Introduction Definition of flap unit of tissue transferred from a donor site to a recipient site while maintaining its own vascular supply Definition of pedicle vascular portion of the transferred tissue usually contains one artery and one or more veins Indications for flap coverage soft tissue injury with exposed bone tendons cartilage orthopaedic implants Classification Blood supply classification axial pattern local flaps contain single arteriovenous pedicle (a "named vessel") indications primary/secondary closure not advisable and area cannot support STSG or FTSG and length-width ratio needed > 2:1 random pattern flaps supported by numerous microcirculation with no single arteriovenous pedicle indications primary/secondary closure not advisable andarea cannot support STSG or FTSG and length-width ratio needed < 2:1 venous flap uses veins as inflow and outflow of arterial blood Tissue type classification cutaneous include skin and subcutaneous tissue fascial flap include fascia with no overlying skin example temporoparietal flap muscle flaps usually requires additional transfer of a skin graft to cover muscle alternatively, muscle can be transposed as part of a musculocutaneous flap (composite flap) if motor nerve is not preserved the flap will atrophy to 50% of its original size bone flaps free fibula based on peroneal artery pedicle useful for diaphyseal reconstruction free iliac crest based on deep circumflex iliac vessels useful for metaphyseal reconstuction composite flaps consists of multiple tissue types examples radial forearm flap (fasciocutaneous) Mobilization type classification local flap tissue transferred from an area adjacent to defect distal random pattern flap transfer of tissue to a noncontiguous anatomic site indications surrounding tissue will not support a local flap length-width ratio needed < 2:1 distal axial pattern flap indications surrounding tissue will not support a local flap length-width ratio needed > 2:1 free tissue transfer indicatoins local or distant tissue not sufficient for distal axial and random pattern flaps Techniques Flap Techniques Fingertips & Hand See Finger amputation and Flaps Arm Flaps Lateral arm flap Lateral arm defects Blood supply by posterior radial collateral artery (branch of profunda brachii) Latissimus Dorsi myocutaneous flap For large defects around the elbow Blood supply provided by perforators off of the thoracodorsal artery Leg Muscle Flaps Medial Gastroc flap Used for medial and midline defects over proximal third of tibia Pedicle supplied by medial sural artery Lateral Gastroc flap Used for lateral defects over the proximal third of tibia Pedicle supplied by lateral sural artery Soleus Used for wounds over the middle third of tibia Supplied by branches of the popliteal artery trunk, the posterior tibial artery (medial), and the peroneal artery (proximal) Gracilis Most common donor for free muscle transfer Nerve is anterior division of obturator nerve Artery is branch of medial femoral circumflex artery Free flap Used for wound coverage over distal third of tibia, or in the middle and proximal leg when soleus and gastrocnemius are damaged Groin flap Axial flap that has been a mainstay of providing soft-tissue coverage of the upper extremity Based on the superficial circumflex iliac artery Risk of injury to lateral femoral cutaneous nerve Bone Flaps Free iliac crest Based on deep circumflex iliac vessels Useful for metaphyseal reconstruction Free fibula Useful for diaphyseal reconstruction Based on peroneal artery pedicle Vascular bone graft from radius Gaining popularity for osteonecrosis of scaphoid fractures Harvested from dorsal aspect of distal radius Based on 1-2 intercompartmental superretinacular artery (branch of radial artery) Index metacarpal transposition Indicated to reduce the space left between the index and ring finger following middle ray amputation. An alternative technique is deep transverse intermetacarpal ligament reconstruction. Little metacarpal transposition Indicated to reduce the space left between the middle and little finger following ring ray amputation. Technique Ladder of reconstruction in order of increasing complexity primary closure secondary closure healing by secondary intention skin graft local flap regional flap free tissue transfer Complications Flap Failure inadequate arterial flow treatment immediate return to operating room inadequate venous outflow treatment loosen dressings, removal of selected sutures return to operating room if not relieved by above measure strongest predictor of wound infection (second is time from definitive fixation to flap coverage) Donor site morbidity may be cosmetically unacceptable pain related to grafting seroma treatment aspiration excision if encapsulated Nonunion for vascularized bone transfer incidence may be as high as 32% if no additional bone graft is used Prognosis Free tissue transfer within 7 days for severe trauma in the upper extremity has been shown to decrease complication rates