Flap (surgery)

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Flap surgery
Erichsen Flap.jpg
Engraving by John Eric Erichsen depicting flap surgery used to cover an amputation stump
ICD-9-CM 86.7

Flap surgery is a technique in plastic and reconstructive surgery where tissue with an intact blood supply is lifted from a donor site and moved to a recipient site. Flaps are distinct from grafts, which do not have an intact blood supply and relies on the growth of new blood vessels. Flaps are done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, wound contraction is to be avoided or to rebuild more complex anatomic structures like breasts or jaws. [1] [2] Flaps may also carry with them tissues such as muscle and bone that may be useful in the ultimate reconstruction.

Contents

Uses

Flap surgery is a technique essential to plastic and reconstructive surgery. A flap is defined as tissue that can be moved to another site and has its own blood supply. This is in comparison to a skin graft which does not have its own blood supply and relies on vascularization from the recipient site. [2] Flaps have many uses in wound healing and are used when wounds are large, complex, or need tissue of various types and bulk for successful closure and function. [2]

Anatomy

Flaps can contain many different combination of layers of tissue, from skin to bone (see § Classification). 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 surgery. [2]

The distribution of the blood vessels in the skin of the sole of the foot. The dermis is referred to as corium. Gray942.png
The distribution of the blood vessels in the skin of the sole of the foot. The dermis is referred to as corium.

Skin anatomy

Flaps may include skin in their construction. Skin is important for many reasons, but namely its role in thermoregulation, immune function, and blood supply aid in flap survival. [2] The skin can be divided into three main layers: the epidermis, dermis, and subcutaneous tissue. Blood is mainly supplied to the skin by two networks of blood vessels. The deep network lies between the dermis and the subcutaneous tissue, while the shallow network lies within the papillary layer of the dermis. [3] 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). [2]

This robust and redundant blood supply is important in flap surgery, [2] because flaps are cut off from other blood vessels when it is raised and removed from its surrounding native tissue. [2] The remaining blood supply must then keep the tissue alive until additional blood supply can be formed through angiogenesis. [4]

Angiosome

The angiosome is a concept first coined by Ian Taylor in 1987. [5] It is a three-dimensional region of tissue that is supplied by a single artery and can include skin, soft tissue, and bone. [5] [6] Adjacent angiosomes are connected by narrower choke vessels, and 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. [4]

Classification

Flaps can be fundamentally classified by their mechanism of movement, the types of tissues present, or by their blood supply. [2] The surgeon generally chooses the least complex type that will achieve the desired effect via a concept known as the reconstructive ladder. [7] [8]

Mechanism of movement

Local flaps
Advancement flap.svg
Advancement flap
Rotation flap.svg
Rotation flap
Transposition flap.svg
Transposition flap

Tissue type

Flaps can be classified by the content of the tissue within them.

Breast reconstruction using the latissimus dorsi muscle and an implant. This is an example of a pedicled musculocutaneous flap. Diagram showing breast reconstruction using the latissimus dorsi muscle and an implant CRUK 405.svg
Breast reconstruction using the latissimus dorsi muscle and an implant. This is an example of a pedicled musculocutaneous flap.

Vascular supply

Classification based on blood supply to the flap:

Contraindications

Anyone who is unstable for surgery should not undergo flap surgery. As with most surgeries, people who are sicker may have more difficulties with wound healing, which include individuals with comorbidities such as diabetes, smoking, immunosuppression, and vascular disease. [15] [16]

Risks or complications

The risks of flap surgery include infection, wound breakdown, fluid accumulation, bleeding, damage to nearby structures, and scarring. [10] 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 insufficient blood flow to the end segments of the flap. [10] This can sometimes be fixed with another surgery or using additional methods of healing in the reconstructive ladder. [17]

Recovery

As with healing of any wound, healing of a flap maintains the same process of wound healing. There are four stages to wound healing: hemostasis, inflammation, proliferation, and remodeling, all of which can take up to a year to complete. [18] [2]

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%. [19] The most commonly cause is by venous insufficiency consisting of 54% of all causes. [19] Venous insufficiency is commonly caused by a venous thrombus within the first 2 days following surgery. [19] [18] 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. [18]

History

Walter Yeo, before (left) and after (right) skin flap surgery performed by Harold Gillies in 1917. Walter Yeo skin graft.jpg
Walter Yeo, before (left) and after (right) skin flap surgery performed by Harold Gillies in 1917.

Skin flaps are an essential part of a surgeon's toolbox in plastic surgery. It is part of the reconstructive ladder. [17] The first known reports of surgical flaps originated in 600 BC in India by Sushruta where the tilemakers' caste would reconstruct noses using regional flaps due to the practice of nose amputations as a form of legal punishment. [20] [17] The next description of flap surgery comes from Celsus, an ancient Roman who described the advancement of skin flaps from 25 BC to 50 AD. [20] [17] In the 15th century, Gaspare 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. [21] The Italian method was rediscovered in 1800 by German surgeon Carl Ferdinand von Graefe. [22] Major advancements in modern plastic surgery are mostly attributed to Harold Gillies, who pioneered facial reconstruction during World War I using pedicled tube flaps on patients like Walter Yeo, and the development of the walking-stalk skin flap by Gilles' cousin Archibald McIndoe in 1930. [20] [23]

Advancements continued in flap surgery. With the introduction of the operating microscope, microvascular surgery advancements allowed for the anastomosis of blood vessels. [12] This led to the ability of free tissue transfers, and in 1958 Bernard Seidenberg transferred a part of the jejunum to the esophagus to remove a cancer. [12] [24] Modern advancements in flap surgeries have continued since this time and are now commonly used in many procedures. [12]

See also

Related Research Articles

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<span class="mw-page-title-main">Rhinoplasty</span> Surgical procedure to enhance or reconstruct a human nose

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<span class="mw-page-title-main">Skin grafting</span> Surgical transplantation of skin

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Grafting refers to a surgical procedure to move tissue from one site to another on the body, or from another creature, without bringing its own blood supply with it. Instead, a new blood supply grows in after it is placed. A similar technique where tissue is transferred with the blood supply intact is called a flap. In some instances, a graft can be an artificially manufactured device. Examples of this are a tube to carry blood flow across a defect or from an artery to a vein for use in hemodialysis.

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References

  1. 1 2 Song DH, Henry G, Reid RR, Wu LC, Wirth GA, Dorafshar AH (2007). "Chapter 2: Grafts and Flaps". Plastic Surgery: Essentials for Students. Plastic Surgery Education Foundation.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Chung KC (2020). Grabb and Smith's plastic surgery (8th ed.). Philadelphia. ISBN   978-1-4963-8824-7. OCLC   1091585260.{{cite book}}: CS1 maint: location missing publisher (link)
  3. 1 2 Clark JM, Wang TD (November 2001). "Local flaps in scar revision". Facial Plast Surg. 17 (4): 295–308. doi:10.1055/s-2001-18831. PMID   11735064. S2CID   42728956.
  4. 1 2 3 4 5 6 Guyuron B, Eriksson E, Persing JA (2009). "Chapter 8: Flaps". Plastic Surgery: Indications and Practice. Vol. 1. Saunders Elsevier. ISBN   978-1-4160-4081-1.
  5. 1 2 Taylor GI, Palmer JH (March 1987). "The vascular territories (angiosomes) of the body: experimental study and clinical applications". Br J Plast Surg. 40 (2): 113–41. doi:10.1016/0007-1226(87)90185-8. PMID   3567445.
  6. ↑ Houseman ND, Taylor GI, Pan WR (June 2000). "The angiosomes of the head and neck: anatomic study and clinical applications". Plast Reconstr Surg. 105 (7): 2287–313. doi:10.1097/00006534-200006000-00001. PMID   10845282. S2CID   34422340.
  7. ↑ Turner AJ, Parkhouse N (July 2006). "Revisiting the reconstructive ladder". Plast Reconstr Surg. 118 (1): 267–8. doi:10.1097/01.prs.0000222224.03137.d5. PMID   16816714.
  8. ↑ Boyce DE, Shokrollahi K (March 2006). "Reconstructive surgery". BMJ. 332 (7543): 710–2. doi:10.1136/bmj.332.7543.710. PMC   1410906 . PMID   16565127.
  9. ↑ Mellette JR, Ho DQ (January 2005). "Interpolation flaps". Dermatol Clin. 23 (1): 87–112, vi. doi:10.1016/j.det.2004.08.010. PMID   15620622.
  10. 1 2 3 Tschoi M, Hoy EA, Granick MS (April 2005). "Skin flaps". Clin Plast Surg. 32 (2): 261–73. doi:10.1016/j.cps.2004.11.005. PMID   15814122.
  11. ↑ Guyuron B, Eriksson E, Persing JA (2009). "Chapter 9: Microsurgery and Free Flaps". Plastic Surgery: Indications and Practice. Vol. 1. Saunders Elsevier. ISBN   978-1-4160-4081-1.
  12. 1 2 3 4 Wolff KD, Hölzle F (2011). Raising of microvascular flaps: a systematic approach (2nd ed.). Berlin: Springer. ISBN   978-3-642-13831-7. OCLC   733542624.
  13. ↑ Cormack GC, Lamberty BG (January 1984). "A classification of fascio-cutaneous flaps according to their patterns of vascularisation". Br J Plast Surg. 37 (1): 80–7. doi:10.1016/0007-1226(84)90049-3. PMID   6692066.
  14. ↑ Cormack GC, Lamberty BGH (1986). The arterial anatomy of skin flaps. London: Churchill Livingstone. OCLC   12808179.
  15. ↑ Carrau, Ricardo L.; Vescan, Allan D.; Snyderman, Carl H.; Kassam, Amin B. (2008-01-01). Myers, Eugene N.; Carrau, Ricardo L.; Eibling, David E.; Ferguson, Berrylin J. (eds.). Chapter 105 - Reconstruction after Skull Base Surgery. Philadelphia: W.B. Saunders. pp. 1061–1068. ISBN   978-1-4160-2445-3 . Retrieved 2022-10-30.{{cite book}}: |work= ignored (help)
  16. ↑ Saint-Cyr M, Wong C, Buchel EW, Colohan S, Pederson WC (December 2012). "Free tissue transfers and replantation". Plast Reconstr Surg. 130 (6): 858e–878e. doi:10.1097/PRS.0b013e31826da2b7. PMID   23190838. S2CID   22788028.
  17. 1 2 3 4 Gottlieb LJ, Krieger LM (June 1994). "From the reconstructive ladder to the reconstructive elevator". Plast Reconstr Surg. 93 (7): 1503–4. doi: 10.1097/00006534-199406000-00027 . PMID   7661898.
  18. 1 2 3 Buchanan PJ, Kung TA, Cederna PS (September 2016). "Evidence-Based Medicine: Wound Closure". Plast Reconstr Surg. 138 (3 Suppl): 257S–270S. doi:10.1097/PRS.0000000000002775. PMID   27556770. S2CID   5865301.
  19. 1 2 3 Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ (December 1996). "Timing of pedicle thrombosis and flap loss after free-tissue transfer". Plast Reconstr Surg. 98 (7): 1230–3. doi:10.1097/00006534-199612000-00017. PMID   8942909. S2CID   20380107.
  20. 1 2 3 Chambers JA, Ray PD (November 2009). "Achieving growth and excellence in medicine: the case history of armed conflict and modern reconstructive surgery". Ann Plast Surg. 63 (5): 473–8. doi:10.1097/SAP.0b013e3181bc327a. PMID   20431512.
  21. ↑ Tomba P, Viganò A, Ruggieri P, Gasbarrini A (2014). "Gaspare Tagliacozzi, pioneer of plastic surgery and the spread of his technique throughout Europe in "De Curtorum Chirurgia per Insitionem"". Eur Rev Med Pharmacol Sci. 18 (4): 445–50. PMID   24610608.
  22. ↑ Erovic BM (2015). Manual of Head and Neck Reconstruction Using Regional and Free Flaps. Springer Vienna. ISBN   978-3-7091-1172-7. OCLC   974391518.
  23. ↑ Gillies HD (2019). Plastic Surgery of the Face Based on Selected Cases of War Injuries of the Face, Including Burns; With Original Illustrations. Forgotten Books. ISBN   978-0-259-73591-5. OCLC   1152260318.
  24. ↑ Seidenberg B, Rosenak SS, Hurwitt ES, Som ML (February 1959). "Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment". Ann Surg. 149 (2): 162–71. doi:10.1097/00000658-195902000-00002. PMC   1450976 . PMID   13627972.
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