Basic Principles of Flap

Basic Principle of Skin Flaps ,Types of Flaps and
Design
Dr Ahmad Rizal Bin Abdul Hamid
Master Phase 1

References
1. Mathes SJ, Hansen SL. Flap Classification and Application, Chapter 16. In Mathes SJ(Ed). Plastic
Surgery, Colume 1, 2nd edition. 2006.
2. Fundamental Techniques of Plastic Surgery and their Surgical Applications. McGregor. 10th
Edition. 2000.
3. S.R. Baker. Local Flaps in Facial Reconstruction. 2nd Edition.2007.
4. Grabb’s Encyclopedia Of Flaps. Head and Neck . Volume One. 1st Ed.
5. Amanda A Gosman. Principles of Flaps. Selected Readings in Plastic Surgery.2004. Volume 10,
Number 1.
6. MR Kayser . Surgical Flaps. Selected Reading in Plastic Surgery. 1999. Volume 9 ,Number 2. .
7. G.G. Hallock. Direct and Indirect Perforator Flaps : The History and the Controversy. Plast.
Reconstr. Surg. 111: 855,2003

Presentation outline
1. Introduction
2. History of Flap Surgery
3. Flap Classification
4. Flap Modification

Introduction
o Flap : A unit of tissue that is transferred from one site ( donor site) to another (
recipient site) while maintaining its own blood supply.
o Graft : Transfer of tissue unattached to vascular source and rely on blood supply
at recipient site for survival.
o The earliest flaps centred around head and neck and lower extremities because
wounds in this region failed to heal by secondary intention.
o Flaps were not based on a specific blood supply.
o Flaps were used without an understanding on how and why they worked.

History of Flap Surgery
600 BC:
• Pedicled flaps for nasal reconstruction attributed to the Samhita . Sushruta
described reconstructions of nose and earlobes with tissue transfer technique.
• Sushruta transposed skin from the forehead to replace missing skin of the nose.
• 1440 AD: The origins of forehead rhinoplasty can be traced back to India.
• 15th Century
• Branca family in Sicily began applying Indian method to nasal reconstruction.
• Substituted flap skin from arm as donor for facial and ear reconstruction.

1597 : Tagliacozzi illustrated in Curtorum Chirurgia per Insitionem description of
delayed arm flap for nasal reconstruction.
• Delayed his upper arm flaps by making parallel incisions through the skin and
subcutaneous tissue overlying biceps tissue.

18th Century
• Letter from an Englishman appearing in
Gentleman’s Magazine in London , October 1794
describing a forehead flap nasal reconstruction
that had been performed on a mutilated soldier.

19th Century
1814 : Joseph Carpue ( London
Surgeon) performed a forehead
flap nasal reconstruction following
precisely the Indian Method 2
decades after researching the
technique.

• 1818 :Carl Ferdinand Von Graefe ( Surgeon General Of Prussian Army) reported
three nasal reconstruction.
• Published Rhinoplastik where he compared the Italian and Indian rocedures
• 1st used the Indian Method, 2nd used the tagliacotian, 3rd used modified
taglicotian without the delay procedure.
• Von Grafe supported the arm flap, as he was unhappy about forehead donor
site scar morbidity.

1889 – Carl Manchot
• German anatomist
• Performed first examination of cutaneous vascular territories. Published in The Cutaneous
Arteries of the Human Body.
• Used cutaneous injection studies to define cutaneous circulation
• Identified the cutaneous perforators , assigned them to underlying source vessels and charted the
cutaneous vascular territories of the body.
• Defined approximately 40 cutaneous territories excluding head, neck, hands and feet.
• Did not address blood supply to deep tissue
• Did not have the advantage of radiography.

1893 – Spalteholz
• Published an important paper on the origin, course and distribution of the cutaneous perforators.
• Main study concentrated on detailed circulation of the skin
• Studied in different regions of adult and neonatal cadavers.
• Arteries injected with gelatin, soft tissue fixed in alcohol and resulting vascular network
embedded in Canada Balsam.
• Distinction made between direct cutaneous vessels and indirect cutaneous vessels .
• Direct cutaneous vessels : Main purpose is to supply the skin
• Indirect cutaneous vessels : Terminal branches of vessels supplying deeper organs.

1930’s – Michel Salmon
• French anatomist and surgeon
• Knew of Manchot’s study and set out to reappraise his work.
• Experimentation included both muscular and cutaneous circulation.
• Aided by radiography – able to delineate the smaller radicles of cutaneous circulation.
• Did not address blood supply to deep tissue
• Charted more than 80 territories encompassing the whole body.
• Noted interconnections that exist between perforators.
• Observation of density and size of vessels in different regions of the body led him to define what
he called the hypervascular and hypovascular zone.

Taylor et al
• Were the first to describe vascular territories of deep tissue
• Delienate relationship between deep tissue and cutaneous territories which is described as
angiosomes.
• Angiosomes : Composite blocks of tissue which san between skin and bone.
• Described relationship between adjacent angionsome that are interconnected in each tissue layer
by reduced choke arteries.
• Relevant in flap planning

History Of Flap Sugery – 20th century
1896 Tansini Latissimus dorsi musculocutaneous flap for breast reconstruction post- mastectomy
1906 Tansini Described skin island for the lat. Dorsi flap
1912 Blair Osseocutaneous flap
1916 Filatov Tubed pedicle neck flap for lower eyelid reconstruction
1917 Gillies Tubed pedicle neck flap
1917 Aymand Tubed pedicle flap for nasal reconstruction
1919 Davis First published observations on pedicle flap principles, reviewed Manchot’s work on
vascular territories, described compound flap for mandibular reconstruction.
1921 Blair Introduced delay phenomenon in non pedicle flaps
1937 Webster Thoracoepigastric tubed pedicles

1942 Converse Median forehead flap
1946 Stark Muscle flap for lower extremity osteomyelitis coverage.
1955 Owens Compound flap consisting sternocleidomastoid with skin for head and neck reconstruction.
1960 Littler Neurovascular flap
1963 McGregor Temporalis flap for mid-face and lower face coverage
1965 Bakamjian Deltopectoral flap for lower 3rd face coverage + oral and esophageal defect.
1971 Ger Musculocutaneous flap for lower extremity.
1972 McGregor and
Jackson
Groin flap
1972 Orticochea Reported on musculocutaneous perforating vessels providing cutaneous territory for
superficial muscles.
1973 Daniel, Taylor,
O’brie, Harii
Microvascular free flap transfers

1976 Radovan Tissue expansion for breast reconstruction
1977 McCraw Description of numerous independent musculocutaneos vascular territories and
muscuocutaneous flaps
1977 Mathes Rectus Abdominis Flap
1981 Nakayama Arterialized venous flaps
1984 Song Free thigh flap
1981 Ponten Fasciocutaneous flaps
1987 Taylor & Palmer Angiosomes
1989 Koshima and
Soeda
Perforator flap while reporting on inferior epigastric flaps based on a single
musculocutaneous perforator

Flap classifications are multiple and vary according to the organizing principle.
Vascularity
• Random (cutaneous)
• Axial
Movement
• Advancement
• V-Y, Y-V
• Single Pedicle
• Bipedicle
• Pivot
• Rotation
• Transposition
• Interpolation/ Island
• Distant
• Direct
• Tubed
• Free
Composition
• Cutaneous
• Fasciocutaneous
• Musculocutaneous
• Muscle
• Osseocutaneous
• Sensory
1. Daniel and Kerrigan ( 1990)

2. Flaps can be classified based on 6c’s ( by Comack and Lamberty):
• Circulation
• Axial
• Septocutaneous
• Myocutaneous
• Composition
• Fasciocutaneous, musculocutaneous,
Cartilage, Bone, Nerve
• Contiguity
• Local Flap
• Regional Flap
• Free Flap
• Construction
• Uni- bipedicled
• Orthograde flow
• Conditioning
• Flap delay
• Tissue expansion
• Pre fabrication
• Conformation
• Special shapes
• Tubed
• Combined flaps

Tolhurst atomic system for cutaneous flap classification
For a complete description of each flap, the “nucleus” was determined by
the circulation and “ electron shells” described other characteristics.

Random Pattern Flap
• Random pattern flaps lack significant bias in
their vascular pattern.
• Raised without regard to any known blood
supply other than the subdermal plexus.
• Resticted to rigid length to width ratio to
ensure viability.
• Limitation
Limited rotation arc
May require delays
Proximity of flap to wound and associated
zone of injury
Decreased bacterial resistance

Axial Pattern Flap
• Single- pedicle flaps that encompass an
anatomically recognizable arteriovenous system
in their long axes.
• They contain at least one specific, direct
cutaneous artery within the longitudinal axis of
the flap
• Have improved survival lengths relative to
random flaps.
• Advantage results from incorporation of a
septocutaneous artery within it’s longitudinal
axis.
• Examples:
• Temporo-parietal flap – superficial temporal
artery.
• Groin flap – superficial circumflex iliac
artery
• Deltopectoral flap – internal mammary
artery
Fig: Axial pattern flap based on named artery for blood
supply.

Classification of skin flap based on
blood supply:
A : Random
B : Arterial Cutaneous
C : Fasciocutaneous
D : Musculocutaneous

Method Of Movement
Movement
• Local :
• Advancement:
• Single Pedicle
• Bipedicle
• V-Y
• Y-V
• Pivot:
• Rotation
• Interpolation
• Transposition
• Distant
• Pedicled
• Tubed
• Free
• Skin flaps can be grouped according to the technique
used to transfer the tissue between donor and
recipient sites.
• Local flaps are used to close defects adjacent to the
donor site and are in turn classified on their method of
movement into flaps that :
I. Advance from the base in the same direction as
the long axis of the flap
II. Pivot on a point
• Distant flaps use donor sites that are not adjacent to
recipient bed.

Advancement Flap
• Definition : A local flap which slid directly forward in to defect without rotation or lateral movement.
• Simplest form is an undermined wound for direct closure.
• Work best in areas of greater skin elasticity
• Principles:
 Flap is adjacent to defect.
 It should be orientated to take advantage of local vascular supply and skin elasticity.
• Techniques:
• Unipedicle advancement flap
• Bipedicle advancement flap
• V-Y
• Y-V

Unipedicle Advancement Flap
• Flap has a single cutaneous pedicle.
• Flap is created by parallel incisions, which allow “sliding” movement of tissue in a
single vector towards defect.
• Designed so incision is placed in or parallel to horizontal creases.
• Preferable to to “square off” defect than “round off “ the flap.
• Designed with ratio defect width to flap length 1:3
• Useful in defects over : Forehead , Medial Cheek, Eyebrow

Unipedicle Advancement Flap
Method
• Typically designed with defect width to flap
length of 1 : 3
• Incise parallel lines from defect.
• Elevate skin in subcutaneous plane.
• Advance rectangular flap into defect.
• Flap base can be excised as two triangles
(Burrow’s) or incorporated as a Z-Plasty:
• Excess skin at base
• Allow greater advancement of upper
portion of tissue.

Bilateral unipedicle advancement flap
• Principles of tissue movement and wound
closure identical to single unipedicle flap.
• Advancement flaps are incised on opposite
sides of defect and advanced towards each
other.
• Advantage over unipedicle flap -> Equal pull
from two opposing flaps lessen tissue
distortion.

V-Y Advancement Flap
• Flap is based on a subcutaneous pedicle.
• A triangular flap via a V-shaped incision is
designed
• Results in suture line with Y configuration.
Method
• Flap elevated as an island, fully detached
from surrounding tissue.
• Flap is based only to its subcutaneous tissue.
• It is advanced to the recipient site forming a
Y- shaped suture line.
• This flap can be used as double when a larger
area has to be reconstructed.

Bipedicle Advancement Flaps
• Primarily used for repair of large defects of the scalp.
• Flap is designed adjacent to the defect and advanced into the defect at a right
angle to the linear axis of the flap.
• Leaves a secondary defect that must be repaired with SSG
• Rarely used for face and neck reconstruction.

Pivot Flaps
• Definition : Local flaps that have an arc of movement about a fixed point( pivot point) to reach
the defect.
• Pivot point : Point of origin of the line of maximum tension in the flap and the point which it
pivots.
• Can be categorized into:
• Rotational flap
• Interpolation flap
• Island flap
• Transposition flap

Rotation Flap
• Definition : Semi-circular flap that rotates about
a pivot point to close the defect
Design
• Defect should be converted into isosceles
triangle with angle of 30’ at its apex (
Triangulation of defect)
• Radius should be 3x the length of side of the 30’
triangle.
• Draw semicircle extending from defect and
pivoting around centre point of circle
• Circumference of flap should be 5-8 x greater
than width of defect.
• Tension line from pivot point to furthest part of
semicircle.
• Tension line can be reduced by backcut.
• Brings pivot point closer – but diminish but
supply entering the base of flap.
S: arc length
S= r x 0

Closure.
• Direct suture with undermining also possible – but must not have the effect of recreating tension
• In head and neck region – tissue laxity seldom adequate.

Transposition Flap
• Usually a rectangular or square flap which
moved laterally from a pivot point into an
immediately adjacent defect.
• Effective length becomes shorter the farther
the flap is rotated, the flap must be designed
longer than the defect to be covered.
• Otherwise a back cut is necessary.
• Variations of transposition flap:
• Bilobed flap
• Rhomboid flap
• Dufourmental flap

Design
• Defect triangulated to excise excess skin at
the base of the defect and flap.
• Length from pivot point to the apex of the
flap should be
• Greater than the length from pivot pint
to the apex of the defect furthest from
the flap.
• Length of leading border of flap should be
• Equal or greater than the length of the
furthest edge of the defect

Bilobed Flap
• Described by Esser( 1918) described
its use in 1918 for reconstruction of
nasal tip defects.
• Original design – angle of tissue
transfer to be 90 between each lobe
of the flap , for total pivotal
movement over 180
• Modification by Zitelli (1989) – use of
narrow angles , 45 between each
lobe , for total pivotal movement <
100
Classic Design of bilobed flap.

Indications
• Nasal region :
• Suited for repair defects less than 1.5 cm in maximum dimension.
• Ideally defect should be at least 0.5 cm above margin of nostril.
• Flap recruits skin from mid and upper dorsum and side wall, where more
generous skin laxity is present.
• Defects of cephalic one half of nose not well suited for flap unless < 0.5 cm in
size. -> require use of thin and immobile skin from region of medial canthus.

Flap Design
• Assess laxity by pinching lateral nasal skin between
thumb and index finger.
1. Radius of defect is measured.
2. Distance equal to radius of defect (r) measured
from lateral border of defect to point marked in
alar groove.
3. Two arcs drawn which centers at the point.
4. Bases of both lobes arise from smaller arc.
5. Height of first lobe extends to second arc, width
equals defect.
6. Height of second lobe twice height of first lobe. ,
width same or slightly less.

7. Axis of defect and two lobes of flap approx. 45 degree apart.
8. Donor site of second lobe closed first.
9. First lobe transposed and standing cutaneous deformity removed.
10. Second lobe transposed and trimmed.

A & B : Sutured rotated about pivot
point marked in alar groove to mark the
two arcs .
C &D : Width of defect equals width of
first lobe.
E: Base of each lobe arises from smaller
arc.
Height if second lobe twice height of
first lobe.
Width of second lobe slightly less that
width of first lobe.

Flap Elevation
1. Flap elevated after LA
2. Dissection in tissue plane between nasal
muscles and underlying perichondrium &
periosteum.
3. Flap and remaining skin of entire nose
completely undermined , sometimes
extending dissection into the cheek.

Interpolation Flaps
• Interpolation flaps rotate on a pivot point
into a defect that is near but not adjacent to
the donor site.
• The pedicle must pass over or under
intervening tissue.
• 2 stage : If pedicle passes over intervening
tissue
• 1 stage : If pedicle de-epithelized or reduced
to subcutaneous tissue only ( island flap).
• Example:
• Paramedian forehead flap
• Littler neurovascular digital pulp island
flap

Rhombus Flap ( Limberg Flap)
• Described by Alexander A. Limberg in 1946.
• Cutaneous, random vascular pattern.
• Transferred primarily by transposition with
limited advancement movement.
• Rhombus shaped transposition flap with
internal angles of 60o and 120o
• Additional skin at defect removed to create a
rhombus
• Usually creates a standing cutaneous
deformity at base of flap
• Common use : cheek , temple, nose ,lip, chin,
neck.

Evaluation of defect
i. Avoid distortion of mobile structures such
as eyelid, lips, nasolabial fold.
ii. Area of skin must be identified with
adequate tissue laxity.
iii. Evaluation of RSTL , LME and aesthetic
boundaries to maximize scar camouflage &
minimize wound closure tension.

• ADEF: 60 degree rhombic defect
• FD: Short diagonal of defect
• AD’C’B: Rhombic flap
• DB : Short diagonal of flap
• AB : Base of flap
• D’C’ : Distal end of flap
* All sides of defect and flap are equal in length

Flap Design
1. Rhombus is marked around lesion with two
lines parallel to lines of maximum
extensibility ( LME).
2. A 60 degree rhombic defect is constructed.
3. Length of all sides and the short diagonal
are equal.
4. Defect short diagonal extended, bisecting
the internal 120’ angles.
5. Short diagonal of flap site should be in
same direction as LME.

Choosing the correct rhombic flap
• Four potential flaps can be designed
• Rhombic defect should be designed so two
sides are as close to parallel to the LME.
• Choose flaps which the short diagonal is
nearly parallel to LME.

Transfer of flap
As flap is transferred , point B ( pivot point of the flap) is advanced
toward D, resulting in primary closure of the donor site.

Effects of donor site closure
B. Point D remains stationary as point
B moves towards D to accomplish
closure of donor site.
C. Results of vector of tension ( VOT)
parallel to ED -> only one area of
tension -> no distortion to flap or
defect
D. If point D must move forward to
point B to effect donor site closure
-> result in widening of defect and
short diagonal of flap.
E. Result in additional VOT in
direction of short diagonal.

Dufourmental Flap
• Dufourmental( 1963) : Modification of
Limberg flap .
• Enable repair of rhombus shaped defect
with any combination of internal angle,
not limited to 60 and 120.
• Reduces tension required to close
rhomboid flap.
• Like Limberg flap, can only be used to
repair defects which all sides are equal.
• Length of short diagonal will vary
according to acuteness of internal angle

Design
• Draw rhomboid around defect.
• Two lines are created
• First line : Extension of short diagonal
of defect.
• Second line : Extension of one side of
defect.
• Third line : Created by bisecting angle
created by 1st and 2nd line -> should be
equal length to side’s of defect.
• The second side of flap is drawn
parallel to long diagonal of the defect,
also equal defect’s side.

Webster 30o Flap
• Also known as the 30o Rhombic Flap
• Consist of two flaps:
• W- Plasty at base of flap
• 30 degree angulation at apex
• Designed by approximately halving an
equilateral triangle.
• Height of triangle designed with height equal
to length of a side of the defect.
• Width of the base of flap is one-half the
greatest width of defect.
• Allows sharing of tension of closure better
than limberg flap.

Z- Plasty
• Dated back as far as Horner( 1837) and
Denonvilliers( 1854)
• Extremely versatile technique to lengthen or
break up a scar
• Involves transposition of two adjacent
triangular flaps are reversed.
• Scar resulting from Z-plasty will counter
forces of scar contracture as each segment of
the Z contracts in a different direction.

Fundamental Functions of Z-Plasty
1. Change scar direction
2. Interrupt scar linearity
3. Release (lengthen) scar contracture
Effects:
1. Gain in length along the direction of the
common limb of the Z
2. The direction of the common limb of the Z is
changed.
3. Contractural diagonal lengthens
4. Transverse diagonal shortens

Geometry
• The angle of the Z- Plasty determines the
potential gain in length.
• Geometric formula gives 25% increase in
length for every 15o increase in angle.
• The greater the angle the more lateral laxity
required to allow transposition of flaps.
• 60- degree is most effective, as it lengthens
the central limb without placing too much
tension laterally
• Narrowing angle below 60 degrees ->reduce
in gain length and influence blood supply to
the flap.

Z- Plasty
Method
• Draw along scar or contracture to be corrected.
• Mark points where new scar will lie.
• If possible ,design it so scars to lie on RSTLs.
• Incise the lines, elevate flaps & transpose.
Complications
• Failing to transpose the flaps and re-suturing Zs
into their starting positions.
• Tip necrosis especially if sutured under tension.
• Inability to transpose flaps because of
insufficient lateral laxity.

Multiple Z- Plasty
• Large Z- Plasty is not always keeping with the
aesthetic and functional goals of scar revision.
• Tissue for transverse shortening is seldom
available in unlimited quantity.
• A way of reducing transverse shortening
without significantly affecting amount of
lengthening.
• Effects:
1. Reduces lateral tension by spreading over
several transverse z-plasty limbs.

Example:
• Single Z Plasty : Achieve 2 cm lengthening
& at the same time construct a series of 4
small z- plasties.
• Each equal in size to a quarter if a single
z- plasty.
Result :
• Single Z- Plasty : achieve 2 cm lengthening
and 2 cm shortening.
• Multiple Z : Each for Z- Plasty achieve 0.5
cm lengthening and 0.5 cm shortening.

Planimetric Z- Plasty
• Variation of classic Z- Plasty
• Maintains flaps in the same plane.
• By minimizing amount of rotation and
excising redundant tissue -> this flap avoids
the contour and depression created by a
simple z-plasty.
• Lateral limb angles planned at 75 degree
angle.
• Ideal for scar releases on flat surface where
lengthening is the primary objective.

W-Plasty
• Described by Borges( 1959)
• Involves excising scar with zig zag design of
triangles on each side which interdigitate
when closed.
• Does not lengthen tissue.
Indications
• Reorient a linear scar
• Break up a linear scar
• Treat a trap door scar

Method
Planning
• Draw continuous line of triangles of zig-zag
down one side of the scar with diminishing
triangles at the extremes of the scar.
• Repeat exact size triangles on opposite side.
Offset so that one triangle will sit insides its
opposite number.
• If possible, design so that some of limbs of the
triangles lie in the RSTL
Incision
• Incise around the design and excise central skin
and scar.
Closure : Close triangles

Four- flap Plasty
• Described by Limberg in 1946
• Consist of two interdependent Z- plasties.
• 2 outer flaps became inner flaps after
transposition
• 2 inner flaps become outer flaps after
transposition.

Five Flap Z- Plasty
• Also called jumping-man flap due to its
appearance
• Useful for releasing contractures on concave
regions such as web space contractures and
epicanthal folds.
• Consist of :
• Central flap advancing in a Y-V
• Two Z- plasties on either side are
transposed.

Distant Flap
• Distant flaps imply that the donor and recipient sites are not in close proximity to
each other.
• Can be divided to :
• Direct Flaps
• Tube flaps
• Free Flaps

Tubed Flap
• Pedicled flap
• Typical tube flap has an axial vascular pattern.
• This allows it to be long in relation to its breadth.
• Making possible to tube its bridge segment.
• Transfer from donor to recipient involves more than 1 stage.
• Examples – Deltopectoral flap / Groin Flap

Mechanism of tube flap transfers
• Flap is raised and its bridge segment
tubed in preparation for transfer.
• Tubing stopped towards distal end.
• Leaves an area of raw surface used to
re-attach flap at it’s new site.
• Waltzing transfer : Used when entire
defect cannot be covered in single
procedure.

Mechanism of tube flap transfers
Transfer using wrist carrier
• The wrist acts as a carrier.
• After flap delay , tubed flap detached
at its base .
• Carried on the wrist to the site of
planned reconstruction.

Direct Flap
• Typical direct flap has a random vascular
pattern.
• Short in relation to its breadth.
• As a result, it cannot be tubed.
• 1:1 length : breadth ratio imposed by its random
vascular pattern.
• However less strict if converted to
fasciocutaneous flap but to be aware of risk of
flap necrosis.
• Transfer from donor to recipient involves more
than 1 stage.
Cross Finger Flap

Mechanism of Direct Flap Transfer
• Shortness of the standard direct flap
makes it necessary to bring the defect
into close proximity with the donor
site.
• When defect is at the arm/hand –
brought to upper abdomen.
• Leg/foot – limbs approximated to
each other as in cross- leg flap.
• Limbs involved to be immobilised for 3
weeks until flap is divided.
Cross Leg Flap

Advantages
• Single-stage procedure
• Variety of donor tissue
• Large amount of tissue can be
transferred
• Donor defect can be hidden in
cosmetically acceptable area
• Less immobilization than pedicle flaps
• Improved vascularity of flap and to
recipient area
• More aesthetic than local flap
Disadvantages
• Lengthy operation
• Recipient vessel may be
unavailable,damaged or
atherosclerotic
• Donor site morbidity ( scar , loss of
function, poor healing,herniation)

Free Flap
Definition:
• Tissue that is removed from one part of the body with its supplying artery and draining vein, and
transferred to another part of the body where the artery and vein are anastomosed to recipient
vessels.
• Also termed microvascular composite tissue transplantation.
• With ability to repair vessels < 2 mm in diameter , microvascular transplantation became possible.
• Eliminates need to select flap with arc of rotation that reaches the defect.
• 1963 :
• Goldwyn et al reported first successful free flap transfer .
• Elevated an island pedicled flap from groin of dogs and divided the pedicles. T
• They then replaced the flap in its original site with microvascular anastomosis

Free Flap
Indications:
• General :
• Post tumour resection, trauma, congenital defect or chronic wounds where free tissue transfer
would give optimum aesthetic and functional result.
Specific :
• Need for a certain tissue ( e.g bone especially if defect > 6 cm)
• Where there is no local option ( e.g foot, distal third of leg, head and neck)
• Massive defects
• Defects requiring complex reconstruction of multiple tissue types

Composition Classification
Flaps can be classified by their composition:
 Cutaneous flaps
 Fasciocutaneous
 Fascial
 Musculocutaneous
 Muscle
 Osteocutaneous
 Osseus

Cutaneous Flaps
• Cutaneous flaps are axial pattern flaps
which are supplied by a direct
cutaneous vessels.
• Example of direct cutaneous flaps:
• Forehead flap – Forntal branch of STA
• Groin Flap -SCIA
• Deltopectoral – Int Thoracic a.
• Dorsalis Pedis Flap - DPA
Fig : Axial vessel runs in the subcutaneous layer
of the cutaneous flap, above the underlying
muscle

Fasciocutaneous Flap
• Definition: Flap with a defined blood supply that is composed of a any or all
component layers found between the skin and deep fascia.
• 1889 : Manchot – “ larger cutaneous arteries appear from the fissure between
muscles”.
• 1981 : Ponten reintroduced principle of fasciocutaneous flaps.
• Lower limb ‘Superflaps” included deep fascia, had longer survival than could
be predicted for random flaps of comparable size.
• No anatomical explanation at that time was given.
• 1981 / 1982 : Haertsch & Barclay et al successfully investigated anatomical
vascular basis of these successful superflaps.

• Fasciocutaneous system blood supply:
• Regional arteries pass along fibrous septa between muscle compartments.
• This vascular plexus is localized to the level of the deep fascia – which then gives
off branches to the skin.

Cormack – Lamberty Classification
Type A ( Random fasciocutaneous
flaps)
• Supplied by multiple fascio-
cutaneous perforators that enter the
base of the flap.
• Extend throughout longitudinal
length.
• Can be based proximally, distally or as
an island.
• Example :
• Ponten super flap in lower leg

Type B (Axial fasciocutaneous
flap)
• Inflow through a solitary, identifiable
perforator.
• Modified : Single perforator removed
in continuity with major vessel from
which it arises. Used as free flap.
• Example :
• Groin flap
• Medial arm flap
• Saphenous artery flap

Type C
• Ladder type
• Multiple small fascial perforators from
a single subfascial source vessel.
• Supplying artery included in flap.
• Example :
• Radial forearm flap
• Ulnar forearm
• Lateral arm
• Posterior Interosseus

Type D
• Extension of type C
• Consist of an osteo-musculo-fascio-
cutaneous free tissue transfer

Mathes – Nahai Classification
Type A (Axial)
• Have direct cutaneous pedicle.
• Vascular pedicle course initially
beneath deep fascia and continues it’s
course superficial to deep fascia.
• Pedicle provides numerous
fasciocutaneous perforators to the
skin.
• Examples:
• Groin
• Sural
• Temporo- parietal fascia

Type B ( Septo-cutaneous)
• Pedicle courses between major
muscle groups in an intermuscular
septum or between adjacent muscle.
• Examples:
• Radial forearm flap
• Lateral arm
• Ulnar
• Anterior lateral thigh
• Post Interosseus

Type C ( Musculo – Cutaneous)
• Perforator to skin travel through
muscle.
• Example:
• DIEP
• ALT
• Delto-pectoral
• Grastrocnemius
• Gracilis

Nakajima Fasciocutaneous Flap Classification7
• Flaps named after origin of perforator to it’s
fascial plexus
Left to right
1. Type I : Direct Cutaneous Flap
2. Type II : Direct Septocutaneous Flap
3. Type III : Direct cutaneous branch of
muscular vessel flap
4. Type IV : Perforating Cutaneous Branch of
Muscular Vessel Flap
5. Type V: Septocutaneous perforator flap
6. Type VI : Musculocutaneous perforator flap

Advantages
• Thin and pliable
• Blood supply reliable and robust
• Donor site morbidity minimal in
regard to function.
• Muscle sparing
• Ability to restore sensation.
Disadvantages
• Lack of bulk for deep defects
• Technically more challenging.
• Size limitations
• Donor site may require skin graft,
leaving donor site deformity.

Muscle and Musculocutaneous Flaps
• Musculocutaneous flaps are composites
of skin, subcutaneous tissue , and
underlying muscle and fascia supplied by
a dominant vascular pedicle.
• 1906 – Tansini- Reconstructed breast with
combination of skin and LD muscle raised
as one unit.
• 1955 – Owens – Repair of massive facial
defects with sternocleidomastoid flap
• 1977 – McCraw, Dibbell, Carraway
described the vascular territories of
several new musculocutaneous units and
defined flap dimensions and useful arcs
of rotation.
Fig : Musculocutaneous flap : Cutaneous flap is
nourished by vessels passing through underlying
muscle carrier.

Mathes and Nahai Musculocutaneous
Classification
• Described in 1981
• Two initial points made :
1. Muscle flap success is based on reliable
blood supply.
2. All muscle categorized into a type of
vascular pedicle supply.
• Patterns of circulation based on :
I. The regional source of the arterial
pedicle
II. Size of pedicle
III. Number of pedicle
IV. Location in relation to origin and
insertion
V. Angiographic patterns of
intramuscular vessels

Type I : One vascular pedicle
• Type 1 : Flap vascular supply via
one major pedicle.
• Example:
• Tensor fascia lata
• Gastrocnemius
• Rectus femoris

Type II : Dominant vascular pedicle and minor
pedicle
• Flap vascular supply via one major and minor
pedicle.
• Most common pattern of circulation observed
in human muscle
• Large dominant pedicle usually sustains
circulation after elevation of flap when minor
pedicles are divided.
• Circulation via minor pedicle alone is not
reliable.
• Examples:
• Gracilis , Trapezius, soleus, biceps
femoris, abductor digiti minimi.

Type III : Two dominant pedicles
• Type III : Flap vascular supply via two major
pedicles.
• Muscle can usually survive on one of its two
dominant pedicles.
• Vascular pattern allows muscle to be split,
allowing use of only part of the muscle.
• Example:
• Gluteus maximus
• Rectus Abdominis
• Temporalis
• Serratus anterior

Type IV : Segmental Vascular Pedicles
• Type IV: Flap vascular supply via segmental
pedicles.
• Each pedicle provides circulation to a
segment of muscle and an immediately
adjacent segment.
• Example:
• Sartorius
• Tibialis anterior
• Flexor & Extensor Digitorum

Type V : One dominant vascular pedicle and
secondary segmental vascular pedicles
• Has one dominant pedicle near the insertion
which can supply the whole muscle.
• Several minor pedicles near origin which can
also supply muscle.
• Useful flaps – can be based on either
dominant pedicle or secondary segmental
pedicles.
• Example:
• Latissimus Dorsi
• Pectoralis Major
• Internal Oblique
• Fibula

Clinical Applications
1. Help predict muscle arc of rotation for pedicled flaps.
• Muscle type I,II,III and V are able to survive solely on their dominant pedicle ,
thus more amenable to rotation or transposition than type IV flap.
• Type III have two potential arcs of rotation.
• Flap classification aids in prediction of viable skin territories.
• Type II, III ,IV muscles are at risk of skin necrosis if distal segmental or or
minor pedicles are divided.
• Type V muscle skin survival is more robust.

Clinical Applications
2. Aids in design of flaps
• Type II & IV will be poor choices for distally based flaps as not all of the
muscle will survive.
• These flaps may benefit from delay technique
• Type I,II & IV are recommended for free flap muscle transplantation.

Taylor Classification
• Taylor et al classify muscles of the body according to their most common pattern
of innervation.
• The pattern of neurovascular anatomy of the muscle influences the way a whole
muscle of segment of muscle can be harvested as a functional muscle
microvascular transfer.
• Clinically, serratus anterior ,latissimus dorsi, gracilis and rectus femoris often used
by taking a portion of the muscle with their motor nerve and blood supply.

Type I
• Single unbranched nerve entering the
muscle
• Muscle supplied by single motor nerve
that divides usually after entering the
muscle.
• Multiple vascular pedicles supply each
muscle
• Possible to remove a vascularized
segment of muscle with its nerve and yet
leave viable muscle in situ
• Examples:
• Lattisimus Dorsi
• Palmaris longus
• Teres minor

Type II
• Single branched nerve entering the
muscle.
• Example:
• Deltoid
• Gluteus maximus
• Trapezius
• Vastus Lateralis
• Serratus Anterior
• Flexor Carpi Ulnaris

Type III
• Multiple branches from same nerve trunk.
• Possible to subdivide each muscle into
separate functional units.
• Multiple vascular pedicles and several nerve
branches
• Example:
• Gastrocnemius
• Sartorius
• Teres Major
• Triceps
• Tibialis anterior
• Soleus
• Peroneus Longus

Type IV
• Multiple branches from different
nerve trunks.
• Each vessel can be subdivided
anatomically into several functional
units because of the multiple,
segmental neurovascular pedicles.
• Examples:
• Rectus abdominis
• Internal Oblique
• Levator scapulae

Advantages
• Provides bulk and protective padding.
• Well vascularized muscle resistant to
bacterial inoculation.
• Often one stage procedure.
• Restoration of function possible
Disadvantage
• Donor defect may lose some degree
of function.
• Donor defect maybe aesthetically
undesirable.
• May provide excessive bulk.
• May atrophy over time thus fail to
procide adequate coverage.
• Contour deformities at donot site.

Perforator Flaps
• Definition : A flap consisting of skin
and subcutaneous fat supplied by
vessels pass through or in between
deep tissue.
• Evolved from musculocutaneous and
fasciocutaneous flaps without muscle
or fascial carrier.
• Has been shown neither a passive
muscle carrier not underlying fascial
plexus are necessary for flap survival.

Brief History
• First perforator flaps were developed for head & neck reconstruction in Japan
and China.
• 1984- Song et al- reported free thigh flap. Included description of ALT flap,
Andromeda and Posterior thigh flap.
• 1989 – Koshima & Soeda – reported successful transfer of an inferior epigastric
artery skin flap based on rectus abdominis perforator to a groin wound and floor
of mouth.
• Allen & Treece & Blondeel – reported the ultimate muscle sparing TRAM flap for
breast recon with DIEP flap.
• Koshima – Raised gluteal perforator flap for sacral wound repair.
• Angrigiani – “ LD musculocutaneous flap without muscle” – based on
thoracodorsal a. perforator

Perforator Flap Nomenclature
• Geddes et al proposed to standardize nomenclature of perforator flaps by
describing all perforator flaps according to the main artery of origin.
1. Perforator flap should be named
after source vessel.
2. Suffix with muscle initials only
necessary when perforating
vessels can pass through different
muscles.
3. Suffix –s indicate perforator flap is
as septocutaneous flap.
4. Example:
• LCFAP- vl( Lat. Circumflex)
• SGAP-gm

Advantages
• Preserve muscle function
• Produce minimal donor site morbidity
• Reduce postoperative recovery time
and pain medication required
• Can be designed of varying sizes &
thickness to improve aesthetic results.
Disadvantages
• Time consuming, meticulous
dissection of pedicle
• Variation in perforator anatomy, size
and location
• Higher risk of fat necrosis compared
with musculocutaneous flap.

Osseous Flaps
• Vascularized bone flaps are used more
infrequently than soft tissue flaps.
Serafin Classification
• Serafin divided osseous flaps to whether they
have a direct ( endosteal) or indirect (
periosteal) circulation.
• Endosteal : Blood supply directly enters the
bone, usually via a nutrient foramen.
• Periosteal : Circumscribes the bone within the
periosteum o eventually reach the bone
indirectly.

Venous Flap
• Definition : A composite flap of skin,
subcutaneous tissue and other tissues such as
nerve, tendo and bone that uses
subcutaneous vein for arterial inflow and
venous outlflow.
• First described by Nakayama et al in 1981.

Classification:
• Type I: Unipedicled venous flap, a
single unipedicled vein is the sole
conduit for perfusion and drainage.
• Type II: Bipedicled flap, with a vein
entering ( caudal end) and leaving (
cephalad end) of flap.
• Type III: Arteriovenous flap that is
perfused by a proximal artery and
drained by a distal vein.

Venous Flaps
Advantages
• Thin and pliable
• Harvest with minimal donor site
morbidity
• Many potential donor site ( forearm,
dorsal foot, hand)
Disadvantage
• Small size
• Unreliable as tissue furthest from
venous plexus prone to congestion
and necrosis

Compound Flaps
• Compound Flaps: Flap which consist of diverse tissue
components that are incorporated into an interrelated
unit.
• Grouped into two major classes according to their most
critical element , their primary means of vascularization.
• Solitary vascularization : Composite Flaps
• Combination of vascularizations:
• Conjoined
• Chimeric
Hallock, G.G. Further Clarification of the Nomenclature for Compound Flaps. Plast. Reconstr. Surg. 7 : 117, 2006

Composite Flaps
• Flap that has a solitary source of vascular supply
• All components are dependent on each other
• Must all remain intact together to sustain overall flap
viability.
• Example :
• Musculocutaneous / Fasciocutaneous flaps
• Skin and subcutaneous tissue paddle depends on
muscle or fascial perforators for sustenance.

Conjoined Flaps
• Combination of at least :
• Two anatomically distinct territories, each retaining their
independent vascular supply
• But joined by means of some physical boundary.
• Harii et al – described a “Combined myocutaneous flap and
microvascular free flap”.
• Skin territory of LD musculocutaneous flap and the groin
flap remained connected together to form a bipedicle flap
based at opposite ends of thoracodorsal and superficial
circumflex iliac vessels.
• Either pedicle could be divided to increase arc of rotation in
a caudal or cepahlad direction – but revascularization was
required for the territory no longer used as a pedicle flap.

Compound Flaps
• Consist of multiple independent flaps that each have an independent
vascular supply , but all pedicles are linked to a larger common source
vessel.
• Advantage : Transfer of flap can be done while requiring only a single
recipient site.
• Huang et al further subdivided into 3 subtypes:
I. Branch based ( classic) – eg. Subscapular system
II. Perforator based - each perforator with its own independent
territory but remain attached to same common source vessel.
• Eg. Anterolateral thigh flap

Compound Flaps
III. Prefabricated : Surgically joined together by
microanastomosis.
a. Sequential type : Fabricated component attached to
terminus of source vessel ( distal continuation)
• Circulation firs had to proceed by means of a “ flow –
through” across first flap or” bridge flap” to the
attached one in sequence.
b. Internal type : Fabricated component attached to a
branch indigenous within the flap ( side branches of the
main source vessel)

Technical Modifications
I. Supercharging
• Supercharged flap : Use of an unrelated
distant vascular source by means of
anastomosis to a flap to augment either
inflow or outflow.
• Example:
• Superior unipedicled TRAM flap
supercharged by anastomosis of a
thoracic or upper extremity vascular
source to the contralateral deep or
superficial inferior epigastric artery.

Technical Modifications
II. Turbocharging
• Turbocharged flap siphons off flow from a vessel already
intrinsic to the flap territory
• If a branch of the major pedicle to a flap were joined to
another minor pedicle -> Flow to the flap could be siphoned
away to augment an ischemic portion.
• Semple – Directly connected the ipsilateral and contralateral
deep inf. epigastric vessel to a TRAM flap of a superior
unipedicled TRAM flap.

Pre fabricated flap
• Introduced by Shen in 1982
• Definition : A flap that is created by implantation of a vascular pedicle into a new territory,
followed by a period of maturation and neovascularization and then subsequent transfer of tissue
based on it’s implanted pedicle.
• Allows tissue volume to be transferred to any specified recipient site thus expands reconstructive
options.
• Indication:
• Head/ neck burn reconstruction
• Desirable to use flaps which are thin with good color match,hair bearing flaps.
• There may be suitable tissues with these special characteristics -> but may not have reliable
axial blood supply.

Pre fabricated flap
• 2 stages:
• Stage 1 : Implantation of vascular pedicle
I. A vascular pedicle dissected out,
transferred to a new area and
implanted.
II. Distal end is ligated and no vascular
anastomoses are performed.
III. Vascular connections occur
spontaneously between implanted
pedicle and surrounding tissue to
create new vascular territory
IV. Tissue expander can be used as an
adjunct for tissue expansion.

• Stage 2 : Transfer of flap
• Neovascularized tissue is harvested
and transferred based on implanted
pedicle after at least 8 weeks.
• Flap can be transferred locally as a
pedicled flap if close to the defect or
via microvascular anastomosis.

Clinical Example:
Hypertrophic burn scar of jaw and neck
• Design of flap to be prefabricated over
left medial thigh
• C : saphenous vein transversing the
length of the flap. Descending branch
of the lat . femoral circumflex which
will be transposed medially (arrow).
• D: Expanded prefabricated flap at 8
weeks, prior to harvest.

• Results 12 months later after two thinning
procedures.

Prelaminated flaps
• Lamination : Bonding together of thin sheets.
• Introduced by Pribaz and Fine in 1994
• 2 stage procedure -
I. Flap Maturation :
• Adding different layers into an axial vascular territory , allowing time for tissues to mature
before being transferred.
• Blood supply is not manipulated , time for flap to mature between 2-4 weeks and achieve
neovascularization.
II. Flap Transfer :
• Transfer after 2-4 weeks to allow graft incorporation.
• Laminated layers are transferred to the defect as a composite structure based on the
original axial blood supply.

Basic Principles of Flap

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Basic Principles of Flap