Flap surgery is a technique in
plastic
Plastics are a wide range of synthetic polymers, synthetic or Semisynthesis, semisynthetic materials composed primarily of Polymer, polymers. Their defining characteristic, Plasticity (physics), plasticity, allows them to be Injection moulding ...
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 implicat ...
where
tissue with an intact
blood supply
In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart an ...
is lifted from a donor site and moved to a recipient site. Flaps are distinct from
grafts
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 techniqu ...
, 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.
Flaps may also carry with them tissues such as muscle and bone that may be useful in the ultimate reconstruction.
Uses
Flap surgery is a technique essential to
plastic
Plastics are a wide range of synthetic polymers, synthetic or Semisynthesis, semisynthetic materials composed primarily of Polymer, polymers. Their defining characteristic, Plasticity (physics), plasticity, allows them to be Injection moulding ...
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 implicat ...
. A flap is defined as tissue that can be moved to another site and has its own
blood supply
In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart an ...
. This is in comparison to a
skin graft
Skin grafting, a type of graft (surgery), graft surgery, involves the organ transplant, transplantation of skin without a defined circulation. The transplanted biological tissue, tissue is called a skin graft.
Surgeons may use skin grafting to ...
which does not have its own blood supply and relies on
vascularization
Vascularisation is the physiological process through which blood vessels form in tissues or organs. Vascularisation is crucial to supply the organs and tissues with an adequate supply of oxygen and nutrients and for removing waste products.
Bloo ...
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 of various types and bulk for successful closure and function.
Anatomy
Flaps can contain many different combination of layers of tissue, from skin to bone (see ). 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.
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 systems that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to bacteria, as well as cancer cells, parasitic worms, and also objects such as ...
, and blood supply aid in flap survival.
The skin can be divided into three main layers: the
epidermis
The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and Subcutaneous tissue, hypodermis. The epidermal layer provides a barrier to infection from environmental pathogens and regulates the ...
,
dermis
The dermis or corium is a layer of skin between the epidermis (skin), epidermis (with which it makes up the cutis (anatomy), cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from s ...
, and
subcutaneous tissue
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, or 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 ma ...
. 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.
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,
because flaps are cut off from other blood vessels when it 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
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 mainly by processes of sprouting and ...
.
Angiosome
The
angiosome is a concept first coined by Ian Taylor in 1987.
It 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 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 generally chooses the least complex type that will achieve the desired effect via a concept known as the
reconstructive ladder The reconstructive ladder is the set of levels of increasingly complex management of wounds in reconstructive plastic surgery. The surgeon should start on the lowest rung and move up until a suitable technique is reached.
There are several small v ...
.
Mechanism of movement
* 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 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.
The pedicle can be removed after a new blood supply has formed. Examples:
pectoralis major myocutaneous flap and deltopectoral flap for head and neck defects, and
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 dorsi'') comes from L ...
flap and
traverse rectus abdominal muscle (TRAM) flap for breast reconstruction.
* 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
The terms free flap, free autologous tissue transfer and microvascular free tissue transfer are synonymous terms used to describe the "transplantation" of tissue from one site of the body to another, in order to reconstruct an existing defect. ...
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 flaps 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 include
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 el ...
,
deep inferior epigastric perforator (DIEP) flaps, and V-Y advancement flaps.
* Fasciocutaneous flaps contain subcutaneous tissue and deep fascia, resulting in a more robust blood supply and ability to fill a larger defect. The Cormack and Lamberty classification is used for the 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
Muscle is a soft tissue, one of the four basic types of animal tissue. There are three types of muscle tissue in vertebrates: skeletal muscle, cardiac muscle, and smooth muscle. Muscle tissue gives skeletal muscles the ability to muscle contra ...
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 without a defined circulation. The transplanted biological tissue, tissue is called a skin graft.
Surgeons may use skin grafting to ...
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 is located superficial to the soleus in the posterior (back) compartment of the leg. It runs from its t ...
flap, latissimus dorsi flap, TRAM flap, and
transverse upper gracillis flap.
* Bone flaps contain bone and are used when structural support is needed such as in jaw reconstruction. Example: fibula flap.
*
Omental flaps can be used in chest wall defects, and
intestinal
The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascular system. T ...
flaps can be used to reconstruct tubular structures like the esophagus.
Vascular supply
Classification based on blood supply to the flap:
* Axial flaps are supplied by a named
artery
An artery () is a blood vessel in humans and most other animals that takes oxygenated blood away from the heart in the systemic circulation to one or more parts of the body. Exceptions that carry deoxygenated blood are the pulmonary arteries in ...
and
vein
Veins () are blood vessels in the circulatory system of humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are those of the pulmonary and feta ...
. 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; they are supplied by the subdermal plexus.
* Pedicled flaps remain attached to the donor site via a pedicle that contains the blood supply, in contrast to a free flap, where the vessels are cut and
anastomosed
An anastomosis (, : 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, or streams. Such a connection may be normal (suc ...
to another blood supply.
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
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 ...
, which include individuals with
comorbidities
In medicine, comorbidity refers to the simultaneous presence of two or more medical conditions in a patient; often co-occurring (that is, concomitant or concurrent) with a primary condition. It originates from the Latin term (meaning "sickness" ...
such as
diabetes
Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...
,
smoking
Smoking is a practice in which a substance is combusted, and the resulting smoke is typically inhaled to be tasted and absorbed into the bloodstream of a person. Most commonly, the substance used is the dried leaves of the tobacco plant, whi ...
,
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 vessels of the circulatory system in the human body, body, including blood vessels – the arteries and veins, and the lymphatic vessels. Vascular disease is a subgroup of cardiovascular disease. Diso ...
.
Risks or complications
The risks of flap surgery include infection,
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, urethr ...
, damage to nearby structures, and
scar
A scar (or scar tissue) is an area of fibrosis, 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 Organ (anatomy), organs, and biological tissue, t ...
ring.
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.
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 of wound healing. 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. Hemostasis involves three ...
,
inflammation
Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
,
proliferation
Proliferation may refer to:
Weapons
*Nuclear proliferation, the spread of nuclear weapons, material, and technology
*Chemical weapon proliferation, the spread of chemical weapons, material, and technology
*Missile proliferation, the spread of lon ...
, 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, o ...
, all of 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. It is part of the reconstructive ladder.
The first known reports of surgical flaps originated in 600 BC in India by
Sushruta
Suśruta (, ) is the listed author of the '' Suśruta Saṃhiāa'' (''Suśruta's Compendium''), considered to be one of the most important surviving ancient treatises on medicine. It is also considered a foundational text of Ayurveda. The treat ...
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 the advancement of 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 surgery, surgeon, pioneer of plastic and reconstructive surgery.
Biography
Tag ...
, 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", an episode of tel ...
.
Major advancements in modern plastic surgery are mostly attributed to
Harold Gillies
Sir Harold Delf Gillies (17 June 1882 – 10 September 1960) was a New Zealand otolaryngologist and father of modern plastic surgery for the techniques he devised to repair the faces of wounded soldiers returning from World War I.
Early life
...
, who pioneered facial reconstruction during World War I using pedicled tube flaps on patients like
Walter Yeo
Walter Ernest O'Neil Yeo (20 October 1890 – December 1960) was an English sailor in the First World War, who is thought to have been one of the first people to benefit from advanced plastic surgery, namely a skin flap.
Early life
Yeo was bo ...
, 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
Arc ...
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 ra ...
, microvascular surgery advancements allowed for the anastomosis 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 specialized for the absorption by enterocytes of small nutrient molecules which have been pr ...
to the
esophagus
The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...
to remove a
cancer
Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...
.
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 wi ...
*
DIEP flap
A DIEP flap (, ) is type of breast reconstruction where blood vessels, fat, and skin from the lower belly are relocated to the chest to rebuild breasts after mastectomy. DIEP stands for the deep inferior epigastric perforator artery, which runs t ...
*
Hand surgery
Hand surgery deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or upper extremity (commonly from the tip of the hand to the shoulder), American Society for Surgery of the Hand. Retriev ...
*
List of plastic surgery flaps
Several techniques for creating flap (surgery), flaps are used in plastic surgery.
List of flaps
See also
* Flap (surgery)
* Perforator flaps
References
{{Skin and subcutaneous tissue procedures , state=collapsed
Plastic surgical proced ...
*
Perforator flaps
Perforator flap surgery is a technique used in reconstructive surgery where skin and/or subcutaneous fat are removed from a distant or adjacent part of the body to reconstruct the excised part. The vessels that supply blood to the flap are isolated ...
*
Rhinoplasty
Rhinoplasty (, nose + , to shape), commonly called nose job, medically called nasal reconstruction, is a plastic surgery procedure for altering and reconstructing the human nose, nose. There are two types of plastic surgery used – plastic sur ...
*
Rotation flap
A rotation flap is a semicircular skin flap that is rotated into the defect on a fulcrum point. Rotation flaps provide the ability to mobilize large areas of tissue with a wide vascular base for reconstruction. The flap must be adequately large, ...
*
Skin cancer
Skin cancers are cancers that arise from the Human skin, skin. They are due to the development of abnormal cells (biology), cells that have the ability to invade or metastasis, spread to other parts of the body. It occurs when skin cells grow ...
*
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 el ...
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 engineers Joanne Berezin and Jeffrey Berezin. The eMedicine website consists of approximately 6,800 medical topic revi ...
{{Authority control
Oral and maxillofacial surgery
Plastic surgery
Surgical procedures and techniques