FLAPS

Rosallia Megawati
Source
Definisi

– Definisi Flap : pemindahan sejumlah volume tertentu jaringan kulit dan

subcutis yang dipindahkan dari satu bagian tubuh (area donor) ke bagian tubuh
lain (area resipien) dengan mempertahankan pedikel pembuluh darah yang
menghidupinya tetap melekat di tempat asalnya.
– Pedikel flap : bagian flap dan jaringan sekitarnya yang membawa pembuluh
darah yang menghidupi flap.
Anatomy
 Klasifikasi Flap
Cara
Vaskularisasi Lokasi Komposisi jaringan
Memindahkan
• Axial • Advancement • Lokal
• Cutaneous
• Random • Transposition • Regional • Fasciocutaneous
• Rotational • Jauh • Musculocutaneous
• Interpolation • Osteocutaneous
Klasifikasi : berdasarkan vaskularisasi :

• A. Axial pattern flap:

Berisi setidaknya satu suplai
darah cabang kulit langsung
di sepanjang sumbu
longitudinalnya.
Klasifikasi : berdasarkan vaskularisasi :

B. Random pattern flap:

- flap diperdarahi oleh pembuluh
darah yang tidak mempunyai
nama
- Sebagian besar flap adalah random
- Diperdarahi oleh pleksus dermal
sub dermal
Klasifikasi : Berdasarkan Lokasi

2. Lokasi
a. Lokal: Shares side with the defect
b. Regional : In same region of the body as the defect, but does not
share defect margin.
c. Distant: Not in the region of the defect, located in a different part
of the body
Klasifikasi :
Berdasarkan Cara Memindahkan Flap

a. Advancement
b. Transposition
c. Rotation
d. Interpolation
e. Free
A. Advancement Flap

• Advancement flaps move directly forward and rely on skin

elasticity to stretch and to fill a defect.
• No rotational or lateral movement is applied
• It is of 3 types:
A.single pedicle advancement flap.
B.bipedicle advancement flap.
C.v-y flap advancement flap.
A. Advancement flap
• Single pedicle advancement flap: Here the
rectangular skin flap is moved forward by virtue
of its elastic properties.
• Bipedicle flap: here an insicion is made parallel to
the defect and the flap is undermined and
advanced
A. Advancement Flap
V-Y advancement flap:
V-Y advancement flaps advance skin on each side of
a V-shaped incision to close the wound with a Y-
shaped closure.
• The V-Y pedicle plasty technique allows
most patients to regain sensation and two-
point discrimination in the fingertip
B. Transposition Flap
rectangular or square flap located immediately adjacent to the defect
C. Rotation Flaps
Diputar atau digeser kesamping
C. Rotation Flaps
D. Interpolation Flap
Klasifikasi :
Berdasarkan komposisi jaringan

• Cutaneous
• Fasciocutaneous
• Musculocutaneous
• Osteomusculocutaneous
 Angiosomes

1. Definition: Composite unit of skin and deeper structures between skin and bone supplied by a
source vessel.
2. Entire surface area of body composed of angiosomes.
3. Majority of flaps cover more than two angiosomes.
4. Neighboring angiosomes can be linked by true arterial anastomoses or by choke vessels (reduced
caliber anastomoses) that dilate under certain circumstances, such as flap delay (see below).
5. Connections between angiosomes explain how flaps can support more than one angiosome area
under certain conditions
FLAP SELECTION

A. Reconstructive goals
1. Restore form and function to the defect
2. Minimize donor site morbidity
 FLAP SELECTION
B. Reconstructive ladder
1. Systematic approach to facilitate decision-making for
reconstruction of defects.
2. Least complicated technique chosen to address needs
of the defect and reconstructive goals.
3. Ladder progresses from simple to complex options
– a. Healing by secondary intention
– b. Primary closure
– c. Skin graft
– d. Local flap
– e. Regional flap
– f. Distant flap
– g. Free flap
Flap selection considerations

– Goals of intervention – Effect on donor site: Morbidity, secondary

defect, distortion of nearby structures
– Shape, contour, and structural needs of
(especially important in face)
reconstruction
– Pedicle length and caliber
– Location of the defect
– Technical demand
– Size of the defect
– Patient expectations
– Exposed and underlying structures – Patient comorbidities
– Viability of surrounding tissue (e.g., – Anticipated risk for complications (infection,
previous radiation, vascular disease, would healing complications, etc.)
tissue necrosis) – Cost of care
– Available donor sites
 CUTANEOUS FLAPS

Indications
– 1. Reconstruction of the local defect with similar, adjacent tissue
– 2. Need for full-thickness skin coverage of relatively less vascularized tissue
(e.g., coverage of bone, tendon without periosteum/paratenon intact) for which
skin graft is insufficient.
 CUTANEOUS FLAPS
Blood supply: Dependent on blood supply from fascial plexus (unless random pattern)
– 1. Direct cutaneous (axial) arteries
– 2. Septocutaneous arteries
– 3. Musculocutaneous arteries
– 4. Random pattern flaps
– a. Designed on random vascular supply from subdermal plexus
– b. *Size limited to length-to-width ratio ~2:1 in lower extremity and up to 4:1 in head and neck.
– c. Ischemia expected when the recommended length-to-width ratio dimensions exceeded without
flap delay.
– d. Most (but not all) small local cutaneous flaps based on random blood supply
CUTANEOUS FLAPS
Method of transfer:
Advancement flaps: Moved by sliding or stretching flap toward the defect in
one direction, requires skin laxity
a. Single-pedicle advancement flap
– i. Raised as square or rectangle
– ii. Undermined and advanced to fill defect sharing border with flap
– iii. Bürow’s triangles made at base to facilitate advancement and closure
(helps correct length discrepancy between skin surrounding wound and
skin of flap margin)
b. Bipedicle advancement flap
– i. Incision parallel to the defect
– ii. Flap undermined and advanced
– iii. Useful for longitudinal defects of extremities
CUTANEOUS FLAPS
V–Y advancement flap
– i. Can be designed as advancement (where skin at base is not divided) or
island flap (where skin at base of flap is divided)
– ii. Flap raised in V shape and advanced to fill the defect
– iii. Closed in Y to close the donor defect
– iv. Flap may be modified to a Y–V variation
– v. Useful on face and fingertips to fill defects (island design) or can be used to
release contracture (advancement design)
CUTANEOUS FLAPS
Pivotal flaps: Moves around fixed point at base of pedicle
Rotation flap: Pivotal flap with curvilinear configuration
– i. Flap raised in semicircle immediately adjacent to the defect.
– ii. Height of the defect = ½ to 1 times radius of flap curvature
– iii. Standing cutaneous deformity may occur at base (depending on shape of the defect),
requiring removal.
– iv. Back cut at base of flap shifts pivot point to reduce tension of closure
– v. Bürow’s triangle at secondary defect margin may help to facilitate closure. (corrects
length discrepancy between flap margin and surrounding skin edge)
– vi. Also uses some advancement or stretch of flap to correct length discrepancy
between lengths of closure of flap margin and skin edge (often called rotation
advancement flap).
– viii. Undermining base of flap and pivot point facilitates advancement and limits
standing cutaneous deformity.
CUTANEOUS FLAPS

Transposition flap: Pivotal flap with linear configuration

i. Rhomboid (Limberg) flap
– a) Defect made into rhombic shape (equilateral parallelogram) with 60 and 120
– degree angles.
– b) First side of flap is a short diagonal of rhombus extended at an equal length.
– c) Second side of flap is a line parallel to and same length as nearest limb of flap.
– d) Four flaps can be designed around sides of the defect, flap design chosen with
– best skin mobility and scar placement.
CUTANEOUS FLAPS
iv. Z-plasty
a) Transposition of two adjacent and opposing triangular flaps
b) Used to lengthen scar contractures, change scar direction, break up scar,
release epicanthal folds or constricting bands.
c) Moves lateral tissue inward from both directions in order to increase tissue
length longitudinally at the expense of width.
d) Classic design: Central segment with limbs oriented at 60 degrees
(although can be 30 to 90 degrees); three lines are equal in length; central
segment oriented along the direction of the desired lengthening (e.g., in the
same direction as scar to be released).
 FACIAL FLAPS

A. Skin elevated with underlying deep fascia (fasciocutaneous flap) or fascia is elevated alone (fascial flap).

B. Indications
– 1. Need for thin, pliable coverage when bulk of muscle flap not desired.
– 2. Cases where secondary procedures anticipated under flap; fascial flaps easier to elevate during reoperative procedures.
– 3. Better gliding surface for coverage of exposed tendons.

C. Blood supply/Mathes and Nahai classification

– 1. Type A: Direct cutaneous perforator; pedicle courses beneath deep fascia on its way to skin (e.g., temporoparietal fascia flap,
groin flap).
– 2. Type B: Septocutaneous perforator; pedicle travels within intermuscular septa (e.g., radial forearm flap)
– 3. Type C: Musculocutaneous perforator; pedicle based on musculocutaneous perforators that travel through muscle to supply
deep fascia and overlying skin (e.g., anterolateral thigh flap)
 MUSCLE FLAPS
A. Muscle can be transferred alone (muscle flap) or with
overlying skin (musculocutaneous flap)

B. Indications
– 1. Muscle flaps are useful when a bulkier reconstruction
is needed.
– 2. Eradication of dead space
– 3. Need for tissue with robust blood supply due to risk
of infection or poor perfusion.
– 4. Restoration of motor function (functional muscle
transfer)
 MUSCLE FLAPS
C. Blood supply/Mathes and Nahai classification
1. Type I: Single vascular pedicle (e.g., gastrocnemius, tensor fascia
lata)
2. Type II: Single dominant pedicle and one or more minor pedicles;
flap cannot survive on minor pedicles alone; most common type of
muscle in body (e.g., soleus, gracilis, rectus femoris, biceps femoris)
3. Type III: Two dominant pedicles; flap can survive on either
pedicle alone (e.g., rectus abdominis, gluteus maximus)
4. Type IV: Segmental pedicles; multiple pedicles enter along course
of muscle, each supplies a portion of the flap; least reliable type
(e.g., sartorius, tibialis anterior)
5. Type V: One dominant pedicle and secondary segmental
pedicles; flap can survive on segmental pedicles alone (e.g.,
latissimus dorsi, pectoralis major)
 MUSCLE FLAPS

D. Flap design
– 1. Skin island is designed to include skin perforators arising from the source artery.
– 2. Musculocutaneous perforators typically located near entry of dominant pedicle into hilum of the
muscle.
– 3. All or part of muscle can be used as a flap.
– 4. May also include bone, motor nerve, or sensory nerve in transfer (depending on donor muscle).
– 5. Functional muscle is sacrificed, thus donor morbidity must be considered when selecting flap.
 POSTOPERATIVE MANAGEMENT

A. Flap monitoring
4. Signs of arterial insufficiency
1. Evidence of arterial or venous insufficiency in immediate post-op period requires
– a. Cool temperature
immediate exploration
– b. White color
2. Clinical evaluation: Gold standard method of flap assessment
– c. Slow capillary refill >2 seconds
– a. Temperature: Should be body temperature
– d. Slow or absent pinpoint bleeding
– b. Color: Should be pink
– e. Low turgor
– c. Capillary refill: Should be approximately 2 seconds
5. Signs of venous insufficiency
– d. Bleeding: Upon introduction of fine-gauge needle, bright-red bleeding
– a. Increased temperature
should be present
– b. Blue to purple color
– e. Firmness: Should be soft, with some appreciable turgor
– c. Brisk capillary refill <2 seconds
3. Additional methods of flap monitoring
– d. Brisk pinpoint bleeding, dark in color
– a. Doppler (implanted or external)
– e. Increased turgor, tense, swollen
– b. Fluorescein dye
– f. If congested, unwrap, release sutures and consider leech therapy (patient must
– c. Pulse oximetry, pH, or temperature sensors be on quinolone or third generation cephalosporin against Aeromonas)
Risk factors for flap vascular compromise

– 1. Tight dressings and/or splints

– 2. Tight sutures
– 3. Patient position or motion that puts pressure on flap
– 4. Hematoma (increases tissue pressure and interferes with perfusion)
– 5. Kinking of flap, pedicle, or both (may be influenced by flap design, pedicle length,
interpositional vein graft length)
– 6. Cool ambient room temperature
– 7. Poor surgical technique
– 8. Systemic patient factors: Use of vasoconstrictive pharmaceutical agents (vasopressors,
nicotine, caffeine, etc.), hypovolemia, anemia, inadequate blood pressure
TERIMA KASIH