Flap surgery is a technique in
plastic
Plastics are a wide range of synthetic or semi-synthetic materials that use polymers as a main ingredient. Their plasticity makes it possible for plastics to be moulded, extruded or pressed into solid objects of various shapes. This adaptab ...
and
reconstructive surgery
Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition.
Description
Reconstructive surgery is a term with training, clinical, and reimbursement implica ...
where any type of
tissue is lifted from a donor site and moved to a recipient site with an intact
blood supply
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
. This is distinct from a
graft
Graft or grafting may refer to:
*Graft (politics), a form of political corruption
* Graft, Netherlands, a village in the municipality of Graft-De Rijp
Science and technology
*Graft (surgery), a surgical procedure
*Grafting, the joining of plant t ...
, which does not have an intact blood supply and therefore relies on growth of new blood vessels. This is done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures such as breast or jaw.
Uses
Flap surgery is a technique essential to
plastic
Plastics are a wide range of synthetic or semi-synthetic materials that use polymers as a main ingredient. Their plasticity makes it possible for plastics to be moulded, extruded or pressed into solid objects of various shapes. This adaptab ...
and
reconstructive Surgery
Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition.
Description
Reconstructive surgery is a term with training, clinical, and reimbursement implica ...
. A flap is defined as a
tissue that can be moved to another site and has its own
blood supply
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
. This is in comparison to a
skin graft
Skin grafting, a type of graft (surgery), graft surgery, involves the organ transplant, transplantation of skin. The transplanted biological tissue, tissue is called a skin graft.
Surgeons may use skin grafting to treat:
* extensive wounding o ...
which does not have its own blood supply and relies on
vascularization
Angiogenesis is the physiological process through which new blood vessels form from pre-existing vessels, formed in the earlier stage of vasculogenesis. Angiogenesis continues the growth of the vasculature by processes of sprouting and splitting ...
from the recipient site.
Flaps have many uses in
wound healing
Wound healing refers to a living organism's replacement of destroyed or damaged tissue by newly produced tissue.
In undamaged skin, the epidermis (surface, epithelial layer) and dermis (deeper, connective layer) form a protective barrier again ...
and are used when wounds are large, complex, or need tissue and bulk for successful closure.
Common uses:
* Abdominal wall reconstruction
*
Breast reconstruction
Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both wit ...
*
Hand reconstruction
*
Mandible reconstruction
*
Rhinoplasty
Rhinoplasty ( grc, ῥίς, rhī́s, nose + grc, πλάσσειν, plássein, to shape), commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two typ ...
*
Scar
A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a na ...
revision
*
Skin cancer
Skin cancers are cancers that arise from the skin. They are due to the development of abnormal cells that have the ability to invade or spread to other parts of the body. There are three main types of skin cancers: basal-cell skin cancer (BCC) ...
Anatomy
Anatomy of a flap
"Plastic surgery is a constant battle between blood supply and beauty." -
Sir Harold Gillies
Flaps can contain many different combination of layers of tissue, from skin to bone (see
classification section). The main goal of a flap is to maintain blood flow to tissue to maintain survival and understanding the anatomy in flap design is key to a successful flap and surgery.
Skin anatomy
Flaps may include skin in their construction. Skin is important for many reasons, but namely its role in
thermoregulation
Thermoregulation is the ability of an organism to keep its body temperature within certain boundaries, even when the surrounding temperature is very different. A thermoconforming organism, by contrast, simply adopts the surrounding temperature ...
,
immune function
The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as cancer cells and objects such as wood splinte ...
, and blood supply aid in flap survival.
The skin can be divided into three main layers including the
epidermis
The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and hypodermis. The epidermis layer provides a barrier to infection from environmental pathogens and regulates the amount of water rele ...
, the
dermis
The dermis or corium is a layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided i ...
, and the
subcutaneous tissue
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and macr ...
. Blood is supplied to the skin mainly by two networks of blood vessels. The deep network lies between the dermis and the
subcutaneous tissue
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and macr ...
, while the shallow network lies within the papillary layer of the dermis.
The epidermis is supplied by diffusion from this shallow network and both networks are supplied by
collaterals, and by perforating arteries that bring blood from deeper layers either between muscles (septocutaneous perforators) or through muscles (musculocutaneous perforators).
This robust and redundant blood supply is important in flap surgery.
This is important because flaps rely on named blood vessels and redundancy in blood supply since the flap will be cut off from other blood vessels when the flap is raised and removed from its surrounding native tissue.
The remaining blood supply must then keep the tissue alive until additional blood supply can be formed through a process called
angiogenesis
Angiogenesis is the physiological process through which new blood vessels form from pre-existing vessels, formed in the earlier stage of vasculogenesis. Angiogenesis continues the growth of the vasculature by processes of sprouting and splitting ...
.
Angiosome
The
angiosome is a concept first coined by Ian Taylor in 1987.
An
angiosome is a three-dimensional region of tissue that is supplied by a single artery and can include skin, soft tissue, and bone.
Adjacent angiosomes are connected by narrower choke vessels and so multiple angiosomes can be supplied by a single artery. Knowledge of these supply arteries and their associated angiosomes is useful in planning the location, size, and shape of a flap.
Classification
Flaps can be fundamentally classified by their mechanism of movement, the types of tissues present, or by their blood supply.
The surgeon should choose the least complex type that will achieve the desired effect, a concept known as the
reconstructive ladder.
Mechanism of movement
Local flaps
* Local flaps are created by freeing a layer of tissue and then stretching the freed layer to fill a defect. This is the least complex type of flap and includes advancement flaps, rotation flaps, and transposition flaps, in order from least to most complex. With an advancement flap, incisions are extended out parallel from the wound, creating a rectangle with one edge remaining intact. This rectangle is freed from the deeper tissues and then stretched (or ''advanced'') forward to cover the wound. The flap is disconnected from the body except for the uncut edge which contains the blood supply which feeds in horizontally. A rotation flap is similar except instead of being stretched in a straight line, the flap is stretched in an arc. The more complex transposition flap involves rotating an adjacent piece of tissue, resulting in the creation of a new defect that must then be closed.
Regional flaps
* Regional or interpolation flaps are not immediately adjacent to the defect. Instead, the freed tissue "island" is moved over or underneath normal tissue to reach the defect to be filled, with the blood supply still connected to the donor site via a pedicle.
This pedicle can be removed later on after new blood supply has formed. Examples: pectoralis major myocutaneous (PMMC) flap and deltopectoral (DP) flap for head and neck defects, and latissimus dorsi (LD) flap and traverse rectus abdominal muscle (TRAM) flap for breast reconstruction.
Distant flaps
* Distant flaps are used when the donor site is far from the defect. These are the most complex class of flap. Direct or tubed flaps involve having the flap connected to both the donor and recipient sites simultaneously, forming a bridge. This allows blood to be supplied by the donor site while a new blood supply from the recipient site is formed. Once this happens, the "bridge" can be disconnected from the donor site if necessary, completing the transfer.
A
free flap has the blood supply cut and then reattached
microsurgically to a new blood supply at the recipient site.
Tissue type
Flaps can be classified by the content of the tissue within them.
Cutaneous
* Contain the full thickness of the skin, fat, and superficial fascia and are used to fill small defects. These are typically supplied by a random blood supply. Examples:
Z-plasty
Z-plasty is a versatile plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision (the central ele ...
,
deep inferior epigastric perforator (DIEP) flap, V-Y advancement flap.
Fasciocutaneous
* Contain subcutaneous tissue and deep fascia, resulting in a more robust blood supply and ability to fill a larger defect. Cormack and Lamberty classification is used for vascular supply of faciocutaneous flaps.
Examples: temporoparietal and anterolateral thigh fascocutaneous flap, lateral fasciocutaneous flap, posterior fasciocutaneous flap.
Musculocutaneous and muscle flaps
* Contain a layer of
muscle
Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...
to provide bulk that can fill a deeper defect. If skin cover is needed, a
skin graft
Skin grafting, a type of graft (surgery), graft surgery, involves the organ transplant, transplantation of skin. The transplanted biological tissue, tissue is called a skin graft.
Surgeons may use skin grafting to treat:
* extensive wounding o ...
can be placed over top of it. Examples:
gastrocnemius
The gastrocnemius muscle (plural ''gastrocnemii'') is a superficial two-headed muscle that is in the back part of the lower leg of humans. It runs from its two heads just above the knee to the heel, a three joint muscle (knee, ankle and subtalar ...
flap,
latissimus dorsi
The latissimus dorsi () is a large, flat muscle on the back that stretches to the sides, behind the arm, and is partly covered by the trapezius on the back near the midline. The word latissimus dorsi (plural: ''latissimi dorsorum'') comes from L ...
flap,
transverse rectus abdominis myocutaneous (TRAM) flap,
transverse upper gracillis (TUG) flap.
Bone
* Contain bone and are used when structural support is needed such as in jaw reconstruction. Example: fibula flap.
Omental and Intestinal
*Omental flaps can be used in chest wall defects and intestinal flaps can be used to reconstruct tubular structures like the esophagus.
Vascular supply
Classification based on blood supply to the flap:
Axial vs random
* Axial flaps are supplied by a named artery and vein. This allows for a larger area to be freed from surrounding and underlying tissue, leaving only a small pedicle containing the vessels.
Reverse-flow flaps are a type of axial flap in which the supply artery is cut on one end and blood is supplied by backwards flow from the other direction. Random flaps are simpler and have no named blood supply. Rather, they are supplied by generic vascular networks.
Pedicled vs free
* Pedicled flaps remain attached to the donor site via a pedicle that contains the blood supply, in contrast to a free flap which the vessels are cut and
anastomosed to another blood supply.
Contraindications
Anyone who is unstable for surgery should not undergo flap surgery. While not absolute contraindications for flap surgery, there are a few
contraindications
In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...
to know. As with most surgeries, people who are sicker may have more difficulties with
wound healing
Wound healing refers to a living organism's replacement of destroyed or damaged tissue by newly produced tissue.
In undamaged skin, the epidermis (surface, epithelial layer) and dermis (deeper, connective layer) form a protective barrier again ...
. This includes people with
comorbidities
In medicine, comorbidity - from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together) - is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary ...
such as
diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
,
smoking
Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have bee ...
,
immunosuppression
Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse react ...
, and
vascular disease
Vascular disease is a class of diseases of the blood vessels – the arteries and veins of the circulatory system of the body. Vascular disease is a subgroup of cardiovascular disease. Disorders in this vast network of blood vessels can cause a ra ...
.
Risks or complications
The risks of flap surgery include infection and
wound breakdown,
fluid accumulation,
bleeding
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
, damage to nearby structures, and
scarring
A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a na ...
.
The most notable risk in this procedure is flap death, where the flap loses blood supply. The loss of blood can be due to many reasons, but is commonly due to tension on the vascular supply and not enough blood flow to the end segments of the flap.
This can sometimes be fixed with another surgery or using additional methods of healing in the
reconstructive ladder.
Recovery
As with healing of any wound, healing of a flap maintains the same process
wound healing
Wound healing refers to a living organism's replacement of destroyed or damaged tissue by newly produced tissue.
In undamaged skin, the epidermis (surface, epithelial layer) and dermis (deeper, connective layer) form a protective barrier again ...
. There are four stages to wound healing:
hemostasis
In biology, hemostasis or haemostasis is a process to prevent and stop bleeding, meaning to keep blood within a damaged blood vessel (the opposite of hemostasis is hemorrhage). It is the first stage of wound healing. This involves coagulation, whi ...
,
inflammation
Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
,
proliferation, and
remodeling
Renovation (also called remodeling) is the process of improving broken, damaged, or outdated structures. Renovations are typically done on either commercial or residential buildings. Additionally, renovation can refer to making something new, ...
which can take up to a year to complete.
Following flap surgery, the biggest risk in recovery is flap death. Flap failure is an uncommon occurrence but does happen. The reported flap failure rate in free flaps is less than 5%.
The most commonly cause is by venous insufficiency consisting of 54% of all causes.
Venous insufficiency is commonly caused by a
venous thrombus within the first 2 days following surgery.
After the immediate postoperative risk, the flap will continue to heal adhering to the stages of normal wound healing and will take over 3 months for an incision to be at 80% tensile strength compared to normal tissue.
History
Skin flaps are an essential part of a surgeon’s toolbox in
Plastic Surgery
Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofa ...
. It is part of the
reconstructive ladder, a stepwise approach to wound closure.
The first known reports of surgical flaps originated in 600 BCE in India by
Sushruta
Sushruta, or ''Suśruta'' (Sanskrit: सुश्रुत, IAST: , ) was an ancient Indian physician. The ''Sushruta Samhita'' (''Sushruta's Compendium''), a treatise ascribed to him, is one of the most important surviving ancient treatises on ...
where the Tilemakers caste would reconstruct noses using regional flaps due to the practice of nose amputations as a form of legal punishment.
The next description of flap surgery comes from Celsus an ancient Roman who described advancement skin flaps from 25 BC to 50 AD.
In the 15th century,
Gaspare Tagliacozzi
Gaspare Tagliacozzi (his last name has also been spelled Taliacotius, Tagliacoze or Tagliacozzio; Bologna, March 1545 – Bologna, 7 November 1599) was an Italian surgeon, pioneer of plastic and reconstructive surgery.
Biography
Tagliacozzi ...
an Italian surgeon helped develop the “Italian Method” for nasal reconstruction, a delayed pedicle skin graft, where the skin from the arm would be attached to the nose for many months to create the reconstruction, first printed in the 1597 book ''De Curtorum Chirurgia per Insitionem''.
The Italian method was rediscovered in 1800 by German surgeon
Carl Ferdinand von Graefe Carl may refer to:
*Carl, Georgia, city in USA
*Carl, West Virginia, an unincorporated community
*Carl (name), includes info about the name, variations of the name, and a list of people with the name
*Carl², a TV series
* "Carl", List of Aqua Teen ...
.
Major advancements in modern Plastic Surgery are mostly attributed to
Harold Gilles who pioneered facial reconstruction during World War I using pedicled tube flaps on patients such as
Walter Yeo and the development of the
walking-stalk skin flap by Gilles' cousin
Archibald McIndoe
Sir Archibald Hector McIndoe (4 May 1900 – 11 April 1960) was a New Zealand plastic surgeon who worked for the Royal Air Force during the Second World War. He improved the treatment and rehabilitation of badly burned aircrew.
Early life
Archi ...
in 1930.
Advancements continued in flap surgery. With the introduction of the
Operating Microscope
An operating microscope or surgical microscope is an optical microscope specifically designed to be used in a surgical setting, typically to perform microsurgery.
Design features of an operating microscope are: magnification typically in the ran ...
Microvascular surgery advancements allowed for the
anastomosis
An anastomosis (, plural anastomoses) is a connection or opening between two things (especially cavities or passages) that are normally diverging or branching, such as between blood vessels, leaf#Veins, leaf veins, or streams. Such a connection m ...
of blood vessels.
This led to the ability of free tissue transfers and in 1958 Bernard Seidenberg transferred a part of the
jejunum
The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialised for the absorption by enterocytes of small nutrient molecules which have been previous ...
to the
esophagus
The esophagus (American English) or oesophagus (British English; both ), non-technically known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the ...
to remove a
cancer
Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...
of the esophagus.
Modern advancements in flap surgeries have continued since this time and are now commonly used in many procedures.
See also
*
Breast reconstruction
Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both wit ...
*
DIEP flap
A DIEP flap is a type of breast reconstruction in which blood vessels called deep inferior epigastric perforators (DIEP), as well as the skin and fat connected to them, are removed from the lower abdomen and transferred to the chest to reconstruct ...
*
Hand reconstruction
*
List of plastic surgery flaps
*
Plastic surgery
Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofa ...
*
Perforator flaps
*
Mandible reconstruction
*
Rhinoplasty
Rhinoplasty ( grc, ῥίς, rhī́s, nose + grc, πλάσσειν, plássein, to shape), commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two typ ...
*
Rotation flap
*
Skin cancer
Skin cancers are cancers that arise from the skin. They are due to the development of abnormal cells that have the ability to invade or spread to other parts of the body. There are three main types of skin cancers: basal-cell skin cancer (BCC) ...
*
TRAM flap
*
z-plasty
Z-plasty is a versatile plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision (the central ele ...
References
External links
Flap surgeryat
eMedicine
eMedicine is an online clinical medical knowledge base founded in 1996 by doctors Scott Plantz and Jonathan Adler, and computer engineer Jeffrey Berezin. The eMedicine website consists of approximately 6,800 medical topic review articles, each of ...
{{Authority control
Oral and maxillofacial surgery
Plastic surgery
Surgical procedures and techniques