A review of flaps and their uses in reconstructive surgery

M Sivakumar; Devi Prasad Mohapatra

doi:10.4103/JASI.JASI_65_20

REVIEW ARTICLE

Year : 2020 | Volume : 69 | Issue : 2 | Page : 103-109

A review of flaps and their uses in reconstructive surgery

M Sivakumar¹, Devi Prasad Mohapatra²
¹ Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
² Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission	14-Apr-2020
Date of Acceptance	22-May-2020
Date of Web Publication	30-Jun-2020

Correspondence Address:
Dr. Devi Prasad Mohapatra
Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JASI.JASI_65_20

Abstract

The field of reconstructive surgery is rapidly advancing with advances in the techniques of anatomical dissection, understanding of the neurovascular physiology, and improvements in surgical instrumentation. Flaps are composite units of tissue which have their own blood supply or an intact arteriovenous system to receive vascular inflow when transferred to a site of defect. Due to a wide array of flaps being used in reconstructive surgery, numerous terminologies can be found in use by reconstructive surgeons. Skin flaps are flaps that are composed of skin and subcutaneous tissues. Composite flaps are those which contain more than one component within the flap substance, and perforator flaps are those based on a cutaneous perforator. The angiosome concept has aided in understanding the vascular basis of flaps and increases their utility. Further research and insights are needed at the moment to have a finer understanding of the tissue neurovascular anatomy and flap behavior.

Keywords: Flaps, microsurgery, perforators, reconstructive surgery, wound management

How to cite this article:
Sivakumar M, Mohapatra DP. A review of flaps and their uses in reconstructive surgery. J Anat Soc India 2020;69:103-9

How to cite this URL:
Sivakumar M, Mohapatra DP. A review of flaps and their uses in reconstructive surgery. J Anat Soc India [serial online] 2020 [cited 2023 Mar 29];69:103-9. Available from: https://www.jasi.org.in/text.asp?2020/69/2/103/288674

Introduction

The word “flap” is derived from the original 16^th-century Dutch word “flappe” which means anything hanging broad and loose, attached only on one side. In contrast, the word graft is derived from “gryft” which is a horticultural word referring to a piece of shoot inserted into a slit in the stem of another plant to derive nutrition from it. In reconstructive surgery parlance, graft refers to a unit of tissue devoid of its own blood supply when used to reconstruct a defect receives its blood supply from the recipient site. In contrast, flaps are composite units of tissue which have their own blood supply or intact arteriovenous system to receive vascular inflow when transferred to a site of defect.

History of Flaps

The earliest mention of flaps for the restoration of body parts can be traced to 700 BC in the Sushruta Samhita where the sage Sushruta describes the use of the facial tissues in the correction of deformity of the nose. During AD 1440, the use of pedicled forehead flap for the correction of nose deformity in the Indian subcontinent was done routinely. However, it was discovered by two Englishmen and reported in the Madras Gazette and The Gentleman's Magazine as the Indian method of nose reconstruction in 1794.^[1] This led to a resurgence of flap procedures in England as well as Europe.

Tagliacozzi was among the first surgeons in Europe to describe his method of rhinoplasty using the distally based upper arm flap which was published in 1597.^[2] Significant advances in flap surgery were reported by Delpech, Labat Dieffenback, Blasius, and Volkmann in Europe and Mutter in the United States. The introduction of tube pedicled flap was done independently by Filatov, Hugo Ganzer, and Major Harold Delf Gillies during the period from 1916 to 1917.^[3] Further refinement in flap procedures came from the experiences of reconstructive surgeons like Kazanjian, Smith, R H Ivy, Sheehan, Bunnell, and Sir Harold Gillies during World War I.^[4]

In 1882, Theodore Dunham of New York reported the two-stage island pedicled flap for the reconstruction of a defect following excision of a large epidermoid cancer of the cheek and eyelid where the vascular pedicle of the flap based on the superficial temporal artery was dissected out and buried in the skin of the cheek.^[5]

Jacques Joseph, in 1931, described the vascular pattern of the deltopectoral flap which was later popularized by V Y Bakamjian, in 1965.^[6]

With further understanding of flap anatomy and physiology, numerous refinements came into the flap design. McGregor and Jackson in 1972 published a landmark paper on the groin flap based on the superficial circumflex iliac artery and introduced the terms axial and random pattern flaps.^[7]

Tanzini, in 1906, introduced the latissimus dorsi muscle flap for the first time, however the detailed anatomy of the latissimus dorsi musculocutaneous flap and axial flap of the skin from the same area was explained by Professor Steffanod'este in 1912.^[8] Over the course of the next 50 years, further understanding of the vascular anatomy of muscle led to refinements in the type and usage of such flaps. By the turn of the century with the advent of the operating microscope, vascular repair techniques of Carell, and the development of microvascular instruments and sutures, an era of free tissue transfer began. The flaps which were up till now tethered to the donor sites could be transferred to the distant sites along with their vessels and nerves. The first report of free flap was the free groin flap by Kaplan et al. in 1971 for an intraoral defect.^[9]

Harii et al., in 1976, reported the use of free gracilis muscle flap with microvascular and microneurotization techniques for the reanimation of facial paralysis.^[10] With this, started an era of functional muscle transfers which has become an important technique of reconstruction in the armamentarium of plastic surgeons today.

In 1994, Taylor et al. published a seminal work on the vascular territories of the skin which was based on preliminary work of Salmon and Manchot. Taylor introduced the concept of “Angiosome” which formed the foundation for more refinements in flap surgery.^[11]

Classification of Flaps

There is no system that can classify all the types of flaps considering that a wide variety of flaps that can be used in reconstructive surgery exist. However, authors have designed comprehensive classification systems which can broadly categorize these flaps. Tolhurst designed an atomic system [Table 1] of flaps wherein he included composition characteristics of flaps.^[12] In contrast, Cormack and Lamberty gave a comprehensive flap classification [Table 2], including the composition as well as circulation characteristics.^[13] As the understanding of vascular basis and anatomy of flaps improved, authors started suggesting flap classification schemes based on vascular supply [Table 3].

Table 1: Tolhurst “atomic” classification of flaps

Click here to view

Table 2: Cormack and Lamberty's 6 C's of flap designbased classification.

Click here to view

Table 3: Different approaches to flap classification

Click here to view

Terminology of Flaps

Due to a wide array of flaps being used in reconstructive surgery, numerous terminologies can be found in use by reconstructive surgeons. Central to utility of any flap is the vascular supply. Random pattern flaps are flaps perfused by dermal vascular plexus without any known vascular pedicle. In contrast, axial pattern flaps are flaps which are raised based on a known vascular axis. Pedicled flaps are those which are transferred to a defect with the vascular supply still attached to the donor site. The attachment which is known as a pedicle may contain skin and subcutaneous tissue, only subcutaneous tissue, or just the arteriovenous axis within it. In contrast, free flaps are separated from the donor site and transferred to the defect to be reconstructed along with the arteriovenous structures. These are then sutured to the arteriovenous structures on the recipient site using microvascular suture techniques. When a flap is used to cover a defect adjacent to it, it is termed as a local flap; when the flap is used to cover a defect in the same anatomical region, it is termed as regional flap. Distant flaps are referred to flaps which are used to cover defects away from the donor site. Local flaps may be transferred to the defect by advancing the flap when they are known as advancement flaps. If the flaps move to the defect in a sideward manner, these will be called as transposition flaps. Frequently, local flaps may move to the defect to be covered by rotating along an arc, when they will be termed as rotation flaps [Figure 1]. Geometric flaps are random pattern local flaps which are generally based on dermal vascular plexus and marked according to geometric shapes. Examples include bilobed flap, rhomboid (Limberg) flaps [Figure 2], VY flaps, etc., If the movement of the flap to an adjacent defect involves the movement under an intact bridge of the skin between the flap donor site and the recipient site, they are known as islanded flaps. Propeller flaps [Figure 3] are a variety of local flaps that are pedicled on an arteriovenous system, designed like a propeller blade, and can be rotated at 180° to cover an adjacent defect.^[14],[15]

Figure 1: Rotation flap to cover a forehead defect

Click here to view

Figure 2: Rhomboid flap used to cover a defect in the sacral region

Click here to view

Figure 3: Propeller flap rotated 180° to cover an adjacent defect over the leg. Note the flap supported by a vascular pedicle

Click here to view

Skin flaps are flaps that are composed of skin and subcutaneous tissues, whereas fasciocutaneous flaps include deep fascia also in the flap composition. The inclusion of deep fascia improves the vascularity and survival of these flaps by incorporating the facial vascular plexus within it. Flaps composed of muscle and its blood supply are termed as muscle flaps. Compound flaps are those that incorporate diverse tissue components into one interrelated unit. These may be composite or combined flaps [Figure 4].

Figure 4: A pectoralis major myocutaneous pedicled flap used to cover a defect created after excision of a buccal carcinoma

Click here to view

Composite flaps are those which contain more than one component within the flap substance as, for example, musculocutaneous flaps, osteocutaneous flaps, and neurocutaneous flaps and depend on a solitary source of vascular supply for the survival of all components. Combined flaps have multiple tissue components supplied by multiple source vessels. These may be conjoined, multiple flaps which have physical continuity but each perfused by their own vascular axis or chimeric, multiple flaps without physical continuity perfused by their own vascular axis, but the vascular axis is connected with a common source mother vessel.^[16],[17]

Perforator flaps are those based on a cutaneous perforator (direct, septocutaneous, or musculocutaneous). Angiosomes are three-dimensional blocks of tissue, including skin and deeper tissue layers that are supplied by specific source arteries.^[18],[19]

Visceral structures along with their blood supply, for example, ileal flaps, colonic flaps, and omental flaps are termed visceral flaps.

Uses of flaps

”… losses must be replaced in kind--bone for bone, cartilage for cartilage, and skin for skin “

Harold DelfGillies, 1917.^[20]

The overarching goal of all reconstructive surgeons is to restore the anatomy as close to normal as possible. This has led to the discovery of new vascular territories, innovative flap designs, and efficient surgical techniques. The principles of reconstruction were governed for a long time by what is known as a reconstruction ladder. Reconstruction was planned in a gradual manner depending on the complexity of the defect and tissues lost. This was later modified into a reconstruction elevator where the most suitable option was selected irrespective of the complexity of defect [Figure 5].^[21]

Figure 5: Choosing a suitable reconstruction based on the complexity of the wound

Click here to view

More recently, reconstruction principles are based on the reconstructive triangle where ideal reconstruction technique depends on providing optimal form and function with maximum safety.^[22]

Geometric flaps are used for coverage of small-to-medium size defects, for example, defects following excision of basal cell cancer of the cheek or forehead. Bigger size defects as in cases of traumatic soft-tissue losses of the scalp or limbs are covered by pedicle flaps, notably transposition or rotation flaps. Complex defects with loss of multiple tissue components such as bone, muscle, and skin are better reconstructed with osteocutaneous flaps using microvascular techniques.^{[23],[24],[25]}

Flap dimensions are planned according to the measurement of the cutaneous defect. In case of pedicled flaps, the reach of the flap should be measured in addition to flap dimensions [Figure 6]. Special situations demand special flaps as in case of osteomyelitis of tibia following trauma; a well-vascularized muscle flap with graft will help in controlling infection faster by increasing blood flow to tissues. Lymphedema control of the lower limbs can be achieved with vascularized lymph node transfer which involves the transfer of flaps containing lymph nodes such as the submental or supraclavicular flaps.^[26] Vascularized joint transfers are utilized to restore joint anatomy and function in the hands.^[27],[28] Visceral flaps are utilized for the restoration of the esophageal, larynx, urethral or vaginal anatomy, etc.^[29],[30] More recently, perforator-based free flaps with their innate ability to cover any kind of defects are being used extensively in reconstruction.^[31] Improvement in microsurgical instrumentations has led to a widespread adoption of perforator flaps in reconstructive practice.^[32]

Figure 6: Flap planning is done using a lint piece to estimate the amount of flap required to cover a defect. Here, a reverse sural artery flap is used to cover a defect of the foot

Click here to view

Dynamic muscle transfers are done to restore function to a specific part as, for example, eyelid closure in facial nerve palsy using the temporalis muscle flap. Function can be also achieved using free functioning muscle transfers as done for severe crush injuries of the limb where gracilis muscle transfer with nerve cooptation is done to achieve finger flexion in cases of nerve injuries of the upper limb.^[33]

Conclusion

The field of reconstructive surgery is rapidly advancing with advances in techniques of anatomy, understanding of the neurovascular physiology, and surgical instrumentation. More refinements are being carried out at a regular basis to provide the most optimal form and function. Further research and insights are needed at the moment to have a finer understanding of tissue neurovascular anatomy and flap behavior, using newer anatomical and imaging techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Carpue JC. An account of two Successful Operations for Restoring a Lost Nose from the Integuments of the Forehead. Birmingham AL, London: Classics of Medicine Library; 1816.
2.	Tagliacozzi G. De Curtorumchirurgia per Institione. Venice: Gaspare Bindoni; 1597.
3.	Tolhurst DE, Haeseker B, Zeeman RJ. The development of the fasciocutaneous flap and its clinical applications. Plast Reconstr Surg 1983;71:597-606.
4.	Gillies HD. Plastic Surgery of the Face. London: Frowde; 1920. p. 364.
5.	Dunham TV. A method for obtaining a skin-flap from the scalp and a permanent buried vascular pedicle for covering defects of the face. Ann Surg 1893;17:677-9.
6.	Bakamjian VY. A two stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plastic and Reconstructive Surgery. 1965;36:173.
7.	McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
8.	Tansini. I. Sopra il mio nuovo processo di amputazione della mamella. (Coverage of the anterior chest wall following mastectomy). Gazz Med Ital 1906;57:141.
9.	Kaplan EN, Buncke HJ, Murray DE. Distant transfer of cutaneous island flaps in humans by microvascular anastomoses. Plast Reconstr Surg 1973;52:301-5.
10.	Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation with microvascular anastomoses for treatment of facial paralysis. Plast Reconstr Surg 1976;57:133.
11.	Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories of the skin and muscles: Anatomic study and clinical implications. Plast Reconstr Surg 1994;94:1-36.
12.	Tolhurst DE. A comprehensive classification of flaps: The atomic system. Plast Reconstr Surg 1987;80:608-9.
13.	Cormack GC, Lamberty BG. Alternative Flap Nomenclature and Classification, the Arterial Anatomy of Skin Flaps. 2^nd ed. Edinburgh: Churchill Livingstone; 1994. p. 514-22.
14.	Ayestaray B, Ogawa R, Ono S, Hyakusoku H. Propeller flaps: Classification and clinical applications. Ann Chir Plast Esthet 2011;56:90-8.
15.	Teo TC. The propeller flap concept. Clin Plast Surg 2010;37:615-26, vi.
16.	Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: An introduction to the chimera flap principle. Ann Plast Surg 1991;27:126-31.
17.	Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: An introduction to the chimeric flap principle. Plast Reconstr Surg 1993;92:411-20.
18.	Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: Experimental study and clinical applications. Br J Plast Surg 1987;40:113-41.
19.	Taylor GI, Palmer JH, McManamny D. The vascular territories of the body (angiosomes) and their clinical applications. In: McCarthy JG, editor. Plastic Surgery. Vol. 1. Philadelphia: WB Saunders; 1990. p. 329-78.
20.	FitzGibbon GM. The commandments of Gillies. Br J Plast Surg 1968;21:226-39.
21.	Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994;93:1503-4.
22.	Neligan PC. Plastic Surgery. 4^th ed. London. Elsevier; 2018.
23.	Hidalgo DA. Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71-9.
24.	Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994;93:294-304.
25.	Lin PY, Lin KC, Jeng SF. Oromandibular reconstruction: The history, operative options and strategies, and our experience. ISRN Surg 2011;2011:824251.
26.	Schaverien MV, Badash I, Patel KM, Selber JC, Cheng MH. Vascularized lymph node transfer for lymphedema. Semin Plast Surg 2018;32:28-35.
27.	Dautel G. Vascularized toe joint transfers to the hand for PIP or MCP reconstruction. Hand Surg Rehabil 2018;37:329-36.
28.	Foucher G, Lenoble E, Smith D. Free and island vascularized joint transfer for proximal interphalangeal reconstruction: A series of 27 cases. J Hand Surg Am 1994;19:8-16.
29.	Chen HC, Chana JS, Feng GM. A new method for vaginal reconstruction using a pedicled jejunal flap. Ann Plast Surg 2003;51:429-31.
30.	Wei FC, Cheng HY, Lin CH. Translational research in Biomedicine: From Auto- to Allotransplantation. Vol. 5. Basel: Karger; 2016. p. 23-35.
31.	Kim JT, Kim SW. Perforator flap versus conventional flap. J Korean Med Sci 2015;30:514-22.
32.	Abdelfattah U, Power HA, Song S, Min K, Suh HP, Hong JP. Algorithm for free perforator flap selection in lower extremity reconstruction based on 563 cases. Plast Reconstr Surg 2019;144:1202-13.
33.	Venkatramani H, Bhardwaj P, Sabapathy SR. Role of free functioning muscle transfer in improving the functional outcomes following replantation of crush avulsion amputations of the forearm. Injury 2019;50 Suppl 5:S105-10.