# Flaps

Flaps

A flap is a block of  tissue that contains an innate blood supply that may be transferred from a donor site to reconstruct a secondary defect; the pedicle is the ‘base’ of  the flap that contains the blood supply . Unlike a graft, a flap can therefore be used to reconstruct a defect that does not have a vascu larised wound bed, such as exposed tendon, cortical bone or a prosthesis. There are numerous methods of  classifying flaps: according to their blood supply , their proximity to the defect, the method by which they ar e transferred and the tissue that they contain. The five Cs methodology is a useful flap classification system based on their circulation, composition, contiguity , contour and conditioning ( Figure 47.12 ). 1 Circulation : random pattern flaps have no dominant blood supply whereas axial flaps have a dominant feeding vessel. 2 Composition : cutaneous, fasciocutaneous, fascial, musculocutaneous, muscle, osseocutaneous, osseous, omentum/bowel. 3 Contiguity : local (where the flap shares a side with the defect) ( Figure 47.13 ), regional (where the flap is near but not immediately adjacent to the defect) ( Figures 47.14 and 47.15 ) and distant (where the flap is far from the defect and can be either pedicled or free) ( Figures 47.16 and 47.17 ). Sydney Reese Coleman , contemporary , plastic surgeon, New Y ork, NY , USA. George Carl Cormack , contemporary , plastic surgeon, Cambridge, UK. Byrom George Harker Lamberty , contemporary , plastic surgeon, Cambridge, UK. Bengt Pontén , 1923–2007, Associate Professor of  Plastic Surgery , Uppsala University , Uppsala , Sweden. Stephen John Mathes , 1943–2007, Professor of  Surgery , University of  California, San Francisco, CA, USA. Foad Nahai , contemporary , Professor of  Surgery , Emory University , Atlanta, GA, USA. into the defect – advancement ( Figures 47.18 and 47.19 ), transposition ( Figure 47.20 ), rotation ( Figure 47.21 ), interpolation, waltzing, crane principle and free. 5 Conditioning : whether the flap is delayed by partially elevating and resetting the flap prior to definitive elevation and transfer. Delay enables a larger flap to be harvested by - improving its blood supply . - Fasciocutaneous flaps comprise a fascial component that augments the flap blood supply owing to a network of  sub - fascial, fascial and suprafascial vessels. Fasciocutaneous flaps may be classified according to Cormack and Lamberty (1984) ( Figure 47.22 ): /uni25CF Type A: multiple perforators that can be direct or indirect (e.g. Pontén flap). /uni25CF Type B: single perforator that is usually direct and runs along the axis of  the flap (e.g. the scapular or parascapular flaps). /uni25CF Type C: segmental perforators that arise from the same source vessel (e.g. the radial forearm and lateral arm flaps) ( Figure 47.23 ). /uni25CF Type D: similar to type C; however, the flap is raised as an osteomyofasciocutaneous flap (e.g. the free fibular flap). In muscle and musculocutaneous flaps the motor nerve is always accompanied by a vascular pedicle, which is often the major source of  the flap circulation. A dominant pedicle can sustain an entire muscle whereas a minor pedicle can nor - mally only sustain a portion of  the flap. T he skin in a musculo - cutaneous flap is supplied by perforators. Muscle flaps are - classified by Mathes and Nahai (1981) ( Figure 47.24 ): /uni25CF Type I: single vascular pedicle (e.g. tensor fascia lata and gastrocnemius). /uni25CF Type II: one dominant pedicle with one or more minor pedicles (e.g. gracilis, biceps femoris, sternocleidomastoid, soleus and trapezius); the flap cannot survive on the minor pedicle(s) alone. /uni25CF Type III: dual dominant pedicles (e.g. gluteus maximus, pectoralis minor, rectus abdominis, serratus anterior and temporalis). /uni25CF Type IV: segmental pedicles (e.g. flexor hallucis longus, sar - torius and tibialis anterior). /uni25CF Type V: dominant pedicle with several smaller segmen - tal pedicles (e.g. latissimus dorsi and pectoralis major) ( Figures 47.25 and 47.26 ); the flap can survive on the minor pedicles alone. A chimeric flap consists of  multiple otherwise spatially independent flaps, each of  which has an independent vascular supply , with all pedicles linked to a common source vessel. For example, the descending branch of  the lateral femoral 

TRANSPOSITION FLAP
Donor
defect
(grafted or
sometimes
closed
Defect
primarily)
Pivot
point
(b)
BILOBED FLAP
Uses a
/f_l
ap to close a convex defect, and a second smaller
/f_l
ap
to close the donor site
Secondary
ap
Flap
(c)
RHOMBOID
Tissue
FLAP
defect
a´
a´ a
A parallelogram-
shaped
transposition
Flap
/f_l
ap
a
Figure 47.12
Local
/f_l
ap diagrams.
(a)
Transposition and Z-plasty
/f_l
aps.
(b)
Bilobed and bipedicled
/f_l
aps.
(c)
Rhomboid and rotation
/f_l
aps. (
continued overleaf
)
Z-PLASTY
Tw
o triangular transposition
/f_l
aps interposed
1
23
B
A
A
B
B
A
45
6
B
B
B
A
A
A
BIPEDICLE FLAP
A ‘bucket-handle’
/f_l
ap supplied from both ends.
Useful to rebuild the lower eyelid
Flap
RO
TA
TION FLAP
a
a b
b



A
DVANCEMENT FLAP
ectangular
Simple r
(with or without Bur
ow
’s
triangle excision at base)
Defect
Tw
o Bu
ro
w’s
triangles can
be excised at
base of
/f_l
ap to
make it slide
V to Y
e.g.
cut
/f_i
ngertip
Flap
(e)
2
1
Mark a long
Bu
rn
scar
zig-zag along
with long
the scar
ellipse
around it
5
4
The cut lines
The
/f_i
nished wound
will look
will look something
something like
like this
this
each becomes
Pad it well, and be
a
a´
Advance the
sure to splint open
b´
b
tips of the
when not exercising
zig-zags into
the spaces
Y to V
Usually multiple
Area of
to r
elease band
scar
scars over joint
s
shaded
This is one of the
fective
most ef
means of r
eleasing
moderate isolated
band bur
n scars
over
/f_l
exion cr
eases
3
Add in the
horizontal
lines to the
zig-zag;
a´
each becomes
a
b´
a ‘Y’
b
Figure 47.12
(
continued
) Local
/f_l
ap diagrams.
(d)
Advancement
/f_l
aps.
(e)
Multiple Y-to-V plasty for burn scar.



Figure 47.13
Bilobed
/f_l
ap reconstruction of a nasal defect following excision of a basal cell carcinoma.
raised.
(c)
Transposition of bilobed
/f_l
ap.
(d)
Immediate postoperative appearance.
(a)
(b)
Figure 47.14
Forehead
/f_l
ap reconstruction of nasal defect following excision of multiple basal cell carcinomas.
demonstrating the forehead
/f_l
ap based on the right supratrochlear artery. The pedicle position is con
/f_i
rmed using a hand-held Doppler probe.
/uni00A0
(b)
Flap inset to nose – note the bulky pedicle at the right medial eyebrow; donor site closed primarily except at the widest point, where it is
allowed to heal by secondary intention.
(c)
The
/f_l
ap pedicle was divided at a second stage, allowing contouring of the
/f_l
ap. Appearance at
6
/uni00A0
months.
(a)
Excision markings.
(b)
Bilobed
/f_l
ap
(c)
(a)
Preoperative markings



(e)
(f)
(a)
(b)
(d)
Figure 47.16
The medial sural artery perforator (MSAP)
/f_l
ap can be used as a pedicled
/f_l
ap for regional defects or as a free
/f_l
ap for distant
defects.
(a)
Traumatic defect of the anterior knee with a partially transected patellar ligament and cortical loss of the tibial tuberosity following
wound debridement.
(b, c)
The MSAP
/f_l
ap is harvested – the perforator (arrow) is identi
/f_i
ed arising from the substance of the gastrocnemius
muscle belly.
(d, e)
The
/f_l
ap remains attached to a pedicle and is transferred through a subcutaneous tunnel to the anterior knee defect.
(f)
/uni00A0
Appearance after inset of the
/f_l
ap.
(g)
Figure 47.15
Reconstruction of calcaneal
osteomyelitis using a pedicled medial plantar
artery
/f_l
ap.
(a)
Chronic wound over calcaneal
osteomyelitis.
(b)
The medial plantar artery
(MPA), a continuation of the posterior tibial
(PT) artery, marked out using a Doppler probe
and the skin
/f_l
ap designed accordingly.
(c, d)
Calcaneal wound debrided and
/f_l
ap
raised.
(e)
Flap transferred onto the heel.
(f)
Immediate postoperative appearance of the
/f_l
ap inset with a meshed split-thickness skin
graft laid on the donor site.
(g)
One-month
postoperative appearance.
(c)
(e)
(f)



(d)
(f)
Figure 47.17
The medial sural artery perforator
(MSAP)
/f_l
ap can be used as a pedicled
/f_l
ap
for regional defects or as a free
/f_l
ap for distant
defects.
(a)
A longstanding diabetic foot ulcer
of the left hallux with underlying osteomyelitis.
(b)
Marking of the MSAP
/f_l
ap.
(c)
Amputation
of the hallux – direct closure would have neces
-
sitated proximal excision of the
/f_i
rst metatarsal
bone, thereby compromising weightbearing.
/uni00A0
(d)
The MSAP pedicle (arrow) dissected.
(e)
The
detached MSAP
/f_l
ap with the pedicle (arrow).
appearance of the
(f, g)
Immediate postoperative
/f_l
ap, with indwelling Doppler monitoring (arrows)
for venous anastomosis patency.
(b)
(a)
Figure 47.18
Excision of a basal cell carcinoma of the right alar groove and reconstruction with a V-to-Y nasolabial advancement
/f_l
ap.
/uni00A0
(a)
Tumour excision margins and
/f_l
ap design markings.
(b)
The defect following excision of the basal cell carcinoma.
/f_l
ap.
(d)
Advancement and inset of the
/f_l
ap.
(e)
(g)
(c)
(d)
(c)
Raising the nasolabial



Figure 47.19
Hatchet
/f_l
ap reconstruction following excision of a skin cancer of the right eyebrow.
the tumour with a back cut to enable
/f_l
ap advancement.
(c)
Insetting of the
/f_l
ap.
(a)
(b)
x
x
y
y
Figure 47.20
Reconstruction of a melanocytic lesion of the left pre-
auricular region using a rhomboid (transposition)
/f_l
ap.
(a)
Preoperative
markings.
(b)
Immediate postoperative appearance.
(a)
(b)
Muscle
Figure 47.22
Cormack and Lamberty classi
/f_i
cation of fasciocutaneous
/f_l
aps.
small, segmental perforators.
(d)
Osteomyofascial perforators.
(a)
Preoperative planning.
(b)
Post excision of
(d)
Immediate postoperative appearance.
(a)
(b)
Figure 47.21
Rotation
/f_l
ap reconstruction following excision of a
pilonidal sinus.
(a)
Preoperative marking of the rotational
/f_l
ap with a
back cut.
(b)
Immediate postoperative appearance.
(c)
(d)
Bone
Muscle
/uni00A0
(a)
Multiple large perforators.
(b)
Single large perforator.
(c)
Multiple,



(d)
(e)
(f)
(g)
Figure 47.23
Wound debridement and reconstruction with a pedicled
/f_l
ap based on a perforator arising from the posterior tibial artery.
sinus overlying internal
/f_i
xation of a medial malleolar fracture.
skin (X).
(c)
The perforator (arrow) and a pair of vena comitans were dissected and the fasciocutaneous
/f_l
ap islanded.
180° clockwise to reconstruct the defect.
(g)
The donor site was able to be closed primarily owing to local skin laxity.
Type I
Type II
Gluteus
maximus
Gracilis
Tensor fascia
lata
Figure 47.24
The Mathes and Nahai classi
/f_i
cation of muscle
/f_l
aps.
/uni00A0
(a)
Chronic
(b)
The perforator has been identi
/f_i
ed using a Doppler probe and marked on the
(d–f)
The
/f_l
ap is propellered
Type IV
Type V
Type III
Latissimus
Sartorius
dorsi



Figure 47.25
The latissimus dorsi
/f_l
ap can be used as a pedicled
/f_l
ap to reconstruct regional defects or as a free
/f_l
ap to reconstruct distant
defects.
(a)
Dermato
/f_i
brosarcoma protuberans of the left breast.
(a)
(b)
(c)
(d)
(e)
Figure 47.26 (a, b)
Limb-threatening, multiplanar degloving injury of the left foot and ankle from a road traf
/f_i
c accident.
debridement, multiple skin defects with exposed extensor tendons and tibiotalar joint.
/f_l
aps as two separate free
/f_l
aps.
(f, g)
Immediate postoperative appearance with meshed split-thickness skin grafts laid over the muscle
/f_l
aps.
(h,
/uni00A0
i)
/uni00A0
Postoperative appearance at 6 months with normal ambulation.
(b)
Reconstruction using a pedicled musculocutaneous latissimus dorsi
/f_l
ap.
(f)
(h)
(i)
(g)
(c, d)
Following wound
(e)
Harvest of left latissimus dorsi and serratus anterior

circumflex artery pedicle can support multiple skin and muscle flaps ( Figure 47.27 ) or the subscapular vascular pedicle can support a scapular flap, a parascapular flap, a latissimus dorsi flap and a serratus anterior flap. This enables the reconstruction of  complex composite defects involving di ff erent tissues. For example, following resection of  a maxillary sinus tumour, a chimeric scapular flap can be used to reconstruct both the bony and skin defects. V enous flow-through flaps are based on a venous rather than arterial pedicle so that the vein delivers both inflow and outflow of  blood. These flaps are thin and pliable but prone to venous congestion and partial necrosis as there is no arterial input and the flap survives on deo xygenated blood. There is minimal donor site morbidity . Examples include the saphenous flap and those based on the superficial veins of  the forearm. 

Figure 47.27 (a, b)
Chimeric
anterolateral thigh
/f_l
ap comprising
spatially independent skin and
muscle
/f_l
aps with all pedicles
linked to a common source vessel
(arrow), the descending branch
of the lateral femoral circum
/f_l
ex
artery.

Flaps

A flap is a block of  tissue that contains an innate blood supply that may be transferred from a donor site to reconstruct a secondary defect; the pedicle is the ‘base’ of  the flap that contains the blood supply . Unlike a graft, a flap can therefore be used to reconstruct a defect that does not have a vascu larised wound bed, such as exposed tendon, cortical bone or a prosthesis. There are numerous methods of  classifying flaps: according to their blood supply , their proximity to the defect, the method by which they ar e transferred and the tissue that they contain. The five Cs methodology is a useful flap classification system based on their circulation, composition, contiguity , contour and conditioning ( Figure 47.12 ). 1 Circulation : random pattern flaps have no dominant blood supply whereas axial flaps have a dominant feeding vessel. 2 Composition : cutaneous, fasciocutaneous, fascial, musculocutaneous, muscle, osseocutaneous, osseous, omentum/bowel. 3 Contiguity : local (where the flap shares a side with the defect) ( Figure 47.13 ), regional (where the flap is near but not immediately adjacent to the defect) ( Figures 47.14 and 47.15 ) and distant (where the flap is far from the defect and can be either pedicled or free) ( Figures 47.16 and 47.17 ). Sydney Reese Coleman , contemporary , plastic surgeon, New Y ork, NY , USA. George Carl Cormack , contemporary , plastic surgeon, Cambridge, UK. Byrom George Harker Lamberty , contemporary , plastic surgeon, Cambridge, UK. Bengt Pontén , 1923–2007, Associate Professor of  Plastic Surgery , Uppsala University , Uppsala , Sweden. Stephen John Mathes , 1943–2007, Professor of  Surgery , University of  California, San Francisco, CA, USA. Foad Nahai , contemporary , Professor of  Surgery , Emory University , Atlanta, GA, USA. into the defect – advancement ( Figures 47.18 and 47.19 ), transposition ( Figure 47.20 ), rotation ( Figure 47.21 ), interpolation, waltzing, crane principle and free. 5 Conditioning : whether the flap is delayed by partially elevating and resetting the flap prior to definitive elevation and transfer. Delay enables a larger flap to be harvested by - improving its blood supply . - Fasciocutaneous flaps comprise a fascial component that augments the flap blood supply owing to a network of  sub - fascial, fascial and suprafascial vessels. Fasciocutaneous flaps may be classified according to Cormack and Lamberty (1984) ( Figure 47.22 ): /uni25CF Type A: multiple perforators that can be direct or indirect (e.g. Pontén flap). /uni25CF Type B: single perforator that is usually direct and runs along the axis of  the flap (e.g. the scapular or parascapular flaps). /uni25CF Type C: segmental perforators that arise from the same source vessel (e.g. the radial forearm and lateral arm flaps) ( Figure 47.23 ). /uni25CF Type D: similar to type C; however, the flap is raised as an osteomyofasciocutaneous flap (e.g. the free fibular flap). In muscle and musculocutaneous flaps the motor nerve is always accompanied by a vascular pedicle, which is often the major source of  the flap circulation. A dominant pedicle can sustain an entire muscle whereas a minor pedicle can nor - mally only sustain a portion of  the flap. T he skin in a musculo - cutaneous flap is supplied by perforators. Muscle flaps are - classified by Mathes and Nahai (1981) ( Figure 47.24 ): /uni25CF Type I: single vascular pedicle (e.g. tensor fascia lata and gastrocnemius). /uni25CF Type II: one dominant pedicle with one or more minor pedicles (e.g. gracilis, biceps femoris, sternocleidomastoid, soleus and trapezius); the flap cannot survive on the minor pedicle(s) alone. /uni25CF Type III: dual dominant pedicles (e.g. gluteus maximus, pectoralis minor, rectus abdominis, serratus anterior and temporalis). /uni25CF Type IV: segmental pedicles (e.g. flexor hallucis longus, sar - torius and tibialis anterior). /uni25CF Type V: dominant pedicle with several smaller segmen - tal pedicles (e.g. latissimus dorsi and pectoralis major) ( Figures 47.25 and 47.26 ); the flap can survive on the minor pedicles alone. A chimeric flap consists of  multiple otherwise spatially independent flaps, each of  which has an independent vascular supply , with all pedicles linked to a common source vessel. For example, the descending branch of  the lateral femoral 

TRANSPOSITION FLAP
Donor
defect
(grafted or
sometimes
closed
Defect
primarily)
Pivot
point
(b)
BILOBED FLAP
Uses a
/f_l
ap to close a convex defect, and a second smaller
/f_l
ap
to close the donor site
Secondary
ap
Flap
(c)
RHOMBOID
Tissue
FLAP
defect
a´
a´ a
A parallelogram-
shaped
transposition
Flap
/f_l
ap
a
Figure 47.12
Local
/f_l
ap diagrams.
(a)
Transposition and Z-plasty
/f_l
aps.
(b)
Bilobed and bipedicled
/f_l
aps.
(c)
Rhomboid and rotation
/f_l
aps. (
continued overleaf
)
Z-PLASTY
Tw
o triangular transposition
/f_l
aps interposed
1
23
B
A
A
B
B
A
45
6
B
B
B
A
A
A
BIPEDICLE FLAP
A ‘bucket-handle’
/f_l
ap supplied from both ends.
Useful to rebuild the lower eyelid
Flap
RO
TA
TION FLAP
a
a b
b



A
DVANCEMENT FLAP
ectangular
Simple r
(with or without Bur
ow
’s
triangle excision at base)
Defect
Tw
o Bu
ro
w’s
triangles can
be excised at
base of
/f_l
ap to
make it slide
V to Y
e.g.
cut
/f_i
ngertip
Flap
(e)
2
1
Mark a long
Bu
rn
scar
zig-zag along
with long
the scar
ellipse
around it
5
4
The cut lines
The
/f_i
nished wound
will look
will look something
something like
like this
this
each becomes
Pad it well, and be
a
a´
Advance the
sure to splint open
b´
b
tips of the
when not exercising
zig-zags into
the spaces
Y to V
Usually multiple
Area of
to r
elease band
scar
scars over joint
s
shaded
This is one of the
fective
most ef
means of r
eleasing
moderate isolated
band bur
n scars
over
/f_l
exion cr
eases
3
Add in the
horizontal
lines to the
zig-zag;
a´
each becomes
a
b´
a ‘Y’
b
Figure 47.12
(
continued
) Local
/f_l
ap diagrams.
(d)
Advancement
/f_l
aps.
(e)
Multiple Y-to-V plasty for burn scar.



Figure 47.13
Bilobed
/f_l
ap reconstruction of a nasal defect following excision of a basal cell carcinoma.
raised.
(c)
Transposition of bilobed
/f_l
ap.
(d)
Immediate postoperative appearance.
(a)
(b)
Figure 47.14
Forehead
/f_l
ap reconstruction of nasal defect following excision of multiple basal cell carcinomas.
demonstrating the forehead
/f_l
ap based on the right supratrochlear artery. The pedicle position is con
/f_i
rmed using a hand-held Doppler probe.
/uni00A0
(b)
Flap inset to nose – note the bulky pedicle at the right medial eyebrow; donor site closed primarily except at the widest point, where it is
allowed to heal by secondary intention.
(c)
The
/f_l
ap pedicle was divided at a second stage, allowing contouring of the
/f_l
ap. Appearance at
6
/uni00A0
months.
(a)
Excision markings.
(b)
Bilobed
/f_l
ap
(c)
(a)
Preoperative markings



(e)
(f)
(a)
(b)
(d)
Figure 47.16
The medial sural artery perforator (MSAP)
/f_l
ap can be used as a pedicled
/f_l
ap for regional defects or as a free
/f_l
ap for distant
defects.
(a)
Traumatic defect of the anterior knee with a partially transected patellar ligament and cortical loss of the tibial tuberosity following
wound debridement.
(b, c)
The MSAP
/f_l
ap is harvested – the perforator (arrow) is identi
/f_i
ed arising from the substance of the gastrocnemius
muscle belly.
(d, e)
The
/f_l
ap remains attached to a pedicle and is transferred through a subcutaneous tunnel to the anterior knee defect.
(f)
/uni00A0
Appearance after inset of the
/f_l
ap.
(g)
Figure 47.15
Reconstruction of calcaneal
osteomyelitis using a pedicled medial plantar
artery
/f_l
ap.
(a)
Chronic wound over calcaneal
osteomyelitis.
(b)
The medial plantar artery
(MPA), a continuation of the posterior tibial
(PT) artery, marked out using a Doppler probe
and the skin
/f_l
ap designed accordingly.
(c, d)
Calcaneal wound debrided and
/f_l
ap
raised.
(e)
Flap transferred onto the heel.
(f)
Immediate postoperative appearance of the
/f_l
ap inset with a meshed split-thickness skin
graft laid on the donor site.
(g)
One-month
postoperative appearance.
(c)
(e)
(f)



(d)
(f)
Figure 47.17
The medial sural artery perforator
(MSAP)
/f_l
ap can be used as a pedicled
/f_l
ap
for regional defects or as a free
/f_l
ap for distant
defects.
(a)
A longstanding diabetic foot ulcer
of the left hallux with underlying osteomyelitis.
(b)
Marking of the MSAP
/f_l
ap.
(c)
Amputation
of the hallux – direct closure would have neces
-
sitated proximal excision of the
/f_i
rst metatarsal
bone, thereby compromising weightbearing.
/uni00A0
(d)
The MSAP pedicle (arrow) dissected.
(e)
The
detached MSAP
/f_l
ap with the pedicle (arrow).
appearance of the
(f, g)
Immediate postoperative
/f_l
ap, with indwelling Doppler monitoring (arrows)
for venous anastomosis patency.
(b)
(a)
Figure 47.18
Excision of a basal cell carcinoma of the right alar groove and reconstruction with a V-to-Y nasolabial advancement
/f_l
ap.
/uni00A0
(a)
Tumour excision margins and
/f_l
ap design markings.
(b)
The defect following excision of the basal cell carcinoma.
/f_l
ap.
(d)
Advancement and inset of the
/f_l
ap.
(e)
(g)
(c)
(d)
(c)
Raising the nasolabial



Figure 47.19
Hatchet
/f_l
ap reconstruction following excision of a skin cancer of the right eyebrow.
the tumour with a back cut to enable
/f_l
ap advancement.
(c)
Insetting of the
/f_l
ap.
(a)
(b)
x
x
y
y
Figure 47.20
Reconstruction of a melanocytic lesion of the left pre-
auricular region using a rhomboid (transposition)
/f_l
ap.
(a)
Preoperative
markings.
(b)
Immediate postoperative appearance.
(a)
(b)
Muscle
Figure 47.22
Cormack and Lamberty classi
/f_i
cation of fasciocutaneous
/f_l
aps.
small, segmental perforators.
(d)
Osteomyofascial perforators.
(a)
Preoperative planning.
(b)
Post excision of
(d)
Immediate postoperative appearance.
(a)
(b)
Figure 47.21
Rotation
/f_l
ap reconstruction following excision of a
pilonidal sinus.
(a)
Preoperative marking of the rotational
/f_l
ap with a
back cut.
(b)
Immediate postoperative appearance.
(c)
(d)
Bone
Muscle
/uni00A0
(a)
Multiple large perforators.
(b)
Single large perforator.
(c)
Multiple,



(d)
(e)
(f)
(g)
Figure 47.23
Wound debridement and reconstruction with a pedicled
/f_l
ap based on a perforator arising from the posterior tibial artery.
sinus overlying internal
/f_i
xation of a medial malleolar fracture.
skin (X).
(c)
The perforator (arrow) and a pair of vena comitans were dissected and the fasciocutaneous
/f_l
ap islanded.
180° clockwise to reconstruct the defect.
(g)
The donor site was able to be closed primarily owing to local skin laxity.
Type I
Type II
Gluteus
maximus
Gracilis
Tensor fascia
lata
Figure 47.24
The Mathes and Nahai classi
/f_i
cation of muscle
/f_l
aps.
/uni00A0
(a)
Chronic
(b)
The perforator has been identi
/f_i
ed using a Doppler probe and marked on the
(d–f)
The
/f_l
ap is propellered
Type IV
Type V
Type III
Latissimus
Sartorius
dorsi



Figure 47.25
The latissimus dorsi
/f_l
ap can be used as a pedicled
/f_l
ap to reconstruct regional defects or as a free
/f_l
ap to reconstruct distant
defects.
(a)
Dermato
/f_i
brosarcoma protuberans of the left breast.
(a)
(b)
(c)
(d)
(e)
Figure 47.26 (a, b)
Limb-threatening, multiplanar degloving injury of the left foot and ankle from a road traf
/f_i
c accident.
debridement, multiple skin defects with exposed extensor tendons and tibiotalar joint.
/f_l
aps as two separate free
/f_l
aps.
(f, g)
Immediate postoperative appearance with meshed split-thickness skin grafts laid over the muscle
/f_l
aps.
(h,
/uni00A0
i)
/uni00A0
Postoperative appearance at 6 months with normal ambulation.
(b)
Reconstruction using a pedicled musculocutaneous latissimus dorsi
/f_l
ap.
(f)
(h)
(i)
(g)
(c, d)
Following wound
(e)
Harvest of left latissimus dorsi and serratus anterior

circumflex artery pedicle can support multiple skin and muscle flaps ( Figure 47.27 ) or the subscapular vascular pedicle can support a scapular flap, a parascapular flap, a latissimus dorsi flap and a serratus anterior flap. This enables the reconstruction of  complex composite defects involving di ff erent tissues. For example, following resection of  a maxillary sinus tumour, a chimeric scapular flap can be used to reconstruct both the bony and skin defects. V enous flow-through flaps are based on a venous rather than arterial pedicle so that the vein delivers both inflow and outflow of  blood. These flaps are thin and pliable but prone to venous congestion and partial necrosis as there is no arterial input and the flap survives on deo xygenated blood. There is minimal donor site morbidity . Examples include the saphenous flap and those based on the superficial veins of  the forearm. 

Figure 47.27 (a, b)
Chimeric
anterolateral thigh
/f_l
ap comprising
spatially independent skin and
muscle
/f_l
aps with all pedicles
linked to a common source vessel
(arrow), the descending branch
of the lateral femoral circum
/f_l
ex
artery.

Flaps

A flap is a block of  tissue that contains an innate blood supply that may be transferred from a donor site to reconstruct a secondary defect; the pedicle is the ‘base’ of  the flap that contains the blood supply . Unlike a graft, a flap can therefore be used to reconstruct a defect that does not have a vascu larised wound bed, such as exposed tendon, cortical bone or a prosthesis. There are numerous methods of  classifying flaps: according to their blood supply , their proximity to the defect, the method by which they ar e transferred and the tissue that they contain. The five Cs methodology is a useful flap classification system based on their circulation, composition, contiguity , contour and conditioning ( Figure 47.12 ). 1 Circulation : random pattern flaps have no dominant blood supply whereas axial flaps have a dominant feeding vessel. 2 Composition : cutaneous, fasciocutaneous, fascial, musculocutaneous, muscle, osseocutaneous, osseous, omentum/bowel. 3 Contiguity : local (where the flap shares a side with the defect) ( Figure 47.13 ), regional (where the flap is near but not immediately adjacent to the defect) ( Figures 47.14 and 47.15 ) and distant (where the flap is far from the defect and can be either pedicled or free) ( Figures 47.16 and 47.17 ). Sydney Reese Coleman , contemporary , plastic surgeon, New Y ork, NY , USA. George Carl Cormack , contemporary , plastic surgeon, Cambridge, UK. Byrom George Harker Lamberty , contemporary , plastic surgeon, Cambridge, UK. Bengt Pontén , 1923–2007, Associate Professor of  Plastic Surgery , Uppsala University , Uppsala , Sweden. Stephen John Mathes , 1943–2007, Professor of  Surgery , University of  California, San Francisco, CA, USA. Foad Nahai , contemporary , Professor of  Surgery , Emory University , Atlanta, GA, USA. into the defect – advancement ( Figures 47.18 and 47.19 ), transposition ( Figure 47.20 ), rotation ( Figure 47.21 ), interpolation, waltzing, crane principle and free. 5 Conditioning : whether the flap is delayed by partially elevating and resetting the flap prior to definitive elevation and transfer. Delay enables a larger flap to be harvested by - improving its blood supply . - Fasciocutaneous flaps comprise a fascial component that augments the flap blood supply owing to a network of  sub - fascial, fascial and suprafascial vessels. Fasciocutaneous flaps may be classified according to Cormack and Lamberty (1984) ( Figure 47.22 ): /uni25CF Type A: multiple perforators that can be direct or indirect (e.g. Pontén flap). /uni25CF Type B: single perforator that is usually direct and runs along the axis of  the flap (e.g. the scapular or parascapular flaps). /uni25CF Type C: segmental perforators that arise from the same source vessel (e.g. the radial forearm and lateral arm flaps) ( Figure 47.23 ). /uni25CF Type D: similar to type C; however, the flap is raised as an osteomyofasciocutaneous flap (e.g. the free fibular flap). In muscle and musculocutaneous flaps the motor nerve is always accompanied by a vascular pedicle, which is often the major source of  the flap circulation. A dominant pedicle can sustain an entire muscle whereas a minor pedicle can nor - mally only sustain a portion of  the flap. T he skin in a musculo - cutaneous flap is supplied by perforators. Muscle flaps are - classified by Mathes and Nahai (1981) ( Figure 47.24 ): /uni25CF Type I: single vascular pedicle (e.g. tensor fascia lata and gastrocnemius). /uni25CF Type II: one dominant pedicle with one or more minor pedicles (e.g. gracilis, biceps femoris, sternocleidomastoid, soleus and trapezius); the flap cannot survive on the minor pedicle(s) alone. /uni25CF Type III: dual dominant pedicles (e.g. gluteus maximus, pectoralis minor, rectus abdominis, serratus anterior and temporalis). /uni25CF Type IV: segmental pedicles (e.g. flexor hallucis longus, sar - torius and tibialis anterior). /uni25CF Type V: dominant pedicle with several smaller segmen - tal pedicles (e.g. latissimus dorsi and pectoralis major) ( Figures 47.25 and 47.26 ); the flap can survive on the minor pedicles alone. A chimeric flap consists of  multiple otherwise spatially independent flaps, each of  which has an independent vascular supply , with all pedicles linked to a common source vessel. For example, the descending branch of  the lateral femoral 

TRANSPOSITION FLAP
Donor
defect
(grafted or
sometimes
closed
Defect
primarily)
Pivot
point
(b)
BILOBED FLAP
Uses a
/f_l
ap to close a convex defect, and a second smaller
/f_l
ap
to close the donor site
Secondary
ap
Flap
(c)
RHOMBOID
Tissue
FLAP
defect
a´
a´ a
A parallelogram-
shaped
transposition
Flap
/f_l
ap
a
Figure 47.12
Local
/f_l
ap diagrams.
(a)
Transposition and Z-plasty
/f_l
aps.
(b)
Bilobed and bipedicled
/f_l
aps.
(c)
Rhomboid and rotation
/f_l
aps. (
continued overleaf
)
Z-PLASTY
Tw
o triangular transposition
/f_l
aps interposed
1
23
B
A
A
B
B
A
45
6
B
B
B
A
A
A
BIPEDICLE FLAP
A ‘bucket-handle’
/f_l
ap supplied from both ends.
Useful to rebuild the lower eyelid
Flap
RO
TA
TION FLAP
a
a b
b



A
DVANCEMENT FLAP
ectangular
Simple r
(with or without Bur
ow
’s
triangle excision at base)
Defect
Tw
o Bu
ro
w’s
triangles can
be excised at
base of
/f_l
ap to
make it slide
V to Y
e.g.
cut
/f_i
ngertip
Flap
(e)
2
1
Mark a long
Bu
rn
scar
zig-zag along
with long
the scar
ellipse
around it
5
4
The cut lines
The
/f_i
nished wound
will look
will look something
something like
like this
this
each becomes
Pad it well, and be
a
a´
Advance the
sure to splint open
b´
b
tips of the
when not exercising
zig-zags into
the spaces
Y to V
Usually multiple
Area of
to r
elease band
scar
scars over joint
s
shaded
This is one of the
fective
most ef
means of r
eleasing
moderate isolated
band bur
n scars
over
/f_l
exion cr
eases
3
Add in the
horizontal
lines to the
zig-zag;
a´
each becomes
a
b´
a ‘Y’
b
Figure 47.12
(
continued
) Local
/f_l
ap diagrams.
(d)
Advancement
/f_l
aps.
(e)
Multiple Y-to-V plasty for burn scar.



Figure 47.13
Bilobed
/f_l
ap reconstruction of a nasal defect following excision of a basal cell carcinoma.
raised.
(c)
Transposition of bilobed
/f_l
ap.
(d)
Immediate postoperative appearance.
(a)
(b)
Figure 47.14
Forehead
/f_l
ap reconstruction of nasal defect following excision of multiple basal cell carcinomas.
demonstrating the forehead
/f_l
ap based on the right supratrochlear artery. The pedicle position is con
/f_i
rmed using a hand-held Doppler probe.
/uni00A0
(b)
Flap inset to nose – note the bulky pedicle at the right medial eyebrow; donor site closed primarily except at the widest point, where it is
allowed to heal by secondary intention.
(c)
The
/f_l
ap pedicle was divided at a second stage, allowing contouring of the
/f_l
ap. Appearance at
6
/uni00A0
months.
(a)
Excision markings.
(b)
Bilobed
/f_l
ap
(c)
(a)
Preoperative markings



(e)
(f)
(a)
(b)
(d)
Figure 47.16
The medial sural artery perforator (MSAP)
/f_l
ap can be used as a pedicled
/f_l
ap for regional defects or as a free
/f_l
ap for distant
defects.
(a)
Traumatic defect of the anterior knee with a partially transected patellar ligament and cortical loss of the tibial tuberosity following
wound debridement.
(b, c)
The MSAP
/f_l
ap is harvested – the perforator (arrow) is identi
/f_i
ed arising from the substance of the gastrocnemius
muscle belly.
(d, e)
The
/f_l
ap remains attached to a pedicle and is transferred through a subcutaneous tunnel to the anterior knee defect.
(f)
/uni00A0
Appearance after inset of the
/f_l
ap.
(g)
Figure 47.15
Reconstruction of calcaneal
osteomyelitis using a pedicled medial plantar
artery
/f_l
ap.
(a)
Chronic wound over calcaneal
osteomyelitis.
(b)
The medial plantar artery
(MPA), a continuation of the posterior tibial
(PT) artery, marked out using a Doppler probe
and the skin
/f_l
ap designed accordingly.
(c, d)
Calcaneal wound debrided and
/f_l
ap
raised.
(e)
Flap transferred onto the heel.
(f)
Immediate postoperative appearance of the
/f_l
ap inset with a meshed split-thickness skin
graft laid on the donor site.
(g)
One-month
postoperative appearance.
(c)
(e)
(f)



(d)
(f)
Figure 47.17
The medial sural artery perforator
(MSAP)
/f_l
ap can be used as a pedicled
/f_l
ap
for regional defects or as a free
/f_l
ap for distant
defects.
(a)
A longstanding diabetic foot ulcer
of the left hallux with underlying osteomyelitis.
(b)
Marking of the MSAP
/f_l
ap.
(c)
Amputation
of the hallux – direct closure would have neces
-
sitated proximal excision of the
/f_i
rst metatarsal
bone, thereby compromising weightbearing.
/uni00A0
(d)
The MSAP pedicle (arrow) dissected.
(e)
The
detached MSAP
/f_l
ap with the pedicle (arrow).
appearance of the
(f, g)
Immediate postoperative
/f_l
ap, with indwelling Doppler monitoring (arrows)
for venous anastomosis patency.
(b)
(a)
Figure 47.18
Excision of a basal cell carcinoma of the right alar groove and reconstruction with a V-to-Y nasolabial advancement
/f_l
ap.
/uni00A0
(a)
Tumour excision margins and
/f_l
ap design markings.
(b)
The defect following excision of the basal cell carcinoma.
/f_l
ap.
(d)
Advancement and inset of the
/f_l
ap.
(e)
(g)
(c)
(d)
(c)
Raising the nasolabial



Figure 47.19
Hatchet
/f_l
ap reconstruction following excision of a skin cancer of the right eyebrow.
the tumour with a back cut to enable
/f_l
ap advancement.
(c)
Insetting of the
/f_l
ap.
(a)
(b)
x
x
y
y
Figure 47.20
Reconstruction of a melanocytic lesion of the left pre-
auricular region using a rhomboid (transposition)
/f_l
ap.
(a)
Preoperative
markings.
(b)
Immediate postoperative appearance.
(a)
(b)
Muscle
Figure 47.22
Cormack and Lamberty classi
/f_i
cation of fasciocutaneous
/f_l
aps.
small, segmental perforators.
(d)
Osteomyofascial perforators.
(a)
Preoperative planning.
(b)
Post excision of
(d)
Immediate postoperative appearance.
(a)
(b)
Figure 47.21
Rotation
/f_l
ap reconstruction following excision of a
pilonidal sinus.
(a)
Preoperative marking of the rotational
/f_l
ap with a
back cut.
(b)
Immediate postoperative appearance.
(c)
(d)
Bone
Muscle
/uni00A0
(a)
Multiple large perforators.
(b)
Single large perforator.
(c)
Multiple,



(d)
(e)
(f)
(g)
Figure 47.23
Wound debridement and reconstruction with a pedicled
/f_l
ap based on a perforator arising from the posterior tibial artery.
sinus overlying internal
/f_i
xation of a medial malleolar fracture.
skin (X).
(c)
The perforator (arrow) and a pair of vena comitans were dissected and the fasciocutaneous
/f_l
ap islanded.
180° clockwise to reconstruct the defect.
(g)
The donor site was able to be closed primarily owing to local skin laxity.
Type I
Type II
Gluteus
maximus
Gracilis
Tensor fascia
lata
Figure 47.24
The Mathes and Nahai classi
/f_i
cation of muscle
/f_l
aps.
/uni00A0
(a)
Chronic
(b)
The perforator has been identi
/f_i
ed using a Doppler probe and marked on the
(d–f)
The
/f_l
ap is propellered
Type IV
Type V
Type III
Latissimus
Sartorius
dorsi



Figure 47.25
The latissimus dorsi
/f_l
ap can be used as a pedicled
/f_l
ap to reconstruct regional defects or as a free
/f_l
ap to reconstruct distant
defects.
(a)
Dermato
/f_i
brosarcoma protuberans of the left breast.
(a)
(b)
(c)
(d)
(e)
Figure 47.26 (a, b)
Limb-threatening, multiplanar degloving injury of the left foot and ankle from a road traf
/f_i
c accident.
debridement, multiple skin defects with exposed extensor tendons and tibiotalar joint.
/f_l
aps as two separate free
/f_l
aps.
(f, g)
Immediate postoperative appearance with meshed split-thickness skin grafts laid over the muscle
/f_l
aps.
(h,
/uni00A0
i)
/uni00A0
Postoperative appearance at 6 months with normal ambulation.
(b)
Reconstruction using a pedicled musculocutaneous latissimus dorsi
/f_l
ap.
(f)
(h)
(i)
(g)
(c, d)
Following wound
(e)
Harvest of left latissimus dorsi and serratus anterior

circumflex artery pedicle can support multiple skin and muscle flaps ( Figure 47.27 ) or the subscapular vascular pedicle can support a scapular flap, a parascapular flap, a latissimus dorsi flap and a serratus anterior flap. This enables the reconstruction of  complex composite defects involving di ff erent tissues. For example, following resection of  a maxillary sinus tumour, a chimeric scapular flap can be used to reconstruct both the bony and skin defects. V enous flow-through flaps are based on a venous rather than arterial pedicle so that the vein delivers both inflow and outflow of  blood. These flaps are thin and pliable but prone to venous congestion and partial necrosis as there is no arterial input and the flap survives on deo xygenated blood. There is minimal donor site morbidity . Examples include the saphenous flap and those based on the superficial veins of  the forearm. 

Figure 47.27 (a, b)
Chimeric
anterolateral thigh
/f_l
ap comprising
spatially independent skin and
muscle
/f_l
aps with all pedicles
linked to a common source vessel
(arrow), the descending branch
of the lateral femoral circum
/f_l
ex
artery.