft: removal of full epidermis + part of dermis (0.006-
0.024 inches)
◦ It is technically easier
◦ Graft takes up better
◦ Donor area heals on it’s own.
◦ Sensation returns in 4-5 weeks & being completed by 12-24 months.
◦ Disadvantages: -
◦ Infection c/I group A beta-haemolytic streptococci
◦ Contracture
◦ Loss of hair growth
◦ Seroma & Haematoma formation will prevent graft take up
◦ C/I : Over bone, tendon, cartilage, joint

Full Thickness Graft
◦ Also known as Wolfe graft
◦ Includes both epidermis + full dermis.
◦ Advantages:
◦ Colour match is good
◦ No contracture
◦ Sensation & function of sebaceous gland, hair follicles retained better
◦ Disadvantages:
◦ Used only for small areas
◦ Wider donor area has to be covered with SSG.

Flap Graft
Blood supply Blood supply is maintained throughout
the transfer
No blood supply
Take Maintains blood supply from donor area
and the vascularity develops from
recipient region
Has 3-phases
Plasmatic circulation: first 48 hrs
Revascularization: neovascularization +
inosculation
Organization:
Nourishment Initially from the donor area From the recipient area
Tissue volume Large amount of tissue can be
transferred
Limited amount of tissue is transferred
Technically difficulty level Difficult Relatively easier
Tissue which can be transferred All the tissues could be transferred There is limitation
Tissue combinations Any combination is possible There is limitation
Reliability Highly reliable Not so reliable 5Dept of Surgery, SPMC

Goals and Principles of Flap Surgery
◦ Goals
◦ For resurfacing of a defect
◦ Reconstruction of the deformed or lost organ
◦ Improving blood supply to the region
◦ Reconstruction should be performed with aesthetic considerations
◦ Principles
◦ Use like to like tissue in reconstruction
◦ Should be able to fill the cavity to the desired extent
◦ Bring more supply for better healing of wound and bone
◦ Should be able to perform function for which it is intended to
◦ Aesthetically it should be acceptable
◦ Minimal scarring and good colour match are intended

Blood supply of skin component
◦ Musculocutaneous arteries: -
◦ Travel perpendicular through muscle to overlying skin
◦ Septocutaneous arteries: -
◦ Arises from segmental or musculocutaneous vessels travel with intermuscular fascial septa to
supply overlying skin

Based on blood supply
◦ Random flaps: -
◦ Three sides of a rectangle, bearing no specific named vessels
◦ length: breadth > 1.5:1
◦ Lengthening by ‘delaying’ the flap & ‘training’ the blood supply
◦ Axial flaps: -
◦ Based on known blood vessels supplying the skin
◦ 6:1 length: breadth
◦ Pedicled/island flaps
◦ Free flaps: - The blood supply has been isolated, disconnected and then reconnected using
microsurgery at the new site.
◦ Pros: select exactly the best tissue, minimise donor site morbidity
◦ Cons: more complex procedure, failure involves total loss of all transferred tissue

Based on region of movement
◦ Local
◦ Regional
◦ Distant

Local flaps
◦ Is raised next to a tissue defect in order to reconstruct it
◦ Rotation flaps: semi-circular flaps of skin and subcutaneous tissue that revolve in an arc around a pivot
point to shift tissue in a circle.

Transposition flaps
◦ Rectangular or square shaped flap which turn laterally to reach the defect

Advancement flap
◦ Move directly forward and rely on skin elasticity to stretch and fill a defect.
◦ V-Y advancement flap: advances skin on each side of a V-shaped incision to close the wound
with a Y-shaped closure. e.g. finger tips

◦ Y-V advancement flap: advances skin on each side of a Y-shaped incision to close the wound
with a V-shaped closure. e.g. scar contracture
◦

◦ Z-plasty: Two interdigitating triangular flaps without tension to use lateral skin to produce a gain
in length along the direction of the common limb of the Z.

◦ Rhomboid flap: rely on the looseness of adjacent skin to transfer a rhomboid-shaped flap into a
defect that has been converted into a similar rhomboid shape.

◦ Bilobed flap: For convex surfaces,
especially nose

◦ Bipedicle flap: For eyelids

Local flaps
◦ Benefits
◦ 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

Tissue Expansion
◦ Technique that uses a mechanical stimulus to induce tissue growth so as to generate soft tissue for
reconstruction use.
◦ Valuable in local flap
◦ It involves placing a device – usually an expandable balloon constructed from silicone – beneath
the tissue to be expanded, and progressively enlarging the volume with fluid while the overlying
tissue accommodates to the changed vascular pressure
◦ Filling the expander is initiated approx. 2 weeks after surgery (usually by sterile saline blue) &
continued at weekly or biweekly intervals
◦ C/I Previously irradiated tissue

Tissue expansion

Distant flaps
◦ To repair defects in which local tissue is inadequate
◦ Distant flaps moved on long pedicle that contain the blood supply
◦ Myocutaneous flap
◦ Fasciocutaneous flap
◦ Perforator flap

Myocutaneous flap
◦ Composites of skin, subcutaneous tissue, underlying muscle and fascia supplied by a dominant
vascular pedicle
◦ Fill the dead space with vascularised tissue, which increases resistance to infection
◦ Cons: bulky, donor site morbidity, risk of functional deficit
◦ Type I: Single pedicle – gastrocnemius, tensor fascia lata
◦ Type II: Dominant pedicle with minor pedicles – gracilis, trapezius
◦ Type III: Dual dominant pedicles – gluteus maximus, serratus anterior
◦ Type IV: Segmental pedicles – sartorius, tibialis anterior
◦ Type V: Dominant pedicle with secondary segmental pedicles – latissimus dorsi

Fasciocutaneous flap
◦ Includes skin, subcutaneous tissue & underlying fascia
◦ Supplied by fascial feeder vessels arises from source vessels, musculocutaneous perforators
◦ Eg. Anterior lateral thigh flap, radial forearm flap, scapular flap
◦ Type A: Flaps supplied by multiple Fasciocutaneous perforators
◦ Type B: Flaps with a single Fasciocutaneous perforator
◦ Type C: Flaps based on multiple small perforators
◦ Type D: Osteomusculofasciocutaneous flap
◦

Perforator flaps
◦ Composed of skin & subcutaneous tissue supplied by a deep fascial perforating vessel.
◦ Technical recommendations:
◦ Identification of at least one vessel with a diameter of 0.5 mm or more
◦ Inclusion of at least two or more perforators, sufficient pedicle length
◦ Preservation of a subcutaneous vein to use for venous outflow in case of deep system of perforator
vein is anomalous
◦ Advantage: Minimal donor site deformity, muscle sparing hence no functional deficit
◦ Ability to design flaps of different sizes, shapes and thickness
◦ E.g. Deep inferior epigastric artery perforator flap

Saltatory flap
◦ It is mobilising the flaps in stages from distant donor area towards recipient area
◦ Waltzing is a technique wherein flap is moved from donor area and attached
adjacent to the recipient defect area. Later in 2nd stage, it is moved towards the
defect formally. It reduces the tension on the flap and increases the success rate.
Dept of Surgery, SPMC 26

Care of flaps & Monitoring
◦ Flap should be observed for tissue colour, warmth and turgor
◦ Pressed to assess blanching and capillary refill time
◦ Loss of arterial inflow results in pale, cold, flaccid tissue
◦ Loss of venous outflow results blue congestion, increased turgor, rapid capillary
refill and initially a warm flap. In pedicled flap, such venous congestion relieved
by releasing suture tension; applying leeches to suck
◦ Care: “wet, warm and comfortable”

Breast Reconstruction
◦ Timing
◦ Most women with stage I or II breast cancer are candidates for immediate reconstruction.
◦ Flap loss, necrosis may delay chemoradiotherapy and thus compromise, in cancer treatment.
◦ 1 or 2 weeks after lumpectomy, once HPE report available
◦ Most common procedures
◦ Tissue expander placement, with later exchange for an implant
◦ Immediate permanent implant placement (Submuscular pocket below P major)
◦ Latissimus dorsi with implant
◦ Autologous tissue (pedicled) – Gold standard
◦ Autologous tissue (free)

Autologous Reconstruction (Pedicled)
◦ Transverse Rectus Abdominis
Myocutaneous (TRAM) flap
◦ Because lower abdominal tissues are similar in
consistency to breast tissue
◦ Based on superior epigastric and inferior
epigastric artery (dual supply)

Vascular territories of abdominal wall provided by
a unilateral TRAM flap

◦ Free TRAM: Is connected via deep inferior epigastric vessels with internal mammary vessels (MC) or
thoracodorsal vessels (originally used).
◦ Muscle-sparing (ms) TRAM: only muscle surrounding the perforating vessels is taken
◦ Deep Inferior epigastric perforator (DIEP) flap: No muscle is taken & perforating vessels are dissected
out in a chain.
◦ Superficial Inferior Epigastric Artery (SIEA) provides a pedicle that does not penetrate the rectus muscle
at all.
◦ >1.5 mm calibre & results least abdominal morbidity

Latissimus Dorsi Reconstruction
◦ Based on Thoracodorsal vessels

Latissimus dorsi flap

Gluteal-based flaps
◦ Used in women have little adipose tissue in lower abdomen
◦ Gluteus maximus flap based on dual supply superior & inferior gluteal artery
◦ Disadvantage: difficulty in dissection, short pedicle length, size discrepancy of
gluteal vein with internal mammary vein.

Gluteal based flaps

Inner Thigh-based Flaps
◦ Ideal for women without abdominal or gluteal tissue.
◦ Transverse upper gracilis (TUG) flap based on ascending branch of medial
circumflex femoral artery.
◦ Disadvantage
◦ Shorter pedicle length
◦ Smaller skin island
◦ Possible contour deformity of medial thigh
◦ Widened donor site scar

Transverse Upper Gracilis flap

Complications
◦ Implant-based reconstruction complication capsular contracture (MC)- 15% without radiation and 42% with
radiation.
% msTRAM DIEP SIEA GAP
Partial flap loss 2 7 3 4
Fat necrosis 3 9 7 -
% Pedicled TRAMs Free Flap
Fat Necrosis 50 17
o Hernia formation 15% in pedicled TRAMs vs 5% in DIEP flap
o Immediate reconstruction followed by radiation has complication rates of 87% vs 8.6%
in patients who have delayed reconstruction.

Nipple-Areolar Reconstruction
◦ Should be 2-3 months after creation of breast mound or completion of adjuvant
therapy
◦ 2-ways
◦ Full- thickness skin graft usually from groin for the native darker pigmentation
◦ Medical tattoo pigments
◦ Creation areola usually occurs 4 to 6 weeks after creation of nipple.

Conclusions of Breast Reconstructions
◦ When possible, immediate reconstruction is preferred because it has not been
show to increase oncologic risk or delay adjuvant therapy, it provides for better
aesthetic outcomes, and it results in less depression.

Reconstructive Ladder
• From simple to more complex
procedure if previous one fails in any
reconstructive procedure
• Exception: local flaps for nasal defects
(Reconstructive elevator)

References
◦ Plastic and reconstructive surgery. Bailey & Love’s Short Practice of Surgery. 27th edition. Volume 1. CRC Press Taylor & Francis
Group; 2018: 633-651.
◦ Plastic Surgery. Sabiston Textbook of Surgery. 1st SEA edition. Volume 2 Elsevier Publication; 2016: 1938-1974.
◦ Breast Reconstruction. Sabiston Textbook of Surgery. 1st SEA edition. Volume 1 Elsevier Publication; 2016: 865-879.
◦ Surgical flaps. Surgery Update 2018. MAMC. 36th National Continuing Medical Education Programme in Surgery: 7-10.
◦ PRS Open url
https://journals.lww.com/prsgo/Pages/videogallery.aspx
o Sural flap for heal pad defect url https://youtu.be/2pUXjMwZWNc Dr. Nikhil Panse

Surgical flaps in plastic surgery

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