Flaps Flashcards
Ponten flap Classification
1981
Fasciocutaneous flaps
A multiple vessels at base of flap (ponten)
B single axial vessel (lower limb)
C multiple perforating vessels from intermuscular septum (RFF)
D type C with bone
Mathes and Nahai muscle classification
Type 1 Single dominant pedicle (TFL)
Type 2 Dominant and minor pedicles (Gracilis)
Type 3 Two dominant pedicles(Glut max)
Type 4 Multiple segmental pedicles (Sartorius)
Type 5 Single dominant and multiple minor pedicles which can support muscle (LD)
1981
Delay concept
Surgical interruption of part of the flap’s blood supply at a preliminary stage with intention to improve survival of the flap.
Pearl 1981:
Open choke vessels
Increase axiality of blood flow in random pattern flaps
Sympathectomy at borders -> vasodilation
Improve tolerance to ischaemia
Reduced hyperadrenergic state and vasoconstriction
Deltopectoral flap
Fasciocutaneous type C
Cutaneous axial pattern, Bakamjian 1965
Perforators from internal thoracic artery (3rd/4th IC space)
Pectoralis minor flap
Terzis 1980s
Type III
Pedicle: Pectoral branch of thoracoacromial artery from subclavian
NS: medial and lateral pectoral nerves
Trapezius flap
McCraw 1977
Type II
Pedicle: TCA (transverse cervical artery) from thyrocervical trunk.
Ascending branch to lateral flap, desc branch to vertical flap.
Lat Dorsi
Tansini 1906
Type V
Pedicle: Dominant: thoracodorsal artery off subscapular (after circumflex scapular a)
Also branches to Serratus anterior
Minor: posterior intercostals, lumbar artery perforators (LAP)
8cm length, 3mm artery
Serratus anterior
Type IV (segmental)
Upper/middle: subscapular, posterior scapular, superior thoracic
Distal: thoracic branch of thoracodorsal artery (only distal 3 of 5 slips can be used)
Scapular flap
dos Santos 1980, Nassif 1982, Hamilton 1982, Gilbert 1982
Adipocutaneous, fasciocutaneous or osteocutaneous.
Pedicle: circumflex scapular a - horizontal scapular branch and longitudinal parascapular bracnch
6cm length, 2mm artery
Omentum flap
1826? Jobet and Lambel
Kiricuta 1950s
1972 Harry Buncke and Donald McLean for scalp defect
Right omental a via gastroepiploic a., 2-3mm. 4-5cm length.
Upper laparotomy - identify greater curvature of stomach to find right & left gastroepiploic arteries. Ligate left and middle omental vessels.
Groin flap
McGregor and Jackson 1972
Fasciocutaneous flap
A: Superficial circumflex iliac artery (from femoral) = 3cm below where femoral a meets inguinal ligament
N: IC branch T12 and lat femoral cut nerve
Skin paddle - just medial to femoral v, to superolateral to vertebral column (35-40cm), 10-12cm width
Parascapular flap
Nassif 1982
Fasciocutaneous
Pedicle: circumflex scapular a (see scapular flap)
Gluteal flap
Ger 1972
Type III muscle or musculocutaneous
Dominant: superior and inferior gluteal arteries
Rectus abdominis
Robins 1979
Type III
Dominant: DIE
Minor: superior epigastric
8-10cm pedicle, 4mm artery
Pennington 1980 - TRAM
Allen 1994 - DIEP
Pectoralis major flap
Ariyan 1979
Type V
Dominant: pectoral branch of thoracoacromial (from subclavian)
Minor: lat thoracic, superior thoracic, intercostal perforators, internal thoracic perforators
Posterior interosseous flap
Penteado 1986
FC flap B
Desc branch of common interosseous division of ulnar a (10% direct from ulnar a)
1/3 from line between lateral epicondyle and DRUJ (pronated)
Enters post compartment betw supinator and APL, runs in septum betw EDM and ECU, with 7-14 perforators, anastomoses with perforating branch of ant IO at wrist
Deltoid flap
Type I
Pedicle: cutaneous branch of posterior circumflex humeral artery (from 3rd part of axillary a)
Temporal flaps
- STF ( STA = terminal branch of ECA, bifurcates 2-4cm above zygomatic arch into frontal and parietal branches, and middle temporal a (deep branch) immed above zygomatic arch)
- DTF (superficial to temporalis, suppl by middle temporal a, branch of STA)
- temporalis muscle (suppl by deep temporal arteries (branches of maxillary), type 3)
Forehead flap
Sushruta Samhita 7th century
FC flap A
Supratrochlear and supraorbital arteries plus VCs
Converse scalping flap
1942
Contralateral superficial temporal arteries
Coronal incision plus skin paddle on contralateral forehead
Washio flap
1969
STA and communication with postauricular a
Raise subgaleal
Bilobed flap
Esser 1918
Local random pattern flap
Abbé flap and Estlander flap
Abbé flap - Sabattini 1838
For upper lip recon
Estlander flap for commissural defect
Karapandzic flap and Webster flap
Karapandzic 1974
Lower lip defect >1/3
Webster flap = transverse cheek advancement, excise large Burrow’s triangles
Tongue flap
Guerrero-santios
Use undersurface of tongue for lower lip, divide at 10 days.
Need mouth block to prevent biting.
Use anteriorly based lateral flaps for upper lip.
Risk of dry mucosa.
Gillies fan flap, McGregor modification
Gillies 1920? 1957 - result in microstomia, similar to Estlander flap
McGregor 1983 - rectangular, vertical element becomes lip border. Rotates around commissure.
Nakajima flap - based on facial artery rather than labial a
Quaba and Maruyama flaps
Maruyama flap - incorporates dorsal MC artery and perforator as reverse flow
Quaba flap - thinner, leaves dorsal MC artery behind
Foucher flap
Holevich 1963 “racquet flap” included branches of sup radial nerve, based over 2nd MC
Then Foucher refinement (tunnelled flap) in 1979
Uses skin over dorsal index P1, based on 1st dorsal MC artery
Atasoy-Kleinert flap
Tranquilli-Laeli 1935, then reported by Atasoy in 1970
VY advancement of pulp
Kutler flap
1947
Bilateral advancement flaps for fingertips
Venkataswami flap
1980
Oblique advancement flap for palmar/oblique fingertips
Cross finger flap
Cronin 1951
Reverse cross finger flap - Atasoy
Hueston flap
Rotation-advancement (hatchet) flap on volar finger for fingertip recon - includes 1 NVB at base
Soquet modification - used both NVBs
Moberg flap
1964 Volar thumb advancement
Also O’Brien - rectangular flap (proximal skin divided) raised on both NVBs and advanced
Littler flap
Neurovascular island pedicle flap - uses ulnar border ring (or little) finger
TFL flap
1978 Nahai, and Hill.
One of earliest described free flaps
Type 1
Lat circumflex artery(lat/asc branches) (6cm below ASIS) + lat cutaneous n of thigh
Now used as pedicled flap for pressure sores
ALT
Song 1984 (popularised by Koshima)
Type C
Descending branch of lat fem circumflex
Vastus lateralis
Type 2
Proximal 1/3: lateral circumflex femoral and transverse descending branch or “great artery” from profunda femoris
Middle 1/3: perforators from profunda femoris
Distal 1/3: 1st collateral of popliteal artery
Usually raised on proximal vessel, to reconstruct around hip, or distal 1/3 can be distally based to cover knee
Lateral arm flap
Song 1982
Fasciocutaneous, osteocutaneous, fascial
Posterior branch of radial collateral artery (from profunda brachii)
8cm pedicle, 2mm artery
Posterior thigh
FC flap
Desc branch of inferior gluteal artery, skin overlying biceps femoris
Can be raised with post cutaneous n of thight (in midline)
Saphenous artery flap
McCraw 1977
Type 2 muscle flap?
Used for knee+ prox 2/3 of tibia
Saphenous a (with saphenous nerve), plus perforator from post tibial a, and perforators from medial head of gastroc.
Gastrocnemius flap
Type 1
Medial and lateral sural arteries from popliteal
Protect sural n.
medial head is longer
Soleus flap
Type 2
Used for middle 1/3 of lower leg, can used medial hemisoleus.
Post tibial and peroneal arteries
Medial plantar
Distal branch of post tibial - check that medial plantar artery is present!
Found at proximal border of Adb hallucis, just distal to tarsal tunnel, need to divide muscle
- deep branch runs adjacent to tarsal bones, superficial branch runs between Abd hallucis and FDB
Sensate via medial plantar nerve
Reverse sural artery flap
Sural nerve and artery pierce deep fascia at mid-calf
Pivot point 3 finger breadths proximal to lat malleolus. Proximal limit is where 2 heads of gastroc meet.
Can also be raised antegrade.
DCIA flap
Mialhe 1975 and Taylor 1979
Can take iliac crest (not ASIS) and internal oblique (if ascending branch preserved, 1cm superior to ASIS)
A: DCIA arises from ext iliac at level of inguinal ligament, courses within fascial sheath behind inguinal lig
8cm pedicle, 4mm artery
Fibular flap
Taylor 1975
A: nutrient artery of fibula, from peroneal, from posterior tibio-peroneal trunk.
Minor pedicle from peroneal artery (medial and post aspect of fibula)
6cm pedicle, 3mm artery
Dorsalis pedis
McCraw 1975
Axial FC flap +- tendon, bone, sensation(deep and superficial peroneal nerves)
Entire dorsum of foot, 1st web space, and medial 3 toes and MTs
Bilobed flap
Esser 1918
2 transposition flap, tertiary defect must loe in line with RSTLs
SGAP
Allen 1995
Type 3
A: sup gluteal
8cm pedicle, 3mm artery
EDB flap
Muscle flap, no skin paddle
Lateral tarsal artery, with branch from DP. Can trace back to origin from ant tibial a
Origin - ant surface of calcaneus and inferior ext retinaculum, insertion onto P1s and long toe extensors
Posterior interosseous flap
Penteado 1986
PIA- descending branch of common interosseous division of ulnar artery (or from ulnar a in 10%)
For 1st web space, thumb, dorsal hand to PIPJ level, palm and wrist coverage
Becker flap
Becker 1988/1992
Used as propellor flap - pivot point 2cm proximal to pisiform
Ulnodorsal artery from ulnar artery - middle branch supplies skin via ascending and descending branches
Radial forearm flap
Yang 1981, Song 1982
Type C
Proximal branch near origin
Middle branch 7-8cm proximal to radial styloid.
Distal branch 2cm proximal to styloid (runs beneath PQ for osseous component)
Perforators lie within septum betw BR and FCR
15cm pedicle, 3mm artery
Gracilis muscle/musculocutaneous flap
Harii 1976/8
Pickrell 1956
Type 2
Pedicle - branch off med fem circumflex (smaller A1 from profunda femoris, A3 from superficial femoral a), VC x2 into profunda femoral v
Nerve - single motor - ant branch of obturator n
8cm pedicle, 3mm artery
