Principles of Surgical Flaps

Introduction

The underlying principle of all surgical flaps is the ability to maintain a viable blood supply upon transfer of flap tissue from a donor site to a recipient site. Given this fundamental capacity to retain vascular circulation, surgical flaps may be classified in many ways. One approach is by composition, as a flap may be made up of many different kinds of tissue. Another is by vascularity, and several different schemata have been developed to categorize flaps by the type of vascular supply. A third manner of categorizing flaps is by method of movement, and it is important to understand the basic techniques of flap transfer. Unlike a graft, which is wholly dependent upon the recipient bed to provide blood supply, a flap by definition is able to preserve its own vascular supply for survival. Thus, whether classifying a flap by composition, vascularity or method of movement, the core principle essential to all flaps is how to maintain blood supply so that the flap tissue will remain robust after transfer to its new site.

Composition

The most basic way to think about a flap is to consider what tissues are contained within it. A flap may contain skin, fascia, muscle, bone or various combinations of these tissues. As the underlying principle of any flap is its ability to retain its own blood supply, the amount of tissue that may be carried within it is dictated by the minimum or maximum amount of tissue that can be transferred with intact vascularity. When more than one type of tissue is contained within a flap, it is called a “composite flap.”

The simplest type of flap is the skin flap. The blood supply of the skin is contained largely in the dermal and subdermal plexus and derives from two main sources: a musculocutaneous vascular system and a direct cutaneous vascular system. When the blood supply to the skin is via a named artery, the skin flap is called an “axial flap.” When the blood supply to the skin lacks a significant pattern in its vascular design, the skin flap is called a “random flap.” Either way, the survival of a cutaneous flap depends on the number and type of blood vessels at the base of the flap. For an axial flap, the survival pattern of the flap is based on the length of the underlying feeding artery. For a random pattern flap, the length and width should be designed in a 2:1 ratio, as a wider base width increases the chance that a large vessel will be incorporated to provide an adequate blood supply to the enclosed dermal-subdermal plexus. Even in an axial flap, the distal borders of the flap are also random pattern with distal perfusion from the dermal-subdermal plexus .

Skin flaps may also be transferred based on the vascular plexus of the deep fascia, in which case they are termed “fasciocutaneous flaps.” The blood supply of the deep fascia is derived from perforating vessels of regional arteries that pass along the fibrous septa of muscle bellies or muscle compartments. Including the deep fascia along with the skin avoids tedious dissection and may also preserve adjacent subfascial arteries. Among the advantages of fasciocutaneous flaps in reconstructive surgery are ease of elevation and transfer, decreased bulk, good reliability, and decreased functional morbidity at the donor site. Depending on the size of the skin paddle, however, the secondary defect at the donor site may require coverage with a split-thickness skin graft.

Progressing one layer deeper still, another common flap in reconstructive surgery is the “myocutaneous” or “musculocutaneous” flap, which combines muscle, skin, and the intervening fascia and subcutaneous tissue. Supplied by one or more dominant vascular pedicle within the muscle instead of a direct cutaneous arterial source, the essential feature of a myocutaneous flap is that the underlying muscle “carries” the blood supply for the overlying skin. Myocutaneous flaps have two key advantages. First, the increased bulk better allows it to fill dead space. Secondly, myocutaneous flaps are also more resistant to bacterial infection than fasciocutaneous flaps by a factor of 100. This makes them very reliable and useful, particularly when increased bulk is needed with a robust arterial supply to fill a defect that has been subjected to chronic infection. If a skin paddle is not needed, muscle can also be transferred alone, without the overlying fascial and cutaneous tissue.

A final type of tissue commonly incorporated into a flap is bone. When taken with the overlying skin, this is called an “osseocutaneous flap.” A dominant vascular pedicle with perforating branches supplies the skin and periosteum. Usually taken as a free flap, the bone is harvested with a cuff of muscle and/or skin to reconstruct a skeletal framework with soft tissue. The long bones of the extremities, such as the fibula, are often used as they provide more length for shaping according to the required need.

Type of Blood Supply

Once the composition has been determined, flaps can be further categorized according to their blood supply. As mentioned earlier, random flaps are based primarily on the cutaneous blood supply from the dermal-subdermal plexus. Pedicled or axial flaps are based on anatomically mapped or named blood vessels.

Fasciocutaneous flaps have been classified into three categories based on their vascular patterns.

Type A: Direct cutaneous pedicle

Type B: Septocutaneous pedicle

Type C: Musculocutaneous pedicle Muscle flaps may be classified in two different ways. First, Mathes and Nahai developed a system of muscle classification based on circulatory patterns.

Type I: Single pedicle (e.g., tensor fascia lata)

Type II: Dominant pedicle(s) with minor pedicle(s) (e.g., gracilis)

Type III: Dual dominant pedicles (e.g., gluteus maximus)

Type IV: Segmental pedicle(s) (e.g., sartorius)

Type V: Dominant pedicle, with secondary segmental pedicle(s) (e.g., latissi

mus dorsi) Second, Taylor developed a system of muscle classification based on mode of innervation.

Type I: Single, unbranched nerve enters muscle (e.g., latissimus dorsi)

Type II: Single nerve, branches prior to entering muscle (e.g., vastus lateralis)

Type III: Multiple branches from the same nerve trunk (e.g., sartorius)

Type IV: Multiple branches from different nerve trunks (e.g., rectus abdominis)

Finally, the body can be further segregated anatomically into three-dimensional vascular territories called “angiosomes.” The angiosome is a composite unit of skin and underlying deep tissue that is supplied by a source artery. Each angiosome defines an anatomic unit of tissue from skin to bone that may be safely transferred as a composite flap. The angiosomes are interconnected by either true anastomotic arteries, in which there is no change in caliber between the vessels of adjacent angiosomes, or reduced-caliber, choke anastomotic vessels. The junctional zone between adjacent angiosomes usually occurs within the muscles of the deep tissues rather than between them, so that most muscles span across two or more angiosomes. Thus, when designing musculocutaneous flaps it is possible to capture the skin island from one angiosome by using muscle supplied from the adjacent angiosome.

Flap delay is defined as the surgical interruption of a portion of the blood supply in a preliminary stage prior to tissue transfer. The purpose of delay is to augment the surviving portion of the flap. There are two schools of thought regarding the pathophysiology of the delay phenomenon. The first holds that delay conditions tissue to ischemic conditions so that it is able to survive with less vascular inflow. The second believes that delay actually increases vascularity by dilating reduced-caliber choke anastomotic vessels and stimulating additional vascular ingrowth.

Another way to increase survival of a myocutaneous flap is by supercharging the blood supply. This method involves augmenting arterial inflow by using microsurgical techniques to bring in an additional vascular pedicle. Classically described for use in a pedicled TRAM flap, the supercharging technique may be performed in one of two ways. First, in the pedicled TRAM flap, the contralateral deep inferior epigastric vessels may be retained in a cuff of inferior rectus muscle in a planned vascular augmentation to a single-pedicle flap. Alternatively, the inferior epigastric vessels on the pedicled side may be used to save a flap during the immediate postoperative period in an emergency “supercharged” TRAM flap.

Techniques of Flap Transfer

The final way to categorize flaps is by the technique of flap transfer. Broadly speaking, flaps can either be pedicled flaps or free flaps. Pedicled flaps remain attached to the underlying blood supply, while the tissue connected to it is transferred to another site. Free flaps are temporarily disconnected from their blood supply, and then the feeding vessels are surgically anastomosed to the blood supply at the recipient site. Flaps can be further categorized by the distance between the donor site and recipient site. Local flapsare used to close defects adjacent to the donor site. Distant flaps imply that the donor site and the recipient site are not in close proximity so that closure cannot be facilitated by a local method.

There are several different types of local flaps. An advancement flap moves along an axis in the same direction as the base to close the defect simply by stretching the skin. Examples of an advancement flap are the V-Y flap, Y-V flap, and the bipedicled flap (. A rotation flap has a curvilinear design and rotates about a pivot point to close a wound defect. The donor site is closed primarily by reapproximating the skin edges or with a skin graft. A back cut in the direction of the pivot point can be made to facilitate closure, but this can also compromise the blood supply to the flap by decreasing the base width. A Burow’s triangle can also be made external to the incision to decrease tension and facilitate primary closure of the donor site . Finally, atransposition flap is a rectangular flap that is rotated laterally about a pivot point into an adjacent defect to be closed. The farther the flap rotates, the shorter the effective length of the flap, so that the flap must be designed longer than the defect in order to close the donor site. Otherwise, the donor site may be closed primarily with a skin graft or with an additional transposition flap, as in a bilobed flap .

There are several important types of transposition flaps. The first is the Z-plasty, in which adjacent triangular flaps are interchanged to exchange the width and length between them. The three limbs of the Z must be equal in length, and the amount of length obtained depends upon the intervening angles, with 60˚ being the classic angle to obtain optimal increase in length while preserving blood supply to the triangular flaps . The rhomboid or Limberg flap is another type of transposition flap that can be used to close a skin defect. Four different flaps can be designed at angles of 60˚, with the longitudinal axis paralleling the line of minimal skin tension . The Dufourmentel flap is like the rhomboid flap, except the angles are at 90˚. Finally, the double opposing semicircular flap can be used to close circular skin defects .

Interpolation flaps also rotate about a pivot point, but they are either tunneled under or passed over intervening tissue to close a defect that is not immediately adjacent to the donor site. Examples include the Littler neurovascular island flap and the pedicled TRAM flap.

Distant flaps involve tissue transfer from one part of the body to another in which the donor site and the recipient site are not in close proximity to each other. There are three types of distant flaps: direct flaps, tubed flaps and free flaps. The direct flap involves the direct transfer of tissue from a donor site to a distant recipient site. Examples of direct flaps include the thenar flap, cross-leg flap and groin flap. Tubed flaps are used when tissue cannot be directly approximated, so that tissue from the donor site is tubed to recipient site. Once the vascular supply has been established, the tube is divided and tissue from the tube is returned to donor site. Examples of this are the forehead flap and the clavicular tubed flap. Finally, free flaps involve complete disconnection of the underlying blood supply, so that the blood vessels from transferred tissue must be surgically reanastomosed to reestablish vascular circulation.

Summary

In sum, the underlying principle of all surgical flaps is the meticulous preservation of blood supply. Unlike grafts, a flap carries its own vascular circulation with it.

The amount and type of tissue that a flap can contain is wholly dependent on the maintenance of adequate blood supply. Knowledge of vascular anatomy is crucial to flap design. Techniques of flap transfer must take care to safeguard the vascular circulation of the flap. With the careful protection of blood supply, it is possible to successfully plan and implement any surgical flap.

Pearls and Pitfalls

The success or failure of a flap is dependent upon blood supply. The ingrowth of new blood vessels from the surrounding tissue occurs over several weeks. As a general rule, the tissue that is most distant from the arterial inflow is at the highest risk of necrosis. Efforts to reduce this risk include the following: (1) preferentially discarding excess tissue from the distant tip; (2) for skin flaps, designing a flap with as broad a base as possible, away from any previous incisions sites; (3) minimizing tension; (4) maximizing inflow.

When designing a flap for covering or filling a defect, it is prudent to follow the carpenter’s rule of “measure twice, cut once.” Defects must be examined and measured three-dimensionally, since the width, depth and length will not always conform to a two-dimensional plane. The final desired contour should also be considered (e.g., if a convex contour is desired, the length of the flap should be greater than the direct length of the defect). Furthermore, it should be determined whether or not moving adjacent structures (such as the arms or legs) will change the dimensions of the defect. For instance, a supraclavicular skin defect will significantly increase in size when the patient’s head is turned away from the defect.