Phẫu Thuật Tạo Hình (Tập 1): Nguyên Lý Cơ Bản – Neligan (2018)

365.e3
References
105. Hallock GG. Muscle perforator flaps: the name game. Ann Plast
Surg. 2003;51:630–632.
106. Appleton SE, Morris SF. Anatomy and physiology of perforator
flaps of the upper limb. Hand Clin. 2014;30:123–136.
107. Koshima I, Soeda S. Inferior epigastric artery skin flap without
rectus abdominis muscle. Br J Plast Surg. 1989;42:645–648.
108. Blondeel PN, Boeckx WD. Refinements in free flap breast
reconstruction: the free bilateral deep inferior epigastric perforator
flap anastomosed to the internal mammary artery. Br J Plast Surg.
1994;47:495–501.
109. Geddes CR. MSc thesis. Dalhousie University, Halifax, Nova Scotia,
Canada.
110. Neligan PC, Blondeel PN, Morris SF, et al. Perforator flaps:
overview, classification and nomenclature. In: Blondeel PN, Morris
SF, Hallock GG, et al., eds. Perforator Flaps. Anatomy, Technique and
Clinical Applications. St. Louis: Quality Medical Publishing; 2006.
111. Voet DVAM, Petrovic M, Masia J, et al. Preoperative planning. In:
Blondeel PN, Morris SF, Hallock GG, et al., eds. Perforator Flaps.
Anatomy, Technique and Clinical Applications. St. Louis: Quality
Medical Publishing; 2006.
112. Blondeel PN, Neligan PC. Complications: avoidance and
treatment. In: Blondeel PN, Morris SF, Hallock GG, et al., eds.
Perforator Flaps. Anatomy, Technique and Clinical Applications. St.
Louis: Quality Medical Publishing; 2006.
113. Song YG, Chen GZ, Song YL. The free thin thigh flap: a new free
flap concept based on septocutaneous arteries. Br J Plast Surg.
1984;37:149–159.
114. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a
new donor site. Anatomy and clinical applications as a fee or
pedicled flap. Plast Reconstr Surg. 1993;92:867–873.
115. Zancolli EA, Angrigiani C. Posterior interosseous island forearm
flap. J Hand Surg Br. 1988;13:130–135.
116. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi
musculocutaneous flap without muscle. Plast Reconstr Surg.
1995;96:1608–1614.
117. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap
for breast reconstruction. Plast Reconstr Surg. 1995;95:1207–1212.
118. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction
with gluteal artery perforator (GAP) flaps. A critical analysis of
142 cases. Ann Plast Surg. 2004;52:118–125.
119. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue
flap? An experience with 672 anterolateral thigh flaps. Plast
Reconstr Surg. 2002;109:2219–2226.
120. Maciel A, Morris SF, Hallock GG. Local flaps including pedicled
perforator flaps. Anatomy, technique and applications. Plast
Reconstr Surg. 2013;131:896e–911e.
121. Prasad V, Morris SF. Propeller DICAP flap for a large defect on the
back. Case report and review of the literature. Microsurgery.
2012;32:617–621.
122. Pribaz JJ, Chan RK. Where do perforator flaps fit in our
armamenatarium? Clin Plast Surg. 2010;37:571–579.
123. Dhar SC, Taylor GI. The delay phenomenon: the story unfolds.
Plast Reconstr Surg. 1999;104:2079–2091.
124. Morris SF, Taylor GI. The time sequence of delay. Plast Reconstr
Surg. 1995;95:526–533.

22 
Flap classification and applications
Joon Pio Hong
SYNOPSIS
■ Flap is tissue(s) with its own vascular supply, allowing transfer from
one site to another.
■ Flaps come in various forms, shapes and function. They may be
composed of a simple skin tissue or multiple composite tissues.
■ The purpose of classification is to understand the anatomy and the
features that each flap provides. It also allows communication not only
with peers but with the patients as well to achieve the common goal of
reconstruction.
■ Various methods can be used to classify flaps, but commonly used
classifications are based on the locality of the flap, vascular supply of
the flap, and tissue components of the flap.
■ By applying a precise knowledge of the anatomy of skin, muscle,
bone, fascia, and other tissue in planning reconstructive procedures,
the surgeon has the ability to restore function in congenital and
acquired defects.
■ This chapter reviews flap classification and gives examples of its
applications.
History
The use of flaps for reconstructive plastic surgery dates back
to 600 BC, when the earliest recorded application of pedicled
flaps for nasal reconstruction is attributed to Sushruta Samhita
(translated by Bhishagratna in 1916).1 The earliest flaps cen-
tered on the head and neck as well as the lower extremities
because wounds in these regions failed to heal by secondary
intention. The initial flaps used would now be considered
random-pattern flaps, as they were not based on a specific
blood supply and were used without an understanding of
how and why they survived. All possible flaps were based on
the simple idea of random flaps.2 Tagliacozzi used a distally-
based arm flap in a two-staged procedure.3 His work was
published in Venice in 1597. Much of this knowledge was
forgotten until the 19th century, when the English surgeon
Carpue successfully used forehead flaps to reconstruct the
noses of two officers.4 The publication of Rhinoplastik by von
Graefe in 1818 further advanced the use of these techniques.5
Attention in the early 20th century remained focused on tubed
random flaps. It was found that the only way to increase
survival of these flaps was to perform a surgical delay. A
German anatomist, Carl Manchot, demonstrated the concept
of anatomic skin territories supplied by consistent vessels in
Die Hautarterien des Menschlichen Korpers, published in 1889.6
Further development into the shape of modern flaps came
with Tansini when he described the skin island of the latissi-
mus dorsi musculocutaneous flap in 1906.7 Davis, crediting
Manchot, demonstrated axial and pedicled muscle and fascial
flaps, as well as composite flaps in 1919.8 McGregor intro-
duced the temporalis flap, which allowed midface and lower
face coverage without the donor site deformity associated
with the previously popular forehead flap.9 Coverage of the
lower third of the face as well as of the oral and esophageal
defects was accomplished by Bakamjian with the use of the
deltopectoral flap.10 The availability of the forehead, tempo-
ralis, and deltopectoral flaps changed the approach to head
and neck cancer extirpative surgery with an emphasis on
immediate reconstruction. A slow evolution of flaps was
based on experience and gradual understanding of anatomy.
The muscle flap for lower extremity reconstruction was
initially described by Stark for coverage of debridement sites
for osteomyelitis.11 Unfortunately, this went unnoticed until
Ger recognized that the leg muscles are a source of well-
vascularized tissue for leg coverage.12 Although Owens, in
1955, used a compound flap consisting of the sternocleido-
mastoid muscle with overlying skin for head and neck
reconstruction, the concept of musculocutaneous perforating
vessels providing a cutaneous territory for superficial muscles
was first reported by Orticochea in 1972.13 Shortly thereafter,
surgeons made significant contributions toward definition of
flaps, expansion, and use of muscle and musculocutaneous
flaps in reconstructive surgery. The contributions included
the concept of cutaneous territory of superficial muscles;14
anatomy of the muscles including specific arcs of rotation;15,16
applications of muscle and musculocutaneous flaps for breast,
  Access video lecture content for this chapter online at expertconsult.com

367
Classification of flaps
staged and ideally functional reconstruction.25 Furthermore,
donor site deformity is frequently avoided because the flap
can be precisely tailored to fit the defect. In 1997, the recon-
structive triangle was introduced to guide the thinking of
complex reconstruction.26 The surgeon may choose the trans-
position flap, microsurgical transplantation, or tissue expan-
sion with the goals of achieving form and function at the
recipient site, avoiding donor site deformity, and providing
safety throughout the reconstructive endeavor. The more
recent introduction of perforator flaps has expanded our
options even more and brought us to the era of free-style
flaps.27 With all the explosive introduction of new flaps, new
ideas and new findings, a classification may not describe all
the innovations involved in the field of reconstruction. Fur-
thermore, the introduction of the corresponding ideas and
nomenclature increases the confusion.
This chapter describes the flap classification based on the
important characteristics of the flap. The atomic classification
of Tolhurst naturally involved the early flap characteristics
and further refinements from Lamberty and Healy describe
the most important factors for flap selection; circulation,
constituents, conformation, contiguity, construction, and
condition.28,29 Further modifications have been made to
accommodate the recent introduction of flaps. In addition,
application of these flaps will be introduced in this chapter.
Classification of flaps
A flap consists of tissue that is mobilized on the basis of its
vascular anatomy. Flaps can be composed of skin (including
subcutaneous fat), skin and fascia, skin and muscle, or skin,
muscle and bone, or various compositions of tissues. Because
the circulation to the tissue to be mobilized is crucial for flap
survival, the development of flap techniques has depended
on defining the vascular anatomy of the skin and underlying
soft tissue.
The first classification can be made for a random pattern
flap with a non-identified pedicle versus flaps with an identi-
fied pedicle. An early concept of vascular anatomy as it per-
tained to flap surgery was the belief that skin circulation
was based on the longitudinal subdermal plexus. A random
pattern flap based on this subdermal plexus was designed to
allow elevation of skin and subcutaneous tissue with a certain
length : width ratio in the range of 2–1.5 : 1. Based on the
simplicity of circulation, the shape and movement of the flap
were important distinguishing factors (Fig. 22.1). Milton
subsequently disproved the concept of length-to-width ratios
as viability depended on the extent of circulation.30 He further
proved his concept by showing that a delay procedure on the
flap can further increase the extent of the flap in a pig model.31
Historically, attempts to use a random pattern flap based on
subdermal circulation distant from the wound location even-
tually resulted in the introduction of the tubed pedicle flap.
Through a series of delays using the initial bipedicle flap
design, the arc of rotation of the skin flap was increased.
Alternatively, the flap was attached to an arm carrier, which
later required transferring the arm carrier of the random
pattern flap from one body region (donor site) to another
(recipient site). This use of the random pattern flap with
multiple delays or the arm carrier allowed reconstruction of
distant complex defects, particularly in the head and neck
chest, extremity, and head and neck reconstruction; and
microsurgical transplantation.17–22 In 1981, Ponten recognized
the input of septocutaneous perforating vessels to the overly-
ing skin circulation.23 On the basis of this observation, the
concept of fasciocutaneous flaps was introduced. Like the
muscle flap, the septocutaneous flap was initially described
in the lower extremity, but the principle of the fasciocutaneous
flap, based on muscle, fascia, and associated cutaneous terri-
tories, was rapidly applied to all body regions (Table 22.1).
Starting in the late 1970s, a proliferation of innovative
techniques reported in the surgical literature throughout the
world defined new anatomic data and applications of the
muscle, musculocutaneous, fascial, and fasciocutaneous flaps.
These advances in flap definition and application have
changed the entire approach to plastic surgery. With the isola-
tion of the vascular pedicles to muscle- and fascia-based flaps,
microsurgical transplantation is selected when the ideal flap
is outside of a traditional and safe arc of rotation to the recipi-
ent site. With the definition of musculocutaneous and fascio-
cutaneous territories, an expander may be used to enlarge flap
dimensions and still ensure direct closure of the donor site.
The reconstructive ladder, introduced in 1982, was appropri-
ate for use in choosing reconstructive methods that ensure
safety in soft-tissue reconstruction.24 With increased under-
standing of the flap anatomy, physiology and even in regards
to donor morbidity, ideal form and function can be achieved
by complex procedures without compromising safety. This
new approach can be considered as an elevator approach to
defects entailing most of the issues to achieve a minimal
Table 22.1  Timeline of the development of flap surgery
600 BC
Sushruta Samhita1
Pedicle flaps in the face and
forehead for nasal
reconstruction
1597
Tagliacozzi3
Nasal reconstruction by tubed
pedicle flap from arm;
described “delay” of
pedicle flap
1896
Tansini207
Latissimus dorsi
musculocutaneous flap for
breast reconstruction
(post-mastectomy)
1920
Gillies397
Tubed pedicle flap
1946
Stark11
Muscle flaps for osteomyelitis
1955
Owens190
Compound neck flap
1963
McGregor9
Temporalis flap
1965
Bakamjian398
Deltopectoral flap
1971
Ger12
Lower extremity
musculocutaneous flap
1972
McGregor and
Jackson399
Groin flap
1972
Orticochea369
Musculocutaneous flaps
1977
McCraw et al.14
Musculocutaneous territories
1981
Mathes and Nahai16
Classification of muscle flaps
based on vascular anatomy
1981
Ponten23
Fasciocutaneous flaps

368
CHAPTER 22 • Flap classification and applications
region, and for coverage of composite wounds when local
tissue was unavailable or severely damaged. Despite this, the
random pattern flap provided no new source of circulation
when transferred to a distant site. Thus, the success of these
flaps ultimately depended on the local wound environment
for nourishment. Although limited in its reach, the random
pattern flap can be elevated and rotated to provide viable skin
and subcutaneous tissue to cover an adjacent wound. Common
flaps based on the subdermal plexus or the underlying vas-
cular source without identification include the bipedicle flap,
Fig. 22.1  (A) Advancement flap. (B) Rotation flap.
A
Design of V–Y flap
V–Y flap advancement
Advancement flap
B
Rotation flap
Inset
Rotation
Fig. 22.2  Keystone flap. A keystone flap is a curvilinear-shaped trapezoidal-design flap essentially being two V–Y advancement flaps along the long axis of the flap.
90º
Excisional
width
=
Flap
width
Ratio 1:1
90º
A
Island flap
V–Y closure
V–Y closure
V–Y
4
5
2
1
3
V–Y
These represent the scissor technique
used for the blunt dissection
90º
90º
B
advancement flaps (i.e., V–Y), and rotation or transposition
flaps. Today these techniques are still widely used for small
or medium-sized defects that can be reconstructed with
regional skin. A similar concept used for larger wounds on
the trunk and extremities is the keystone flap. Described by
Behan, the keystone flap is a curvilinear-shaped trapezoidal-
design flap, essentially being two V–Y advancement flaps
along the long axis of the flap (Fig. 22.2).32 The longitudinal
tension of the flap is released, thus creating laxity and redun-
dancy in the midportion allowing movement horizontally

369
Classification of flaps
toward the defect with minimal tension. Because of the large
size of the flap, identification of the vascular source is not
necessary and it is presumed to have various blood supplies
from the perforators entering from the deep fascia. But when
perforators are identified using a Doppler, one can also call
this a keystone-design perforator island flap.32
Previously with random pattern flaps, type of movement,
shape of the flap or anatomical region was the focus for differ-
entiating the types. But as the anatomy of the vessel became
more evident and the importance recognized, flap description
began to depict the circulation.28 The evolution from random
pattern flaps to fasciocutaneous flaps, myocutaneous flaps and
then recently to perforator flaps was based on the develop-
ment and findings of vascular anatomy throughout the body.
Pioneering work from Manchot, Salmon, Cormack, Lamberty,
Taylor, Morris, Tang, Nakajima and others clarified the vas-
cular anatomy for skin territory originating from a source
vessel.6,29,33–37 The flap elevation practice changed with the
work of Taylor and Palmer presenting the angiosome concept,
which increased our knowledge of vascular territory of the
skin flap.33 Now the concept of vascular territory has evolved
from thinking of the angiosome as the basic unit to applying
the perforator as the basic unit, termed “perforasome”.38
Circulation being clearly the most important characteristic
of flaps with identified pedicle, Cormack and Lamberty were
the first to advocate the source of the circulation as the most
important characteristic of flap selection.29 The six Cs included,
in addition to circulation, constituents (composition), confor-
mation (form/shape), contiguity (destination), construction
(type of pedicle), and conditioning (preparation) (Fig. 22.3).
Hallock further outlined this classification in accordance
with the six Cs and named it “complete classification of
flaps”.39 With the addition of recent flaps and advances, a
modified outline for the basis of flap classification is shown
in Table 22.2.
This approach to muscle flaps can be demonstrated with
the gracilis muscle flap shown in Fig. 22.4:
■ Circulation: medial circumflex femoral artery
■ Constituents: gracilis muscle
■ Contiguity: free flap
■ Construction: antegrade flow
Fig. 22.3  Updated modified “atomic system” with “six Cs” of flap characteristics,
but especially “core” or source of flap circulation, where each has a distinct role in
determining flap nomenclature. (From Hallock GG. The complete classification of
flaps. Microsurgery. 2004;24:157–161.)
Circulation
Direct vessel
Indirect vessel
Constituents
Construction
Contiguity
Conformation
Conditioning
Table 22.2  The basis for flap classification
1. Circulation (blood supply)
Direct vessels
axial
septocutaneous
endosteal
Indirect vessels
myocutaneous
periosteal
2. Constituents (composition)
Skin (with subcutaneous fat)
Fasciocutaneous/fascia
Muscle/musculocutaneous
Visceral
Nerve
Bone
Cartilage
Lymph node (with subcutaneous fat)
Other
3. Contiguity (destination)
Local
Regional
Distant (free)
4. Construction (flow)
Unipedicle*
Bipedicle
Antegrade*
Retrograde (reverse)
Turbocharged
Supercharged
Arterialized venous
5. Conditioning
Delay
Tissue expansion
Prefabrication
Sensate (sensory nerve)
Functional (motor nerve)
None*
6. Conformation
Special shapes
Tubed
Combined flaps
None*
*Denotes default or standard for flaps and can be omitted in the use of
complete classification.
■ Conditioning: none
■ Conformation: muscle only
Thus the gracilis muscle flap from Fig. 22.4 can be named
medial circumflex femoral artery-based (circulation) gracilis
muscle (constituents) free (contiguity) flap with antegrade
flow (construction) with no conditioning (conditioning) and
muscle only (conformation) according to the complete clas-
sification. But, as default, “antegrade flow with no condition-
ing” can be omitted from the nomenclature. Also, since there
is one conformation, “muscle” does not have to be repeated
and, finally, since the circulation from the “medial circumflex

370
CHAPTER 22 • Flap classification and applications
Fig. 22.4  Example of a gracilis muscle flap. It can be named a medial circumflex
femoral artery-based (circulation) gracilis muscle (constituents) free (contiguity)
flap with antegrade flow (construction) with no conditioning (conditioning) and
muscle only (conformation) according to the complete classification.
femoral artery” is an established one for any muscle flaps, this
can be considered to be understood and does not have to be
reiterated. Thus the final classification using the “complete
classification” can be described as “gracilis muscle free flap”.
For muscle flaps, the circulation can be from multiple varia-
tions and these variations play an important part in survival
of each muscle flap. Therefore further classification of muscle
flaps should be addressed.16
The next example would be a musculo-fascio-cutaneous
flap from the same region as shown in Fig. 22.5:
■ Circulation: medial circumflex femoral artery
■ Constituents: gracilis muscle and upper medial thigh
fasciocutaneous
■ Contiguity: free flap
Fig. 22.5  Example of a musculo-fascio-cutaneous flap including the gracilis
muscle and the combined skin and fascia.
■ Construction: antegrade flow
■ Conditioning: none
■ Conformation: combined muscle and fasciocutaneous flap
The flap in Fig. 22.5 can be named as medial circumflex
femoral artery-based (circulation) gracilis muscle and upper
medial thigh fasciocutaneous (constituents) free (contiguity)
flap with antegrade flow (construction) with no conditioning
(conditioning) and combined with muscle and fasciocutane-
ous component (conformation) according to the complete
classification. As defaults are omitted from the nomenclature,
the “complete classification” should be: “combined gracilis
musculo(-fascio-)cutaneous free flap”.
The actual source of circulation feeding the subdermal
plexus of the skin was described in a tripartite system from
Cormack and Lamberty.29 The system consisted of axial (direct
cutaneous), musculocutaneous, and fasciocutaneous types of
free flaps. They further described the fasciocutaneous flap
into subtypes leading to the fasciocutaneous flap classifica-
tion.40 These classifications should be recognized as they rely
on the anatomical vascular system of the flap and improve the
design and survival of the flaps.
When the skin portion of this flap is isolated on a single
perforator, the constituents become a combination of medial
circumflex artery perforator flap and gracilis muscle flap.
Combined flaps with identified circulation can also undergo
a classification for combined/compound flaps.41,42 Thus, this
variation of flap should be named “combined (conjoint)
medial circumflex femoral perforator and gracilis muscle free
flap”.
The final example is shown in Fig. 22.6. Note that this
flap from the upper medial thigh is supplied only with a
perforator.
■ Circulation: medial circumflex femoral artery (perforator)
■ Constituents: upper medial thigh skin (with fat)
Fig. 22.6  Example of flap from the upper medial thigh, supplied only with a
perforator without the gracilis muscle and the fascia.

371
Classification of flaps
4. The angiographic patterns of the intramuscular
vessels.
This classification system enables the surgeon to categorize
the various muscle and musculocutaneous flaps into distinctly
different, clinically applicable groups based on the vascular
anatomy. There are five different vascular patterns by which
the various muscles are categorized (Fig. 22.7).16
Type I: one vascular pedicle – Type I muscles are supplied
by a single vascular pedicle (Table 22.3).
Type II: dominant vascular pedicle and minor pedicle –
Type II muscles are supplied by both a dominant and minor
vascular pedicle. The larger dominant vascular pedicle will
usually sustain circulation to these muscles after the elevation
■ Contiguity: free flap
■ Construction: antegrade flow
■ Conditioning: none
■ Conformation: skin (with fat) only
The circulation to this flap is the same source vessel as the
gracilis muscle or musculocutaneous flap. But this is a flap
supplied with an identified perforator, so recognition should
be made of the perforator as the main circulation. Thus, this
flap should be named as “medial circumflex femoral artery
perforator-based (circulation) upper medial thigh skin (with
fat) (constituents) free (contiguity) flap with antegrade flow
(construction) with no conditioning (conditioning) and skin
only component (conformation) according to the complete
classification. As defaults are omitted from the nomenclature,
the “complete classification” should be “medial circumflex
femoral artery perforator skin flap”.
This type of perforator-based flap has been subject to
controversy as there have been many classifications proposed.
The Gent consensus for classification of perforator flaps will
be reviewed as an example of perforator flap classification.
Flaps based on the constituents
Muscle and musculocutaneous flaps
In 1981, Mathes and Nahai described a classification system
for muscles based on the following anatomic relationships
between the muscle and its vascular pedicles:
1. The regional source of the pedicle entering the muscle
2. The number and size of the pedicle
3. The location of the pedicle with respect to the muscle’s
origin and insertion
Fig. 22.7  Mathes–Nahai classification of muscle and musculocutaneous flaps.
Type I
Type II
Type III
Type IV
Type V
Tensor fascia lata
Gracilis
Gluteus maximus
Sartorius
Latissimus dorsi
Table 22.3  Type I vascular pattern muscles
Abductor digiti minimi (hand)
Abductor pollicis brevis
Anconeus
Colon
Deep circumflex iliac artery
First dorsal interosseous
Gastrocnemius, medial and lateral
Genioglossus
Hyoglossus
Jejunum
Longitudinalis linguae
Styloglossus
Tensor fascia lata
Transversus and verticalis linguae
Vastus lateralis

372
CHAPTER 22 • Flap classification and applications
This vascular pattern allows the muscle to be split, allowing
the use of only part of the muscle as a muscle or musculocu-
taneous flap (Table 22.5).
Type IV: segmental vascular pedicles – Type IV muscles are
supplied by segmental vascular pedicles entering along the
course of the muscle belly. Each pedicle provides circulation
to a segment of the muscle. Division of more than two or three
of the pedicles during elevation as a flap may result in distal
muscle necrosis (Table 22.6).
Type V: one dominant vascular pedicle and secondary
segmental vascular pedicles – Type V muscles are supplied by
a single dominant pedicle and secondary segmental vascular
pedicles. These muscles have one large dominant vascular
pedicle near the insertion of the muscle with several segmen-
tal pedicles near the origin. The internal vasculature can be
supplied by either the dominant or the segmental pedicles,
and therefore the muscle may be elevated as a flap on either
vascular system (Table 22.7).
When a flap is used based on the pedicle as a local or an
island flap, the dominant vascular pedicle to the flap is pre-
served. A factor that may prevent successful flap transposition
is the flap’s arc of rotation. The arc of rotation of a muscle is
determined by the extent of elevation of the muscle from its
anatomic bed and the ability of the muscle to reach adjacent
areas without devascularization. The mobility of a muscle
depends on the number of vascular pedicles and the location
of the dominant vascular pedicle relative to the muscle’s
origin and insertion (Fig. 22.8). The area covered by the arc of
rotation varies among individuals. On the basis of the flap
of the flap when the minor pedicles are divided. This is the
most common pattern of circulation observed in human
muscle (Table 22.4).
Type III: two dominant pedicles – Type III muscles possess
two large vascular pedicles from separate vascular sources.
These pedicles have either a separate regional source of circu-
lation or are located on opposite sides of the muscle. Division
of one pedicle during flap elevation rarely results in loss of
muscle within its vascular distribution. The muscle will
usually survive on one of its two dominant vascular pedicles.
Table 22.4  Type II vascular pattern muscles
Abductor digiti minimi (foot)
Abductor hallucis
Brachioradialis
Coracobrachialis
Flexor carpi ulnaris
Flexor digitorum brevis
Gracilis
Hamstring (biceps femoris)
Peroneus brevis
Peroneus longus
Platysma
Rectus femoris
Soleus
Sternocleidomastoid
Trapezius
Triceps
Vastus medialis
Table 22.5  Type III vascular pattern muscles
Gluteus maximus
Intercostal
Omentum
Orbicularis oris
Pectoralis minor
Rectus abdominis
Serratus anterior
Temporalis
Table 22.6  Type IV vascular pattern muscles
Extensor digitorum longus
Extensor hallucis longus
External oblique
Flexor digitorum longus
Flexor hallucis longus
Sartorius
Tibialis anterior
Table 22.7  Type V vascular pattern muscles
Fibula
Internal oblique
Latissimus dorsi
Pectoralis major
Fig. 22.8  Arc of muscle rotation (latissimus muscle).

373
Classification of flaps
length distal to the point of rotation and the length of the
vascular pedicle, a safe standard arc of rotation is measured
for each flap. A modified arc of rotation is also available based
on refinements in design and specific modifications of the
flap. Precise knowledge of the safe standard and modified
arc of rotation is necessary to avoid loss of the flap from
excessive tension or damage to the pedicle from overzealous
dissection.
In general, the arc of rotation is inversely proportional to
the number of vascular pedicles. If a muscle has a large
number of pedicles, it usually has a limited arc of rotation.
Type IV muscles, such as the sartorius and tibialis anterior,
are examples of muscles with multiple segmental vascular
pedicles and limited arcs of rotation. Similarly, the location of
the dominant vascular pedicle relative to the muscle’s origin
and insertion greatly determines the arc of rotation. The closer
the dominant vascular pedicle is to either the origin or inser-
tion of the muscle, the greater the arc of rotation. The point of
rotation for types I, II, III, and V muscles generally are located
at one end or the proximal third of the muscle. For example,
type V muscles, such as the pectoralis major and latissimus
dorsi, have their major vascular pedicle near their insertion,
and correspondingly have a wide arc of rotation. Certain
muscles, such as type V muscles, have two arcs of rotation.
The first arc of rotation is based on the dominant blood supply,
while the second is based on the secondary segmental vascu-
lar pedicles. Reverse arc of rotation refers to the degree of
transposition of a flap based on its secondary segmental
vascular pedicles.
A muscle can be split and a portion in continuity with the
dominant vascular pedicle can be used as a transposition flap
using just a segment of the muscle. Techniques of muscle
splitting to preserve tissue and function have been described.
The remaining muscle with its origin and insertion is main-
tained to preserve function. Alternatively, the entire muscle
may be split and used to cover two defects simultaneously.
Frequently, only a part of the muscle in proximity to the
dominant vascular pedicle is elevated for microvascular
transplantation. The skin territory may also be modified and
split into two separate skin islands or elevated with only a
segment of the muscle flap. However, the skin territory must
include vascular connections via musculocutaneous perforat-
ing vessels from the segmental flap (Figs. 22.9 & 22.10).
The basis for splitting the pectoralis major muscle was
demonstrated by Tobin in 1985.43 The pectoralis has three
segmental neurovascular subunits: the clavicular, the sterno-
costal, and the external subunit. These can be surgically split
and independently transferred on vascular pedicles from
the thoracoacromial, internal mammary and lateral thoracic
vessels.44 Splitting of the pectoralis major muscle into seg-
ments has been performed when the segmental transfer of a
single intercostal portion of the pectoralis muscle, based on a
single medial perforating branch of the internal thoracic
artery, is required for chest wall and neck reconstruction (Figs.
22.11 & 22.12).45 The concept of segmental transposition of
muscle allows transplantation of independent neuromuscular
units (segments of muscle innervated by a single nerve
fascicle).46
Selection of the most appropriate reconstructive method
can be difficult. Careful consideration must be given to all the
possible methods of repair, and the advantages and disadvan-
tages of each technique must be weighed accordingly.
Fig. 22.9  Gluteus maximus segmental muscle transposition. (A) Superior half of
gluteus maximus, arc to sacrum. (B) Inferior half of gluteus maximus muscle.
Arc to sacrum
A
Arc to sacrum
B
The advantages of muscle or musculocutaneous flaps
include the following:
1. The vascular pedicles are specific and reliable.
2. The vascular pedicle is often located outside the surgical
defect, which can be particularly important for wounds
with an extensive zone of injury beyond the actual
wound (e.g., after irradiation, trauma).

374
CHAPTER 22 • Flap classification and applications
Fig. 22.10  (A–E) Function-preserving muscle flap design.
A
B
C
D
E
3. The muscle provides bulk for deep, extensive defects
and protective padding for exposed vital structures
(e.g., tendons, nerves, vessels, bones, and prostheses).
4. Muscle is malleable and can be manipulated (e.g.,
folded on itself) to produce a desired shape or volume.
5. Well-vascularized muscle is resistant to bacterial
inoculation and infection.47
6. Reconstruction by use of muscle or musculocutaneous
flaps is often a one-stage procedure.
7. Restoration of function, whether motor or sensory, is
possible with certain flaps.
8. The reliability and availability of muscle and
musculocutaneous flaps make them an excellent
alternative means of reconstruction when the closure

375
Classification of flaps
method of choice for a particular defect is unavailable
or inadequate.
The disadvantages of muscle and musculocutaneous flaps
include the following:
1. The donor defect may lose some degree of function.
2. The donor defect may be aesthetically undesirable.
3. Reconstruction with muscle or musculocutaneous flaps
may provide excessive bulk, leaving an aesthetically
unacceptable result.
A
Fig. 22.11  (A,B) Pectoralis major muscle flap segmental transposition.
B
Fig. 22.12  Tibialis anterior muscle flaps split for segmental transposition. (A) Segmental flap. (B) Posterior advancement. (C) Anterior turnover flap.
A
B
C
4. Muscle or musculocutaneous flaps may atrophy over
time and thus fail to provide adequate coverage.
5. Removal of the muscle or musculocutaneous flap may
result in contour deformities at the donor site.
The preservation of function can be extremely important
when nonexpendable muscles are used as flaps. The tech-
niques of function preservation generally involve transposing
part of the muscle without completely interrupting the
origin or insertion of the donor muscle. For example, the

376
CHAPTER 22 • Flap classification and applications
transposition of the superior half of the gluteus maximus
muscle for sacral coverage in the ambulatory patient can be
performed without loss of thigh extension or hip stability
because the remainder of the gluteus maximus is functionally
intact.48,49
Fascia and fasciocutaneous flaps
A growing knowledge of the source of skin circulation after
the recognition of the muscle and musculocutaneous system
led to the identification of vascular pedicles emerging between
muscles (septocutaneous pedicles) and entering the deep
fascia. Elevation of the skin with its deep fascia represented a
new vascular basis for flap design.
A fascial flap consists of fascia detached from its normal
origin or insertion and transposed to another location. Without
the overlying skin and fat, this represents a delicate flap. A
fasciocutaneous flap, originally called an axial flap, includes
the skin, subcutaneous tissue, and underlying fascia, which
may be distinct from the fascia covering the underlying
muscle. The vascular supply is derived at the base of the flap
from musculocutaneous perforators or direct septocutaneous
branches of major arteries.
The first fascia and fasciocutaneous flaps were described by
Ponten in 1981 for lower extremity reconstruction and Tolhurst
in 1983 for trunk and axillary reconstruction.23,28 Investigations
have shown that the fasciocutaneous system consists of perfo-
rating vessels that arise from regional arteries and pass along
the fibrous septa between muscle bellies or muscle compart-
ments. The vessels then spread out at the level of the deep
fascia, both above and below, to form plexuses, which in turn
give off branches to the skin. In 1975, Schafer found three
major vascular systems of the deep fascia.50
1. Perforating arteries from underlying muscle giving off
several radiating branches, which perforate the fascia
before continuing to the subdermal plexus.
2. Subcutaneous arteries running in the fat and
anastomosing frequently with the superficial plexus of
the deep fascia and with each other.
3. Subfascial arteries arising from the intermuscular septa
and running in the loose areolar tissue beneath the deep
fascia and adjoining the deep and superficial plexus.
These pedicles consist of an artery (generally a branch of the
artery to the specific anatomic region of the fascia and regional
musculature) and paired venae comitantes that drain into
corresponding major regional veins. Direct cutaneous and
septocutaneous pedicles are fairly constant in location. There
is a greater variability in location of the musculocutaneous
perforators. These pedicles provide a vascular basis for spe-
cific fascial or fasciocutaneous flaps. On this basis, Mathes and
Nahai have classified fascia and fasciocutaneous flaps as
types A, B, and C (Fig. 22.13).26
Anatomic studies demonstrate that type A fasciocutaneous
flaps have a vascular pedicle to the deep fascia that emerges
from a regional source coursing initially beneath the deep
fascia and eventually continuing its course superficial to the
deep fascia. This pedicle provides numerous fasciocutaneous
perforators to the skin. Because the pedicle tends to course
in a radial fashion from its regional source into its distal
cutaneous distribution, the flap is often referred to as an axial
flap. The long, relatively superficial course of the dominant
Fig. 22.13  Mathes–Nahai classification of fascia/fasciocutaneous flaps.
Type A
Type B
Type C
pedicle permits evaluation by palpation or Doppler probe
(Table 22.8).
Type B fasciocutaneous flaps have a septocutaneous
pedicle, which courses between major muscle groups in an
intermuscular septum or between adjacent muscles. This
pedicle is located within the intermuscular septum or the
potential space between adjacent muscles and supplies a
regional fascial vascular system. The largest septocutaneous
pedicles are dominant pedicles to specific fasciocutaneous
flaps and are fairly constant in location (Table 22.9).
In certain regions, larger musculocutaneous perforators
enter the deep fascia and contribute to both the deep fascia
and cutaneous circulation. The design of a fasciocutaneous
flap can be based on these dominant perforating vessels
without incorporation of the underlying muscle; this vascular
pattern represents the type C fasciocutaneous flap. However,
increasing pedicle length will necessitate proximal dissection
of the pedicle through muscle to its regional source or incor-
poration of all or part of the muscle in the flap design. Type

377
Classification of flaps
Table 22.8  Type A fascial and fasciocutaneous flaps
Deep external pudendal artery
Digital artery
Dorsal metacarpal artery
Gluteal thigh
Great toe (hallux)
Groin
Lateral thoracic (axillary)
Pudendal – thigh
Saphenous
Scalp
Second toe
Standard forehead
Superficial external pudendal artery
Superficial interior epigastric artery
Sural artery
Temporoparietal fascia
The supplying artery is included within the flap. It may be
based proximally, distally, or as a free flap. The type D flap is
an osteomusculofasciocutaneous flap, and is based on multiple
small perforators similar to the type C flap, but also includes
a portion of adjacent muscle and bone. It may be based proxi-
mally or distally on a pedicle or used for microvascular tissue
transplantation (Fig. 22.14).
Nakajima et al. expanded the types of fasciocutaneous flaps
and described them originating from 6 different types of
perforators piercing the deep fascia feeding to the plexus
of the skin (Fig. 22.15).37 Type A, direct cutaneous branch of
muscular vessel was described in the same manner as axial
pattern flaps of McGregor and Morgan.51 Type B, septocutane-
ous perforator was the same as type B from the classification
of Cormack and Lamberty.40 Type C, direct cutaneous branch
and type D, musculocutaneous perforator supplying the
fasciocutaneous flap were not quite described in previous
classifications. These types, especially type D from the
Nakajima et al. classification, further play a pivotal role for
setting up the concept of true perforator flaps.52 Type E, direct
septocutaneous describes type C from the classification of
Cormack and Lamberty and type F, perforating cutaneous
branch of muscular vessel resembles traditional musculocu-
taneous flaps.22,29,40
The fasciocutaneous flap is used as a local flap, the standard
arc of rotation is determined by the extent of elevation of the
deep fascia from its normal anatomic position to reach adja-
cent defects. The point of rotation is based on the site of
entrance of the dominant vascular pedicle into the fascia. The
fascia or fasciocutaneous flap is elevated to the point of
entrance of the flap pedicle, and the fascia and overlying skin
distal to this point are rotated into the defect.
The advantages and disadvantages of these flaps are some-
what similar to those of muscle flaps, although there are a few
exceptions. The advantages include the following:
1. They are thin and pliable.
2. The blood supply is reliable and robust.
3. The donor site morbidity is minimal in regard to
function.
4. They are muscle sparing.
5. They have the ability to restore sensation.
6. There are many potential donor sites.
The disadvantages of fascia, fasciocutaneous, and perforator
flaps include the following:
1. There is a lack of bulk for deep defects.
2. They are technically more challenging (pedicle
dissection; many require microvascular anastomosis or
at least microvascular techniques).
3. There are size limitations.
4. The arc of rotation is sometimes limited though often
better than the similar muscle flap because of the longer
pedicle.
5. Donor site may require skin graft closure, resulting in
donor site deformity.
Perforator flap (skin with fat and with or
without fascia)
Further refinements in flap application have led to the devel-
opment of perforator flaps. Perforator flaps have evolved
Table 22.9  Type B fascial and fasciocutaneous flaps
Anterolateral thigh
Anterior tibial artery
Deltoid
Dorsalis pedis
Inferior cubital artery (antecubital)
Lateral arm
Lateral plantar artery
Lateral thigh
Medial arm
Medial plantar artery
Medial thigh
Peroneal artery
Posterior interosseous
Posterior tibial artery
Radial forearm
Radial recurrent
Scapular
Ulnar recurrent
Table 22.10  Type C fascial and fasciocutaneous flaps
Anterolateral thigh
Deltopectoral
Nasolabial
Median forehead
Thoracoepigastric (transverse abdominal)
Transverse back
C flaps are generally the anatomic model used for the perfora-
tor flap in microsurgical transplantation (Table 22.10).
Cormack and Lamberty also classified fasciocutaneous
flaps based on vascular anatomy.29,40 The type A flap is sup-
plied by multiple fasciocutaneous perforators that enter at the
base of the flap and extend throughout the longitudinal
length. The flap can be based proximally, distally, or as
an island. The type B flap has a single fasciocutaneous perfo-
rator, which is of moderate size and is fairly consistent. It is
intended for use as a free flap. The type C flap is based on
multiple small perforators that run along a fascial septum.

378
CHAPTER 22 • Flap classification and applications
Fig. 22.14  Classification of fasciocutaneous flaps.
Vascular plexus of the deep
fascia supplying overlying skin
Subcutaneous vein draining
the skin through the superficial
venous system
Muscle belly – generally long,
thin muscles
Venae comitantes of regional artery
May also receive veins draining down
along fascial septum
Fasciocutaneous perforators
lying in intermuscular
fascial septum
Major regional artery
General scheme of vascularization
Type A
Type B
Type C
Type A – Subcutaneous
pedicle
B – modified
Type D

379
Classification of flaps
Fig. 22.15  The six distinctive deep fascia perforators according to Nakajima and
colleagues are indicated. A, direct cutaneous branch of a muscular vessel; B,
septocutaneous perforator; C, direct cutaneous; D, musculocutaneous perforator; E,
direct septocutaneous; F, perforating cutaneous branch of a muscular vessel. A
separate type of fasciocutaneous flap could be named after each different perforator.
(Modified from Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to
the skin and classification of skin flaps according to their vascularization. Ann Plast
Surg. 1986;16:1–19.)
A
B
C
F
E
D
Fig. 22.16  Evolution of the abdominal skin flap for breast reconstruction from
transverse rectus abdominis muscle (TRAM) flap (A) to muscle-sparing TRAM
(B) to deep inferior epigastic perforator (DIEP) flaps (C).
A
B
C
from musculocutaneous and fasciocutaneous flaps without
the muscle or fascial carrier. It was a natural evolution as
reconstruction needed fine-tuning while aiming to minimize
donor morbidities. A good example of this evolution would
be the change from transverse rectus abdominis muscle
(TRAM) flaps to muscle-sparing TRAM to deep inferior epi-
gastic perforator (DIEP) flaps (Fig. 22.16). Transformation of
these flaps has shown that neither a passive muscle carrier
nor the underlying fascial plexus of vessels are necessary for
flap survival.53 Thus, a perforator flap is a skin flap (with or
without fascia) based on a single perforator.54 Like the angio-
some concept showing the vascular territory of a source
vessel, one must understand the anatomy and physiology of
a single perforator territory to obtain the ideal design of
the perforator flap.33 The perforasome theory by Saint-Cyr
reported four major characteristics of a perforator flap: (1)
each perforasome is linked with adjacent perforasomes by
means of direct and indirect linking vessels (Fig. 22.17); (2)
flap design and skin paddle orientation should be based on
the direction of the linking vessels, which is axial in the
extremities and perpendicular to the midline in the trunk (Fig.
22.18); (3) filling of the perforasomes occurs within perfora-
somes of the same source artery first followed by perforators
of the other adjacent source arteries; (4) mass vascularity of a
perforator found adjacent to an articulation is directed away
from that same articulation (Fig. 22.19).38 This theory provides
insights into perforator flap vascularity and can clinically
guide to the harvest of a safer free or pedicle perforator flap.
In 1989 Koshima and Soeda used the term “perforator
flaps” in their harvest for paraumbilical skin and fat island
flaps based on a muscular perforator.53 Since then, perforator-
based flaps using lower abdomen skin flaps have been applied
for breast reconstruction.55,56 Slowly other perforator-based
flaps have been introduced from various parts of the skin.
The nomenclature of perforator flaps is confusing and
oftentimes misstated. Perforator flaps have been designated
by their location (e.g., anterolateral thigh flap), arterial supply
(e.g., deep inferior epigastric artery perforator flap), or the
muscle of origin (e.g., gastrocnemius perforator flap). Thus, a
clear definition and classification for perforator flaps was
needed. Hallock defines a perforator as any vessel that pierces
through the fenestration in the deep fascia regardless of
origin.54 In a consensus document for perforator flap terminol-
ogy, perforators that pierce through the deep fascia without
traversing any other structural tissues were called direct
perforators while indirect perforators run through deeper

380
CHAPTER 22 • Flap classification and applications
Fig. 22.17  Each perforasome is linked with adjacent perforasomes by means of direct and indirect linking vessels. Direct linking vessels communicate directly with
adjacent perforators and indirect linking vessels are communicating through the subdermal plexus.
Anterolateral thigh
perforator complex
Anteromedial thigh
perforator complex
Linking vessel
Linking vessel
Descending branch to
the subdermal plexus
Fascia
Suprafascial
plexus
Subdermal plexus
Skin
Adipose layer
Fig. 22.18  Orientation of the perforators should be
understood and utilized when designing flaps. The skin
paddle orientation should be based on the direction of the
linking vessels, which is axial in the extremities and
perpendicular to the midline in the trunk.
SCAP flap
SCAP
SEAP flap
UAP flap
ATAP flap
SEAP
UAP
ATAP
IMAP flap
DIEP flap
RAP flap
ALT flap
AMT flap
PTAP flap
PIAP flap
SGAP flap
PFAP flap
MAP flap
PinAP flap
IGAP flap
PAP flap
SCAP flap
TDAP flap
LAP flap
PIAP
SGAP
MAP
PFAP
PinAP
IGAP
PAP
TDAP
LAP
Posterior intercostal artery perforator
Superior gluteal artery perforator
Metacarpal artery perforator
Profundus femoris artery perforator
Posterior interosseus artery perforator
Inferior gluteal artery perforator
Peroneal artery perforator
Thoracodorsal artery perforator
Lumbar artery perforator
IMAP
DIEP
RAP
ALT
AMT
PTAP
Supraclavicular artery perforator
Superior epigastric artery perforator
Ulnar artery perforator
Anterior tibial artery perforator
Internal mammary artery perforator
Deep inferior epigastric perforator
Radial artery perforator
Anterior lateral thigh
Anterior medial thigh
Posterior tibial artery perforator
structures such as muscles, septum and perimysium.54,57
Evolved from the six patterns of fascial perforators of Naka-
jima et al., the consensus paper simplified it into 5 types of
perforator based on the surgical approach for dissection of the
perforators (Fig. 22.20). Type 1: direct perforators perforate
the deep fascia only; type 2: indirect muscle perforators
predominantly supply the subcutaneous tissues; type 3:
indirect muscle perforators predominantly supply the muscle
but have secondary branches to the subcutaneous tissues;
type 4: indirect perimysial perforators travel within the peri-
mysium between muscle fiber before piercing the deep fascia;
type 5: indirect septal perforators travel through the

381
Classification of flaps
Definition 6: A perforator flap should be named after the
nutrient artery or vessels and not after the underlying
muscle. If there is a potential to harvest multiple perforator
flaps from one vessel, the name of each flap should be
based on its anatomical region or muscle.
This terminology and the classification into indirect and
direct perforator flaps and further into septal and muscle
perforator flaps were set up to clearly identify the course of
these small terminal branches before they pierce the deep
fascia and the technical implications during the surgical pro-
cedure.57,58 Table 22.11 shows some of the popular perforator
flaps based on this terminology. Recent innovations in this
field have made some of the terminology and classification
somewhat misleading. As with all evolution, new classifica-
tion and terminology will be constantly updated.
The perforator flap concept simplified and overcame the
applications and limits of classic local flaps. By identifying
the perforator as the pedicle and further dissecting toward
the source vessel, it allowed improved movement and better
survival of flap. One form of perforator-based local flap, the
propeller flap, is an island flap that reaches the recipient site
through an axial rotation.59,60 When a perforator propeller flap
is being elevated, the perforator is dissected free from the
fascial and fat adhesions to minimize the chance of kinking.
Although less rotation reduces the chance for kinking, the
skin island may be safely rotated up to 180° (Fig. 22.21).
Advantages of perforator flaps include:
1. Reduced donor site morbidity
2. Versatility in flap design
3. Muscle sparing (less functional deficit)
4. Improved postoperative recovery of the patient.61–65
Disadvantages of perforator flaps may include:
1. Meticulous dissection needed to isolate the perforator
vessels
2. Increased operative time especially in muscle
perforators
3. The variability in the position and size of the perforator
vessels
4. Steep learning curve.66,67
However, modifications such as the free-style approach and
supermicrosurgery have further simplified the approach
and increased the use of perforator flaps.68–70 The free-style
intermuscular septum before piercing the deep fascia. Based
on this distinction of different perforators, the consensus
paper gives definitions and classification for perforator flaps
as follows:
Definition 1: A perforator flap is a flap consisting of skin
and/or subcutaneous fat. The vessels that supply the
blood to the flap are isolated perforator(s). These
perforators may pass either through or in between deep
tissues (mostly muscle).
Definition 2: A muscle perforator is a blood vessel that
traverses through septum to supply the overlying skin.
Definition 3: A septal perforator is a blood vessel that
traverses only through septum to supply the overlying
skin.
Definition 4: A flap that is vascularized by a muscle
perforator is called a muscle perforator flap.
Definition 5: A flap vascularized by a septal perforator is
called a septal perforator flap.
Fig. 22.19  Direction of perforator flow between
articulations.
Distal and proximal perforators – unidirectional flow away from articulation
Central perforators – bidirectional flow towards joints
Perforator location
Direction of blood flow
Fig. 22.20  The different types of direct and indirect perforator vessels with regard
to their surgical importance. 1, Direct perforators perforate the deep fascia only; 2,
indirect muscle perforators predominantly supply the subcutaneous tissues; 3,
indirect muscle perforators predominantly supply the muscle but have secondary
branches to the subcutaneous tissues; 4, indirect perimysial perforators travel
within the perimysium between muscle fibers before piercing the deep fascia; 5,
indirect septal perforators travel through the intermuscular septum before piercing
the deep fascia. (Adapted from Blondeel PN, Van Landuyt KH, Monstrey SJ, et al.
The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast
Reconstr Surg. 2003;112:1378–1383; quiz 1383, 1516; discussion 1384–1387.)
Deep fascia
1
2
3
4
5
Muscle
Source vessel

382
CHAPTER 22 • Flap classification and applications
to the stomach with a long segment of jejunum where one
pedicle is revascularized in the upper chest or neck and the
second pedicle is left intact. Additional uses of the colon or
jejunum as flaps have been for vaginal reconstruction. The
appendix, as a type I pattern based on the appendiceal artery
and vein, has been used for reconstructing the urethra and for
voice reconstruction.72–74
approach identifies the perforator feeding the skin flap first
and then dissects proximally toward the source vessel con-
trary to the classic approach where identification of the source
vessel was made first and then dissection toward the perfora-
tor. This allows the freedom to design flaps based on any
perforator as well as alleviate the risk for pedicle variation.68
The supermicrosurgery approach, perforator to perforator
anastomosis, allows harvesting the flap as a short pedicled
flap, reducing the dissection time and minimizing the risk for
traumatizing the pedicle during dissection.69,71
Visceral flaps
The abdominal viscera are not easily classified; however, for
the purposes of flap transposition or microvascular tissue
transplantation, the colon, jejunum, and omentum fall conve-
niently into the muscle classification system (Table 22.12). For
microvascular transplantation, the segment of bowel (jejunum
or colon) is elevated on one vascular arcade with a single
dominant vessel, a type I pattern of circulation. In unusual
circumstances where a longer segment of bowel extends
beyond the vascular territory of one arcade, two vascular
arcades must be included to ensure viability of this longer
segment of bowel. In this instance, the pattern of circulation
will be type III (two dominant arcades or pedicles). It is pos-
sible to reconstruct the esophagus from the base of the tongue
Table 22.11  Perforator flap terminology
Flap – abbreviation
Flap – full name
Nutrient artery
Muscle perforator flaps
DIEP
Deep inferior epigastric perforator
Deep inferior epigastric vessels
TAP
Thoracodorsal artery perforator
Thoracodorsal vessels
SGAP
Superior gluteal artery perforator
Superior gluteal vessels
IGAP
Inferior gluteal artery perforator
Inferior gluteal vessels
IMAP
Internal mammary artery perforator
Internal mammary vessels
ICAP
Intercostal perforator
Intercostal vessels
PLP
Paralumbar perforator
Paralumbar perforating vessels
GP
Gracilis perforator
Medial circumflex femoris vessels
TFLP
Tensor fasciae latae perforator
Transverse branch of the lateral circumflex femoris vessels
ALTP
Anterolateral thigh perforator
Descending branch of the lateral circumflex femoris vessels
AMTP
Anteromedial thigh perforator
Innominate branch of the descending branch of the lateral
circumflex femoris vessels
SAP
Sural artery perforator
Sural vessels
PTAP
Posterior tibial artery perforator
Posterior tibial vessels
ATAP
Anterior tibial artery perforator
Anterior tibial vessels
Septal perforator flaps
RAP
Radial artery perforator
Radial vessels
AP
Adductor perforator
Medial circumflex femoris vessels
AMTP
Anteromedial thigh perforator
Innominate branch of the descending branch of the lateral
circumflex femoris vessels (if perforator runs only in septum)
ALTP
Anterolateral thigh perforator
Descending branch of the circumflex femoris lateralis vessels
(if perforator runs only in the septum)
(From Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg.
2003;112:1378–1383; quiz 1383, 1516; discussion 1384–1387.)
Table 22.12  Abdominal visceral flap classification
Flap
Type
Circulation
pattern
Size
Colon
Bowel
Type I
20–25 cm in length
Lumen diameter of
8 cm
Jejunum
Bowel
Type I
7–25 cm may be
transferred on
one pedicle
Lumen diameter of
3–5 cm
Omentum
Omentum
Type III
Variable; up to
40 × 60 cm

383
Classification of flaps
Bone flap (vascularized bone, osseous–
periosteal flap)
Bone is vascularized through endosteal and periosteal sources
(Fig. 22.22). The complex blood supply of bone is based on
nutrient vessels entering the bone directly and through vas-
cular connections between muscles and bone, typically where
the muscle has a large bony origin or insertion. Vascularized
bone is useful in muscles suitable for microvascular trans-
plantation or in those muscles designed for transposition
when the vascular attachments to bone are distal to the point
of rotation. The commonly transferred bones include the
fibula based on the peroneal artery, iliac crest based on the
deep circumflex iliac artery (Fig. 22.23), the scapula based on
the circumflex scapula or thoracodorsal arteries (Fig. 22.24),
and the radius based on the radial artery (Fig. 22.25). The
calvarial osseous flap based on the superficial temporal artery
or occipital artery with partial- or full-thickness bone is also
useful for reconstructing facial anomalies and deformities
(Fig. 22.26).82–85
The use of periosteum and part of the cortical bone as an
osseous–periosteal flap is being widely used for nonunion of
the bone and small bone defects. The genicular osseous–
periosteal flap, also known as the medial femoral condyle
flap, based on the articular branch of the descending genicular
artery and vein with periosteum and a thin (0.5 to 1.0 mm)
layer of outer cortical bone, was first reported by Sakai et al.
to treat fracture nonunion (Fig. 22.27).86 Further applications
of this flap with or without skin and cartilage expanded to
reconstructing small bone defects, avascular necrosis of the
bone and other complex defects of the hand.87–89
There is no widely accepted classification of bone flaps
alone. Perhaps it is due to the complexity of the vasculature
to each bone. One of the most widely used, the fibula, has
vascular supply from the branches of the anterior tibial artery
supplying the head, neck, and epiphysis while the peroneal
Fig. 22.21  One form of perforator-based local flap, the propeller flap, is an island
flap that reaches the recipient site through an axial rotation.
Fig. 22.22  Flap vascular connections to bone.
Periosteal
connections
Endosteal
connection
The omentum may be based as a transposition flap on
either the right or left gastroepiploic vessels and is thus clas-
sified as having a type III pattern of circulation. The omentum
is also commonly transferred microsurgically. The omentum
can be used to reconstruct a wide range of extraperitoneal
defects and has been shown to have immunologic and
angiogenic properties.75–77 Although useful for reconstruction,
donor site complications can be significant, including abdomi-
nal wall infection and hernia.78,79 With the advances in mini-
mally invasive surgery, the abdominal viscera can successfully
be harvested laparoscopically obviating the need for a large
midline incision providing a better cosmetic result and less
donor site morbidity.31,80,81

384
CHAPTER 22 • Flap classification and applications
Fig. 22.23  Deep circumflex iliac artery composite flap.
(A) Marking. (B) Division of the external oblique
aponeurosis and pedicle identification. (C) Division of
the internal oblique. (D) Release of TFL. (E) Completion
of dissection.
A
B
C
D
E

385
Classification of flaps
artery gives rise to multiple arcuate vessels along the fibula
and a nutrient vessel in the mid third of the fibula bone (Fig.
22.28). Thus, depending on the portion of the fibula bone
being harvested, the pedicle of the bone flap can differ not
only in anatomical region but also in type of vascular supply
to the bone. The fibula bone flap with or without the skin
(fasciocutaneous) flap is frequently used for segmental bone
defects especially after mandibular resection, long bone resec-
tion and for pelvis reconstruction (see Fig. 22.23).90 The fibular
bone including the head and epiphyseal growth plate is used
in patients who need further growth of the long bone such
as reconstruction after sarcoma resection of the proximal
humerus.91,92
Nerve flap
The sensory nerves are supplied by an extrinsic and intrinsic
blood supply. The extrinsic blood supply to the peripheral
nerves consists of arteriae nervorum that rise directly from the
perforating vessels. These perforating vessels may originate
from various deeper vessels as seen from Nakajima’s perfora-
tor classification.37 These small arteriae nervorum enter the
nerve and terminate intraneurally. The intrinsic blood sup-
plies are the longitudinally oriented arterioles located on the
epineurium, perineurium, and endoneurium. The intrinsic
vessels communicate and receive vascular supply from the
extrinsic arteriae nervorum and the end branches (Fig.
22.29).93,94 Thus, the nerve flap can be harvested from superfi-
cially located sensory nerves based on perforating vessels
originating from a proximal source vessel. Based on this clear
distinction of tissue being supplied by a vascular source, the
term “vascularized nerve graft” would be a misnomer and
“nerve flap” should be used to minimize confusion. Currently
there is no classification for nerve flaps.
Well-known examples of nerve flaps would be superficial
radial nerve flap based on the radial artery and accompanying
veins, saphenous nerve flap proximally based on the branches
Fig. 22.24  Independent vascularized segments of the scapula based on circumflex
scapular and thoracodorsal pedicles. s, subscapular artery; D, circumflex scapular
artery; t, thoracodorsal artery; a, scapular arterial branch.
s
t
D
a
Fig. 22.25  An osteocutaneous flap with composition of radius bone, and attached
fasciocutaneous flap is elevated based on the proximal radial artery and vein
pedicle.
Osseous segment
Pronator teres
Pronator quadratus
Brachioradialis
Radial donor defect
from the femoral artery and distally based on the saphenous
artery, and sural nerve flap based on the superficial sural
artery or medial sural artery.95–99
In cases where perforators are not found leading to the
superficial nerve, one can use the accompanying vein along
the superficial nerve in an arterialized fashion. A typical
example would be the sural nerve flap, where an arterial
supply such as superficial sural artery, medial or lateral sural
artery would be missing and the lesser saphenous vein would
be arterialized (Fig. 22.30).100–102
Lymph node flap
Each lymph node has afferent lymphatic vessels that transport
lymph to the node and an efferent vessel that transports fluid
toward the thorax and into the chylothoracic duct. The node
itself also has its vascular supply based on arterial inflow and

386
CHAPTER 22 • Flap classification and applications
Fig. 22.26  The calvarial osseous flap based on the
superficial temporal artery with a segment of temporal
fascia and muscle is elevated.
Dura
Temporal branch of
facial nerve
Temporalis
Calvarial graft isolated on anterior
branches of superficial temporal
artery and vein
venous outflow (Fig. 22.31). This is why lymph node(s) with
fat can be considered as a flap. It is this lymph node flap
transfer that offers a solution to lymphedema patients. Often
lymph node vessels are extremely small and may require
supermicrosurgery technique to anastomose to a recipient
vessel but can be anastomosed comfortably when dissected
proximally toward the source vessels such as superficial
inferior epigastric artery, superficial circumflex iliac artery,
and supraclavicular artery.103–106 Although the mechanism
remains unclear, clinical reports have been encouraging along
with lymphovenous shunting for lymphedema.106,107
Flaps based on construction (flow)
For most of the flaps, whether they be muscle or skin or a
combination of various tissues, the pedicle usually drains into
a single source making unipedicle the most common form. We
do not use the term unipedicle as part of the nomenclature
but as a default to communicate. The same can be said for
antegrade (orthograde) flow. A bipedicle flap is a flap with
dual pedicle, often used as a random pattern skin flap to cover
a defect on the extremity, or a transabdominal bipedicle flap
can be raised to provide coverage on the dorsum of the hand
(Fig. 22.32).
Retrograde-flow flaps
A flap based on the antegrade flow has a major pedicle that
flows with the flap but, when the same flap has its orthograde
pedicle ligated proximally, becomes a flap based on the distal
part of the major pedicle and the flow of the flap becomes
reversed (Fig. 22.33A). This concept was first reported by
Bostwick et al. using a reverse-flow temporal artery island
flap.108 In reality, some of the random pattern flaps or axial
cutaneous flaps were used in a reverse manner without real-
izing the axiality and direction of the flow, such as acromio-
thoracic tube pedicle.109
A number of clinically useful retrograde (reverse) flow
flaps have been described since its original description in
1976, including the distally based radial forearm fasciocutane-
ous flap, posterior interosseous flap, and the reversed first
dorsal metacarpal artery flap used in hand reconstruction.110–112
The distally based radial forearm flap relies on retrograde
flow through the deep palmar arch and associated venae

387
Classification of flaps
Fig. 22.27  The genicular osseous–periosteal flap, also
known as the medial femoral condyle flap, is based on the
articular branch of the descending genicular artery and vein
with periosteum and thin (0.5–1.0 mm) layer of outer cortical
bone (A). It is commonly used to reconstruct small bone
defects, avascular necrosis of the bone and other complex
defects of the hand (B). MCL, medial collateral ligament.
Descending
genicular artery
Medial superior
genicular artery
Recipient bone
Graft transferred and
wrapped around defect
Bone chips
in defect
MCL
A
B
comitantes with the rotation point of the reverse flap at the
level of the wrist (Fig. 22.33B). Examples of reversed flow
flaps used for lower extremity reconstruction are sural fascio-
cutaneous flaps based on perforators from the peroneal artery,
lateral calcaneal flaps based on reverse flow of the lateral
calcaneal artery and reversed flexor hallucis longus flaps
based on retrograde flow through the peroneal artery.113–115
The reverse-flow island sural flap is based on the superficial
sural artery. The anatomic structures in the path of the pedicle
are superficial and deep fascia, the sural nerve, the short
saphenous vein, and the superficial sural artery. The sural
nerve usually descends between the two heads of the gastro­
cnemius muscle and penetrates the deep fascia at the mid leg.
The median branch of the superficial sural artery follows the
course of the sural neve and descends to the ankle region
anastomosing with the peroneal artery. Thus, when the sural
artery and nerve is ligated proximally and the flap is distally
positioned, the flap has a reverse flow from the peroneal
artery (Fig. 22.34).113,116 There are some disadvantages for
reverse-flow island flaps regarding venous drainage despite
the connections between accompanying veins, and they may
result in venous congestion. Patients with venous insufficiency
and increasing age were identified as risk factors for flap
complications.117 Other concerns can be the poor cosmetics of
the donor site as it has to be grafted for larger flaps and
hypoesthesia of the lateral aspect of the foot. Nevertheless, it
can provide excellent coverage for heel, ankle and the dorsum
of the foot when microsurgery is not feasible.
Turbocharged and supercharged flap
This term was based on the observation of automotive terms
by Semple.118 “Supercharging” is using an external power
source to boost the engine’s performance. Thus, in addition to
its original vascular source, using an unrelated distant vascular
source to anastomose to a flap may result in augmentation of
either inflow or outflow. An example would be the superior
unipedicled transverse rectus abdominis musculocutaneous
(TRAM) flap salvaged by an anastomosis of a thoracic or
upper extremity vascular source to the contralateral deep or
superficial inferior epigastric vessels.42,119,120 “Turbocharging”
is using the engine exhaust for additional power. Thus, using

388
CHAPTER 22 • Flap classification and applications
Fig. 22.28  One of the most widely used bones, the fibula,
has vascular supply from the peroneal artery, giving rise to
multiple arcuate vessels along the fibula and a nutrient
vessel in the mid third of the fibula bone (A). The branches
of the anterior tibial artery supply the head, neck, and
epiphysis and this part of the fibula bone can be used as an
osseous flap to reconstruct the defect after proximal humerus
resection in a growing child (B).
Posterior tibial artery
Peroneal artery
Fibula
Muscle cuff
Skin island
Segment of anterior
tibial artery to be
included in graft
Segment of peroneal artery
to be included in graft
Fibular epiphysis
A
B
Radial artery
Superficial radial
nerve
Arteriae nervorum
Vasa nervorum
Unmyelinated
nerve fiber
Myelinated nerve fiber
A
B
Fig. 22.29  The extrinsic blood supply to the peripheral
nerves consists of arteriae nervorum that rise directly from
the perforating vessels (A). These small arteriae nervorum
enter the nerve and terminate intraneurally. The intrinsic
blood supplies are the longitudinally oriented arterioles
located on the epineurium, perineurium, and endoneurium
(B). Thus, the nerve flap can be harvested from
superficially located sensory nerves based on perforating
vessels originating from a proximal source vessel.

389
Classification of flaps
the main vascular source to connect to an additional pedicle
from the same flap creates a direct flow to the vascular terri-
tory of the connected branch. An example would be directly
connecting the ipsilateral and contralateral deep inferior epi-
gastric vessels of a TRAM flap to improve the vascular supply
to the whole TRAM flap (Fig. 22.35).42,118,121
Venous flaps (arterialized venous flap)
A venous flap is defined as a composite flap of skin, subcuta-
neous tissue and other tissues such as nerve, tendon, and
bone that uses a subcutaneous vein for the arterial inflow
and venous outflow. Nakayama et al. first described these
flaps in 1981.122 Arterialized venous flaps differ from conven-
tional flaps in that the arterial inflow–capillaries–venous
outflow is replaced by the arterial inflow–without capillary
network–venous outflow. The flap does not require a donor
site artery; the flap can be harvested very thinly based on the
superficial veins, and can be harvested rapidly. It is widely
Fig. 22.30  The sural nerve flap, where an arterial supply such as the superficial
sural artery, medial or lateral sural artery would be missing and the lesser
saphenous vein would be arterialized.
Sural nerve
Lesser saphenous vein
Superficial sural artery
Fig. 22.31  Lymph node vascular supply, based on arterial inflow and venous
outflow, should be elevated with the surrounding fat tissue.
Afferent lymphatics
Efferent lymphatics
Fig. 22.32  A bipedicle flap is a flap with dual pedicle often used as a
random pattern skin flap to cover the defect on the extremity or transabdominal
bipedicle flap.
used for soft tissue repair on the hands and fingers when local
flaps and other conventional flaps are not readily available.123–125
There are considerable controversies on the mechanism of
flap survival but three main theories have been postulated:
(1) A–V shunting: retrograde flow from the venous system to
the arterial system via paralyzed arterial–venous shunts;
(2) reverse flow: flow from the venules into the capillaries;
(3) capillary bypass: flow through the venous system without
entrance into the arterial side until neovascularization.126

390
CHAPTER 22 • Flap classification and applications
Fig. 22.33  A flap based on the antegrade flow has a major
pedicle that flows with the flap (A) but when the same flap has
its orthograde pedicle ligated proximally, it becomes a flap based
on the distal part of the major pedicle and the flow of the flap
becomes reversed (B).
A
Antegrade flow with standard arc to antecubital fossa
B
Reverse flow with reversed arc to palmar surface
A
B
Fig. 22.34  The reverse sural flap is elevated by ligating the sural artery and nerve
proximally (A) and distally positioning the flap resulting in a reverse flow from the
peroneal artery (B). The arc of rotation allows the flap to reach the heel but skin
graft is usually needed to cover the donor site.

391
Classification of flaps
Fig. 22.35  Supercharging is using an external power source to boost the engine’s
performance (A). Turbocharging is using the engine’s exhaust for additional power,
like using the same main vascular source to connect to an additional pedicle from
the same flap (B).
A
B
Fig. 22.36  The venous flap classification. Type I is a “through-and-along-valve”
type which mimics similar blood flow as in a standard vein graft with a straight or
Y-shaped pattern. Type II is against-valve, which is arterial inflow against the valve
through the afferent vein with a reversed Y- or H- shaped venous network. In type III
venous flaps, venous flow drains through efferent veins against intravenous valves.
Venous flap
Recipient artery
Recipient vein
Type I. Through-valve type
Flow-through antegrade
Type I. Through-valve type
Y-shaped pattern
Type II. Against valve type
Reversed Y pattern
Type II. Against valve type
H-shaped pattern
Type III. Mixed pattern:
through and against valves
A
V
Va
Ve
A
V1
Va
A
Va
V
Ve1
A
Va
V
Ve1
V1
Ve1
A
Va
V2
A
V
Afferent vein
Efferent vein
Intra-venous valve
Venous outflow
Arterial inflow
Ligation
Anastomosis
Va
Ve
Ve2
Ve1
V2
Ve2
V3
Ve3
V4
Ve4
Based on the earlier classification by Thatte and then by
Chen, in 2007, Woo et al. refined the classification of arterial-
ized venous flaps used in hand and finger reconstruction into
three types.125,127,128 Woo’s classification is based on the pres-
ence of an intravenous valve, the venous network of the donor
site, the location, and the number of veins at the recipient site.
Type I is a “through-and-along-valve” type which mimics
similar blood flow as in a standard vein graft with a straight
or Y-shaped pattern. Type II is against-valve, which is arterial
inflow against the valve through the afferent vein with a
reversed Y- or H-shaped venous network. In type III venous
flaps, venous flow drains through efferent veins against
intravenous valves (Fig. 22.36).
These flaps have had success in hand reconstruction. The
availability of small, thin flaps with defined arterial inflow
and venous outflow is limited. Thus, when local flaps are not
available, arterialized venous free flaps provide a good solu-
tion for successful soft tissue reconstruction (Fig. 22.37).
Flaps based on conditioning
Delay
The delay procedure was naturally developed to overcome
the limitations of random pattern flaps. Given the vascular
limitations of the random pattern flap, investigators attempted
different means by which to maximize the potential area of a
flap, which led to the concept of flap delay. Although the
delay procedure has been used for several hundred years, it
was not until the early 1900s that the concept was recognized.
Blair introduced the term “delayed transfer” in 1921.81 In the
16th century Tagliacozzi delayed his upper arm flaps by
making parallel incisions through the skin and subcutaneous
tissue overlying the biceps muscle. In 1965, using the pig

A
B
C
D
E
F
Fig. 22.37  (A–H) Venous flap to thumb.
G
H

393
Classification of flaps
Fig. 22.38  Standard delay flap modification. (A) Cutaneous territory of flap.
(B) Delay incision. (C) Delay incision with partial distal flap elevation.
A
B
C
Delay incision
Delay incision
with partial distal
flap elevation
Delay incision
Cutaneous
territory of flap
model, Milton investigated the effectiveness of four different
methods of delaying a flap. He found that in developing a
bipedicled flap, the best form of delay was by making two
incisions and undermining the skin between the incisions.31
The goal of a delayed flap is to enhance flap circulation, ensur-
ing flap survival after advancement, transposition, or trans-
plantation to a defect site. Flap delay may be used to increase
circulation to the muscle or fascia or to enhance vascular
connections to the overlying cutaneous territory or adjacent
structures to be included during flap elevations (tendon,
fascia, and bone). Although delay may be accomplished by
biochemical means to improve flap perfusion, currently the
most effective method to ensure delay is surgical manipula-
tion of the flap. To date, no pharmacologic method has sur-
passed the reproducibility and the degree to which surgical
delay protects against flap necrosis.77 There are two theories
that describe the potential mechanism by which the delay
phenomenon prevents skin necrosis. The first is that delay
acclimatizes the flap to ischemia (tolerance), permitting it to
survive with less blood flow than would normally be required.
This theory suggests that vascular delay causes adaptive
metabolic changes at a cellular level within the tissue.96 The
second theory is that delay improves vascularity by increasing
flow through pre-existing vessels, reorganizing the pattern of
blood flow to more ischemic areas.103,104 On the basis of experi-
mental data, it appears that both of these mechanisms, either
directly or indirectly, contribute to the beneficial effects of
surgical delay. Regardless of the underlying mechanisms,
most experimental work on surgical delay demonstrates
changes at the microcirculatory level.129,130
Surgical flap delay is accomplished in two ways: standard
delay, with an incision at the periphery of the cutaneous ter-
ritory or partial flap elevation; and strategic delay, with divi-
sion of selected pedicles to the flap to enhance perfusion
through the remaining pedicle or pedicles.
The technical aspects of standard surgical delay to enhance
circulation are straightforward. The flap cutaneous territory
is outlined and incisions are made through all or part of the
border of a planned cutaneous territory (Fig. 22.38). Minimal
to partial flap undermining is performed. The incisions are
then closed. The flap is then elevated after 10–14 days. It has
been shown that after 1 week, the blood flow into the area of
delay reaches a maximum.131
Strategic pedicle delay is accomplished by making inci-
sions at the border of the planned flap cutaneous territory. The
dissection is either deep to muscle or fascia, depending on the
flap type, to reach pedicles entering the flap territory. These
pedicles are divided and the incision is closed. Second-stage
flap elevation is performed after a 2-week period. Effective-
ness of strategic delay based on ligation of the dominant
vascular pedicle was initially demonstrated in the converse
model of the gracilis musculocutaneous flap.22 This type of
delay is usually advocated in patients with risk factors for flap
ischemia (i.e., smoking history, obesity, radiation therapy,
abdominal scar). New techniques for strategic delay are
designed to minimize incision length and procedure-related
morbidity. Endoscopic techniques allow access and division
of pedicles with minimal incisions. Interventional radiology
techniques may also be used to occlude dominant or second-
ary pedicles to the flap territory to enhance perfusion to the
remaining flap pedicles.
Although important historically, the delay technique is used
less frequently because of the development of better tech-
niques, including axial, musculocutaneous, fasciocutaneous,
transposition, perforator and microvascular free flaps. As with
the random-pattern flap, the limitation of the delayed flap is
that a parallel blood supply is not efficient. Flap delay also has
disadvantages: a preliminary operation is required; inadver-
tent injury to the desired pedicle for flap design is possible; and
resultant scar tissue at the site of flap delay may impair subse-
quent manipulation and inset of the flap at the recipient site.
The delay phenomenon may result in part from a sympa-
tholytic state that results from cutting the sympathetic inner-
vation to the vasculature and the subsequent vasodilatation.
Drugs that block vasoconstriction or those that vasodilatate
may be of theoretic value. Attempts have been made to stimu-
late the delay phenomenon pharmacologically by manipulat-
ing the autonomic nervous system.132 Although pharmacologic
delay is of theoretical importance, additional studies need to
be done to prove its effectiveness.
Tissue expansion
Skin and soft tissue adjacent to the defect are preferred for the
closure of the defect because of the similarity in skin color,
texture, and contour. Design of local advancement flaps will
frequently allow use of adjacent tissue, particularly if there is
skin excess in the donor area. A rotation or advancement flap
frequently requires either a back-cut or skin graft at the donor
site. The size of the defect or the surrounding zone of injury
often prevents the use of adjacent tissue, which is frequently
not available for wound closure or composite defect recon-
struction. In these circumstances, tissue expansion may allow
the use of the desired adjacent tissue for reconstruction. Tissue
expansion is an effective method to enlarge the cutaneous
territory of superficially located muscle and fascial flaps.
Although it is most commonly used to increase the cutaneous
flap territory, the principle of tissue expansion may also be
applied to all soft tissues, including fascia and peripheral
nerve. Neumann is credited with the first modern report of
this technique in 1957.133 Radovan further described the use
of this technique for breast reconstruction in 1976.134
Technically, the tissue expander is inserted under the skin to
provide a mechanism for increasing skin dimensions
to provide sufficient skin circumference for designing an

394
CHAPTER 22 • Flap classification and applications
advancement or transposition flap. If a fasciocutaneous flap is
planned, the expander is placed below the deep fascia. If a
musculocutaneous flap is planned, the expander is placed
beneath the deep surface of the muscle. The expander should
not be placed directly beneath the dominant vascular pedicle
at its point of entrance into the flap territory to avoid injury to
the pedicle during the expansion process. Although immediate
skin expansion is possible, delayed expansion is usually per-
formed prior to flap elevation. During a selected time interval,
usually 6 weeks to 3 months, the expander is injected with
saline at weekly intervals. Once the desired amount of expan-
sion has been achieved, the expander is removed and the
modified flap skin territory is recruited for reconstruction.
Safe tissue expansion depends on surgical judgment
regarding its usefulness for a specific problem. The benefits
of local surrounding tissues in reconstructive surgery are well
recognized; however, this tissue is frequently injured because
of its proximity to the traumatic or surgical defect obviating
the ability to use this tissue. Failure of tissue expansion is
usually attributable to inadequate stability of skin and associ-
ated soft tissue during the expansion process. Failure of the
expander is signaled by wound dehiscence followed by
expander exposure and infection. Unlike failure of flap trans-
position or transplantation techniques, expander failure is not
generally associated with increased wound complexity or
donor site problems.36,135
Prelaminated and prefabricated flaps
Flap prelamination, a term coined in 1994, involves surgical
manipulation of a flap that requires partial to complete flap
elevation and suturing of the flap to form structures at the site
of the reconstruction.136 This technique may also incorporate
new tissues into the flap territory, establishing a multilayered
flap. When these structures at the donor site have healed, flap
transposition or transplantation is performed. With suture
lines or various grafts healed at the time of flap inset, complex
reconstructions are theoretically accomplished with less risk
of complications at the recipient site. This is commonly done
in flaps to be used in head and neck reconstruction. Baudet
et al. and Pribaz et al. have used prelamination techniques on
the forearm for nasal and central face reconstruction.32,137
Although it is useful, many reconstructive surgeons still
prefer to perform secondary procedures after successful initial
flap inset rather than flap prelamination at the donor site.
Another form of flap manipulation is termed prefabrication.
Prefabrication provides a new dominant vascular pedicle to
structures for subsequent transposition or transplantation. A
suitable artery and vein are selected and buried in fascia or sub-
cutaneous tissue in the planned flap territory. A large pedicle to
an adjacent muscle is frequently used. The pedicle and a small
segment of muscle are elevated and inset beneath the proposed
flap site. In 6 weeks, the flap based on the new vascular pedicle
is elevated and either transposed or transplanted by microsur-
gery. This technique for prefabrication is not always reliable for
establishing a new dominant pedicle to a flap territory. With
the numerous options available for safe flap selection, this
technique of flap prefabrication is rarely used.138
Sensory flap
Specific sensory nerves are identified in the cutaneous terri-
tory of many of the flaps available for reconstructive surgery.
All flaps using the skin component may be designed to incor-
porate the sensory nerve in the flap base. If the cutaneous
nerve does not enter the flap base in proximity to the vascular
pedicle, it is also possible to divide the sensory nerve during
flap elevation and then subsequently coapt the nerve to a
suitable sensory nerve at the recipient site.
Muscle flaps with intact motor nerves or with re-anastomosis
of the motor nerve to suitable motor or sensory nerves at the
recipient site appear to retain protective sensibility, possibly
through nerve fibers of proprioception. Maintenance of pro-
tective sensation is essential for hands, feet and other weight-
bearing areas. Another common area in which sensate flaps
are used is the oral cavity and this potentially improves
postoperative intraoral function.139–141 Harris et al. state that
reconstruction of weight-bearing areas should provide ade-
quate contour for normal footwear, thick durable skin, protec-
tive sensation, and solid anchorage to the deep structures to
resist shearing forces.142 Studies have shown benefits of pro-
tective sensation for ankle and heel reconstruction both with
rotational flaps and by microvascular tissue transfer.110,143,144
Sensory reinnervation for free flaps showed faster sensory
recovery and flaps without sensory reinnervation did recover
protective sensation but never two-point discrimination.144,145
Functional muscle flaps
Release of the origin or insertion of the muscle transposition
flap will result in loss of muscle function. However, many of
the muscle flaps may be designed for both coverage and
functional muscle transfer. For function to be preserved, the
motor nerve must be preserved along with dominant vascular
supply, the muscle must be reattached to a new bone or
tendon across a joint, and the muscle must exert a direct force
on its new point of attachment. Muscles suitable for use as
transposition flaps or microvascular composite tissue trans-
plantation, providing both coverage and function, include
the latissimus, gluteus maximus (segmental), gracilis, gastro­
cnemius and serratus muscles. Restoration of the original
muscle length-to-width ratio and repair of the motor nerve to
a suitable receptor motor nerve at the recipient site are essen-
tial for restoration of transplanted muscle function at its new
inset site.
Flaps based on conformation
In the era of random pattern flaps, the issues related were
regardless of circulation and focused on shapes and the
methods to transport flaps to distant regions. Nowadays
with complex defects, multiple tissues are used to obtain an
ideal reconstruction. The conformation of the flap frequently
combines multiple flaps. A compound flap typically consists
of multiple tissue components linked together in a manner
that allows their simultaneous transfer and consequently
more efficient reconstruction.39,41,42 Hallock’s classification of
compound flaps has been simplified to enhance communi-
cation and further advance the role of complex flaps, not
only microsurgical but local flaps as well (Table 22.13).41,42
The compound flap can be partitioned into two major classes
according to their primary means of vascularization (Fig.
22.39). First are the “solitary compound flaps” which are
composite flaps based on solitary circulation. It is the sim-
plest form of compound flap that contains en bloc multiple

395
Classification of flaps
Fig. 22.40  The “conjoined flaps” are flaps with at least two anatomically distinct
territories, each retaining their independent vascular supply but joined by means of
some common physical boundary. Conjoined flaps can be further divided into two
subgroups distinguished by the different source of vascularization: perforator based
or branch based. The larger caliber and often subfascial or axial branches of the
branch-based form may have completely unrelated origins from different
angiosomes (the independent type), or these branches may arise from a common
source vessel (common type).
Independent
Common
Fig. 22.39  Compound flaps can be subdivided into solitary (composite) or
combined types (conjoined and chimeric) based on primary source of
vascularization.
Composite
Conjoined
Chimeric
Table 22.13  Classification of compound flaps
Solitary vascularization
Composite flaps
Combined vascularization
Conjoined flaps
perforator-based
branch-based
independent
common
Chimeric flaps
perforator-based
branch-based
sequential
internal
tissue components.29 The components are dependent on each
other and must remain intact together supplied by a solitary
source.146 Most of the classic musculocutaneous, septocutane-
ous, and osteoseptocutaneous flaps can be seen as composite
flaps because they basically consist of muscle or fascial plexus
connecting with the skin paddle, which is dependent on the
perforators originating from muscle or fascia (see Fig. 22.39).
Second is the “combined compound flap” which is a com-
pound flap that has multiple sources and combined vascular-
ization. There are two major subtypes – conjoined flaps and
chimeric flaps – primarily differing in physical relationship of
their component but retaining an independent blood supply
for each component.41,42 The “conjoined flaps” are flaps with at
least two anatomically distinct territories, each retaining their
independent vascular supply but joined by means of some
common physical boundary.42 Conjoined flaps can be further
divided into two subgroups distinguished by the different
source of vascularization: perforator based or branch based.
The larger caliber and often subfascial or axial branches of the
branch-based form may have completely unrelated origins
from different angiosomes (the independent type), or these
branches may arise from a common source vessel (common
type) (Fig. 22.40). The “chimeric flaps” consist of multiple
otherwise independent flaps that each have an independent
vascular supply, but in turn all pedicles are linked to a larger
common source vessel.42,146,147 The chimeric flap can be further
divided into three subclasses: (1) perforator-based; (2) branch-
based; and 3) fabricated. The fabricated component can be

396
CHAPTER 22 • Flap classification and applications
customized approach.42 When planning a complex reconstruc-
tion, one should ask whether a simpler approach is sufficient
and there must be unrivaled advantages to choosing the
combined type of compound flap.41
Flap applications
The reconstructive elevator
Once the cause of defect is determined and relative problems
solved or planned for further intervention, soft tissue
attached to the terminus of the source vessel to the combina-
tion (sequential type) or to a branch indigenous within the
flap (internal type) (Figs. 22.41 & 22.42). Fig. 22.43 shows a
patient with tibia and soft tissue defects after trauma being
reconstructed using a chimeric fabricated anterolateral thigh
(ALT) perforator flap with a small strip of vastus lateralis
muscle sequentially combined with contralateral fibula flap.
The peroneal vessels are sequentially anastomosed to the
descending branch of the lateral femoral circumflex vessel.
This approach provides simultaneous transfer of multiple
tissues, is able to fill large defects, allows immediate cov-
erage, needs only one recipient vessel site, and enables a
Fig. 22.41  The “chimeric flaps” consist of multiple otherwise independent flaps that each have an independent vascular supply, but in turn all pedicles are linked to a
larger common source vessel. It is further divided into three subclasses differentiated by: (1) perforator-based, (2) branch-based, and (3) fabricated. The fabricated
component can be attached to the terminus of the source vessel to the combination (sequential type) or to a branch indigenous within the flap (internal type).
d
e
s
a
b-h
c
n
ar
B
d
e
s
a
b-rotarofre
P
la
nretnI
laitn
e
u
q
e
S

397
Flap applications
complex techniques, depending on local wound requirements
and complexity. Direct closure represents the simplest and
most straightforward technique. Direct closure may be pre-
cluded by the size of the wound or the consequences of
wound tension at the closure site resulting in malalignment
of adjacent tissues. When this occurs, a more complex closure
technique, such as a skin graft that uses distant skin for defect
coverage, is required. Although still valued and widely
taught, the reconstructive ladder comes from the concept of
the wound-closure ladder dating back beyond the era of
modern reconstructive surgery.25 A skin graft after mastec-
tomy can still provide coverage but a pedicled TRAM (trans-
verse rectus abdominis muscle) flap will provide superior
results in addition to coverage. Now with introduction of
DIEP (deep inferior epigastric perforator) flaps, the recon-
structive ladder approach seems to show more flaws. In the
era of modern reconstructive surgery, one must consider not
only adequate closures but form and function. The reconstruc-
tive triangle emphasizes the selection of a technique that
safely achieves a successful reconstruction and restores form
and function (Fig. 22.45). Increased experience has led to the
safe use of techniques such as flap transposition, microvascu-
lar composite tissue transplantation, and tissue expansion.
The surgeon should now consider the reconstructive triangle
to select the optimal technique to achieve predetermined
reconstructive goals without donor site complications. Other
techniques including tissue expansion, skin stretching and
vacuum-assisted closure have changed the approach to
reconstructive options. A simpler reconstructive option may
not necessarily produce optimal results. The “reconstructive
elevator” concept proposed by Gottlieb and Krieger suggests
the most appropriate floor from which to choose our
coverage is then considered. One must also consider the
defect by means of the true defect size compared to the appar-
ent defect. The concept of the reconstructive ladder was
proposed to achieve adequate closure of wounds using a step-
ladder approach from simple to complex procedures (Fig.
22.44). The reconstructive ladder concept was developed to
establish priorities for technique selection based on the com-
plexity of the technique and the defect requirements for safe
wound closure. The ladder provides a systematic approach to
wound closure, emphasizing selection first of simple and then
Fig. 22.42  Chimeric flaps from the subscapular artery system.
a
b
c
s
t
a
b
c
s
t
axillary artery and vein
crossing branch for seratus muscle
circumflex scapular artery and vein
subscapular artery and vein
thoracodorsal artery and vein
Scapular
flap
Serratus anterior
Latissimus
dorsi
Fig. 22.43  A sequential chimeric flap is used for a patient with tibia and soft
tissue defect after trauma. A chimeric fabricated anterolateral thigh (ALT) perforator
flap with small strip of vastus lateralis muscle sequentially combined with
contralateral fibula flap is shown.
Fig. 22.44  Reconstructive ladder.
Complex
Simple

398
CHAPTER 22 • Flap classification and applications
Fig. 22.45  Reconstructive triangle.
Microsurgery
Tissue expansion
Safety
Flaps
Form
Function
reconstruction, based on the specific requirements of the
patient, the wound and the circumstances.25 Thus, to provide
optimal form and function, we jump up and down the rungs
of the ladder. The reconstructive elevator requires creative
thought and consideration of multiple variables to achieve the
best form and function, rather than a sequential climb up the
ladder (Fig. 22.46). This paradigm of thought does not elimi-
nate the concept of the reconstructive ladder but replaces it as
a ladder of wound closure and makes its mark in the field
where variety of advanced reconstructive procedures and
techniques are not readily available. Using the reconstructive
elevator, the method of reconstruction should be chosen based
on procedures that result in optimal form and function.
The guide for reconstruction using flaps
Flaps, whether pedicled or free, are used to reconstruct defects
originating from various causes. However, despite the best
efforts, necrosis can occur partially or totally to the flap. The
overall survival not only depends on the proper flap selection
but preoperative planning, intraoperative techniques and
postoperative management involved in reconstruction.
Preoperative planning
Preoperative evaluation is the initial step for all reconstruc-
tion. One must think about the final outcome and the
Fig. 22.46  The “reconstructive elevator” concept suggests the most appropriate
floor from which to choose our reconstruction, based on the specific requirements
of the patient, the wound and the circumstances.
Microvascular
Tissue expansion
Distant flap
Local flap
Skin graft
Direct closure
surrounding factors during the preoperative planning. Sur-
rounding factors may include whether the patient will have
psychological support, be irradiated, undergo any secondary
procedures, need prosthesis, or be ambulant, among others.
Once a rough plan has been postulated, the first critical step
is for the surgeon to educate the patient about the procedure
and the possible outcome, obtaining an informed consent.148
The recipient site should be evaluated for the vertical and
horizontal aspect of the defect. The vertical aspect may include
subcutaneous tissues like bone, muscle, tendon, nerve, major
vessels, and other deep tissues. The horizontal aspect should
address the skin paddle size and the thickness of the skin flap.
Added function such as functional muscle or sensate flaps
should be planned based on the need of the recipient. Wound
analysis includes assessment of the defect in terms of location,
size and physical components. When the defect involves a
significant percentage of the body surface area (e.g., burns or
giant hairy nevus), the reconstructive options may be limited
to skin grafts for acute coverage (e.g., burns) or sequential
tissue expansion for elective reconstruction (e.g., giant hairy
nevus). Complex reconstruction may need to combine various
flaps as conjoined or chimeric flaps to achieve ideal recon-
struction. Each component affects function and form at the
defect site. Selection of a reconstructive option is based on the
feasibility and relative importance of replacing each compo-
nent of the defect. Preoperative planning allows designing
and selecting the ideal vascular system to combine various
tissues.
Systemic factors should also be considered prior to recon-
struction. Obesity, smoking, hypertension, immunosuppres-
sion, heart failure, diabetes, hypercoagulability, peripheral
vascular disease, chronic renal insufficiency, and others are
known to be related to higher complications of donor and
recipient sites including flap failure.149–157 However, as the
development of microsurgical instruments and technique
continues, well-known risk factors seem less significant in
outcome of flap survival. Nevertheless, these systemic factors
should be controlled to minimize not only flap-related com-
plications but also donor site complications.151,153,158
Imaging using CT (computed tomography) scans, angio-
grams, or MR (magnetic resonance) angiograms help to
identify the vasculature of the recipient and donor site. The
use of CT angiography may obtain vascular information of
the recipient region without the risk of complications from
arterial puncture of the groin and can also provide vascular
information of the donor flap facilitating the planning and the
surgical procedure.159,160 Fig. 22.47 shows that the descending
branch of the lateral femoral circumflex artery is the collateral
vessel responsible for flow to the distal leg and one should
not harvest the anterolateral thigh flap based on this major
collateral as it may hinder the flow to the leg. In association
with prior injuries to the lower extremity, the routine preop-
erative use of angiogram is controversial but selectively rec-
ommended in patients who have loss of one or more peripheral
pulses, a neurologic deficit secondary to the injury, or a com-
pound fracture of the extremity that has undergone reduction
and either external or internal fixation.161 Prior trauma or
incisions may also end in damage of the vascular pedicle of
the flap and thus warrant preoperative imaging to confirm the
pedicle status. The use of preoperative imaging has now
expanded to gather information on the pedicle of the perfora-
tor flap. It can show the emerging perforator of the superior

399
Flap applications
Flap selection should be based on the defect’s need for form
and function. Safe and reliable muscle or musculocutaneous
and fascial or fasciocutaneous flaps and perforator flaps have
been described for use in all areas of the body. When design
is properly based on the precise vascular territory of their
vascular pedicles, the majority of flaps survive transposition
to a defect. The technique selected for defect closure or recon-
struction should restore normal shape or contour. Although
initial experience with the musculocutaneous flaps resulted in
safe wound closure, the excessive bulk was often unsightly.
Frequently, a muscle flap with a skin graft provided a superior
restoration of form at the recipient site. With the identification
of muscle and fascial units suitable for design either as a
standard transposition or microvascular composite tissue
transplantation, the surgeon may select the flap best suited
for defect closure. When a skin island is required, the surgeon
may select a flap with a thin layer of overlying subcutaneous
tissue (i.e., radial forearm flap or a perforator flap) or may
plan secondary flap revision by direct excision or suction-
assisted lipectomy to improve flap contour in thicker flaps.
The availability of numerous flap donor sites allows selection
of a technique for either standard transposition or microvas-
cular composite/compound tissue transplantation that best
restores form for reconstruction. Specialized functions at the
site of reconstruction include hair growth, sensibility, skeletal
support (bone), and motion (animation). Techniques of recon-
struction must consider these specialized requirements.
Although function restoration may require staged procedures,
especially for a composite defect, it is often possible to restore
all functional requirements with a single procedure. After
evaluating the character of the defect, Table 22.2 may guide
the selection process of the flap based on circulation, composi-
tion, contiguity, construction, conditioning and conformation.
The final flap design is usually delayed until dimensions of
the defect is confirmed. One should think of the true defect
compared to the apparent defect. An ideal reconstruction
would replace defect with like tissue or with tissue that will
best give the form and function.
Donor site morbidity should also be considered when
selecting a flap. When possible, the donor site should be
closed directly to preserve form. Use of a flap that requires a
skin graft for donor site closure is justified when the flap
harvested is clearly superior to alternate flaps for the defect.
If it is possible to stage the flap elevation with preliminary
insertion of a tissue expander, an increase in both the cutane-
ous flap dimensions for defect closure and the adjacent skin
territory for donor site direct closure may be accomplished.
Although the ultimate form at the flap recipient site remains
the primary basis for flap selection, deformity due to loss of
form at the donor site should be avoided when possible. Thus,
reconstructive balance is achieved with selection of a tissue
source to restore the defect or deformity while form and func-
tion are preserved at the donor site. In an effort to minimize
donor site morbidity, many surgeons have evaluated the
utility of endoscopic harvest of muscle flaps. Minimally
invasive techniques for harvest of several muscles have been
described. These include the latissimus dorsi, rectus abdomi-
nis, gracilis, rectus femoris, external oblique, and gastrocne-
mius muscles. In addition to the endoscopic harvest of
muscles, laparoscopic techniques are frequently used to
harvest the omentum. This has been a significant advance as
the benefits include decreased scarring, less postoperative
gluteal artery piercing the deep fascia reaching the skin. This
image allows us to visualize the perforators and to select the
best perforator for this flap. The CT angiogram gives informa-
tion such as the caliber of the pedicle, the intramuscular
course of the pedicle, location of the corresponding flap, and
the subcutaneous branching from the pedicle. This informa-
tion allows for more detailed preoperative planning regarding
the flap. The CT angiogram remains the gold standard for
preoperative imaging.162
Hand-held Dopplers allow us to simply and quickly gather
information about the perforator and the main axial vessels.
However, it may lack detailed information such as the course
of the perforator and the actual positive finding may not
correlate clinically. Nevertheless, hand-held Dopplers remain
the first-line tool to gather information regarding the pedicle
of the flap. The color Doppler imaging provides better infor-
mation and helps the surgeon to identify the presence of the
vessels, the direction of the flow, whether the flow pattern is
venous or arterial, and the flow velocity.163
For local flaps, flap loss may result when the defect is
located beyond the standard arc of rotation causing excessive
tension on the vascular pedicle. Defect size beyond the vas-
cular territory of the flap pedicle may result in either an
inappropriate increase in flap dimensions or excessive flap
tension at the inset site. Selection of a flap with a pedicle
location in the zone of injury or use in patients with pre-
existing vascular compromise may result in failure. Flap
modifications, including segmental and distally based designs,
are also subject to vascular compromise and potential loss.
Thus, flap success is determined preoperatively based on
anatomic design and on assessment of the specific reconstruc-
tive requirements.
Fig. 22.47  The angiogram shows that the descending branches of the lateral
femoral circumflex artery are the collateral vessels responsible for flow to the distal
leg. This information can be vital in maintaining the flow to the distal leg and ALT
flaps should not be elevated.

400
CHAPTER 22 • Flap classification and applications
pain and theoretically less donor site morbidity.164–166 Skin or
perforator flaps have evolved to harvest flaps from less con-
spicuous sites. Although many factors are involved when
choosing a perforator flap, DIEP (deep inferior epigastric
perforator), SGAP (superior gluteal artery perforator), SCIP
(superficial circumflex iliac artery perforator), and TDAP
(thoracodorsal artery perforator) flaps are well hidden in
regular clothing and have minimal donor site morbidity.
Finally, for the preoperative planning, the surgeon should
always think of a plan B flap just in case plan A does not go
as ideally planned. This allows preoperative visual practice,
reduction of surgical time, minimizing unwanted variables,
and to maintain the high spirit of motivation.167,168
Intraoperative techniques
When possible the patient is positioned to allow visualization
of both donor and recipient sites. This allows a two-team
approach and does not need additional surgical time to change
the patient’s position during operation. The patient in Fig.
22.48 shows a defect on the posterior aspect of the heel pad
with chronic osteomyelitis. After complete debridement, a
superior gluteal artery perforator flap was used to reconstruct
the heel pad without changing the patient position during
surgery.169 For surgeries with an expected long operating time,
careful padding of potential pressure sites to avoid injury to
normal structures, active warming to minimize hypothermia
(which may decrease peripheral blood flow), deep vein
thrombosis prophylaxis, and an intensive glucose control for
diabetes are needed to ensure a positive outcome.148
The recipient site must be completely ready prior to flap
application. For cancer, adequate resection margins must be
obtained and wounds must achieve a clean field through
debridement. The design of the flap is of paramount impor-
tance. The final design of a flap intended for standard trans-
position, staged expansion, or microvascular transplantation
should be based on the actual defect size. The original design
of the flap has an impact on future procedures if the defect
should recur or require further revisions. In general, flap
design is delayed until adequate wound debridement
or tumor resection is accomplished. If simultaneous flap
elevation and resection are performed, the flap design
should allow for the maximal defect size. If tissue expansion
is used, the expander advancement or transposition flap
should be elevated and advanced to the potential defect site
before the resection is performed. Repeat expansion will be
necessary if adequate tissue is not available to cover the defect
created at the resection site. A careful assessment should be
made of the extent of debridement required to remove nonvi-
able structures subject to bacterial invasion and impaired
vascularity. Inability to accurately predict the amount of
debridement required may necessitate sequential wound
debridement with subsequent wound observation and bacte-
rial culture of the wound. When regional vascular insufficiency
involving the wound site is observed, preliminary or simul-
taneous vascular procedures may be required in conjunction
with wound debridement and coverage. The continuing
debate on which flap composition is better for chronic osteo-
myelitis remains, but growing reports have shown that with
adequate debridement, flaps – whether they be primarily
muscular or skin component – can be equally effective.170–174
Furthermore, the skin/fasciocutaneous flaps better allow for
staged reconstructions, are easy to elevate and are less scarred
and fibrotic when compared to muscle flaps. They also provide
a thin flap which leads to very good aesthetic results.174
Flap elevation requires precise knowledge of flap anatomy.
Random pattern flaps are still used commonly in smaller
wounds but as the flap gets larger, identification of the pedicle
and angiosome increases the chance for success. In the case of
free flaps, the recipient vessels need to be ready and patency
confirmed prior to microsurgery.
When insetting the flap, tension must be avoided especially
around the vascular pedicle. Postoperative swelling should be
taken into account as swelling will increase tension. Meticu-
lous coagulation of the flap as well as the recipient bed is
crucial to minimize hematoma after surgery. A closed suction
drain system is generally used at both the donor and recipient
closure sites. One must be careful not to place the drain near
the pedicle as the negative pressure of the drain may compress
the pedicle.175 Drains are not removed until the patient is
mobilized since the resultant motion may temporarily increase
the risk of seroma formation. Drains in proximity to a tissue
expander or prosthetic implants are a potential source of
infection and are removed as quickly as possible. When
seroma drainage decreases to 20 mL in a 24-hour period, the
closed drainage system is removed. When possible, drainage
systems are removed by postoperative day 10 to avoid poten-
tial wound contamination through the drain exit site.
Postoperative management
Postoperative flap management is of equal importance to the
success of a reconstruction. The maintenance of proper posi-
tioning, temporary immobilization, and proper dressing of
the wound are critical.
Pressure on the flap base is to be avoided during the post-
operative period. When possible, the area of the flap inset is
elevated as in head and neck and extremity reconstruction. If
the area of the flap lacks protective sensation, the site of
reconstruction is placed in a nondependent position. Use of
an air-fluidized bed is recommended to avoid pressure on
dependent areas in patients with spinal cord injury.
Constricting bandages are avoided, particularly in the area
of the flap base where pressure on the flap pedicle may com-
promise flap circulation. The flap is observed for potential
circulatory problems during the initial postoperative period.
Those patients undergoing head and neck reconstruction
with microvascular tissue transfer should have strict orders
to have nothing placed circumferentially around the head or
neck. Nasal cannulas, oxygen masks, eye glasses, and trache-
ostomy collars should be avoided due to the risk of pedicle
compression.
Excessive motion in the area of the flap inset is to be
avoided by padding of areas adjacent to the flap inset site. In
extremity reconstruction, the use of a plaster splint to immo-
bilize the joint proximal and distal to the flap inset site is
recommended. Circular casts are avoided because of the risk
of pressure associated with postoperative edema and diffi-
culty in observing flap circulation.
Perioperative antibiotics are recommended when flaps are
inset at the site of contaminated defects. If an expander
or permanent implant insertion site has a history of prior
infection, perioperative antibiotics are also recommended.
Cultures of the wound site will determine the necessity for

401
Flap applications
bearing for up to 6 weeks. Weight bearing at the site of flap
inset for pressure sore coverage is avoided for 4–6 weeks.
Range of motion exercises at the donor site are encouraged
when wound healing is complete, usually by postoperative
day 7–10, to avoid joint stiffness and muscle weakness.
If the patient has difficulty regaining function at either the
donor or recipient sites, a physical therapy program is recom-
mended. Pain management for patients treated for complex
defects may require consultation with a pain specialty clinic
postoperative antibiotic therapy. Continued use of postopera-
tive antibiotic therapy should be based on wound cultures
and selection of culture-specific antibiotic agents.176
Prolonged bed rest is avoided when possible following
reconstructive surgery. With the exception of those undergo-
ing reconstruction of the perineum and lower extremity, most
patients are ambulatory after the first postoperative day. Eleva-
tion and immobilization of upper and lower extremities are
generally recommended for 10 days followed by nonweight
Fig. 22.48  Using an available flap without changing position allows for a safe and
faster surgery. The patient shows a defect on the posterior aspect of the heel pad
after resection of malignant melanoma (A). A flap is designed and elevated based on
the superior gluteal artery along with the superficial nerve (B). Follow-up shows
good contour of the heel and the donor site (C,D).
A
B
C
D

402
CHAPTER 22 • Flap classification and applications
the selected muscle so that the donor site is not
impaired. However, if no synergistic muscle groups are
available, either techniques to preserve donor muscle
function (e.g., muscle splitting) should be employed or a
different muscle chosen.
4. The status of the vascular pedicle that will sustain the
proposed flap must be known preoperatively. Selective
arteriography must be considered if there is a history of
previous surgery in proximity to the vascular pedicle
of the proposed muscle flap or if muscle paralysis is
noted on physical examination. Earlier division of
the motor nerve may also include ligation of the
vascular pedicle. Examples of clinical situations
when arteriography is particularly useful include the
evaluation of the sural artery (gastrocnemius) after knee
surgery, of the transverse cervical artery (trapezius) after
neck and shoulder surgery, and of the thoracodorsal
artery (latissimus dorsi) after axillary surgery.149
5. The donor defect must be carefully considered.
Some patients do not accept the use of a skin graft
at the donor site, and certain muscles are more
likely than others to require grafts for closure.
Likewise, some patients prefer one scar site to another
(e.g., the abdominal scar of the TRAM flap versus
the back scar of the latissimus dorsi flap in breast
reconstruction).
6. The cutaneous territory of the proposed flap must be of
sufficient size and of acceptable texture. The harvested
skin should be an acceptable match to the recipient site
(e.g., not hair-bearing).
7. If restoration of sensation or motor function is necessary
a select number of muscle, musculocutaneous and
fasciocutaneous flaps are available. Common examples
of muscles which provide sensation or restore function
include the serratus muscle, rectus abdominis, and
latissimus dorsi.177–181
8. Osteomusculocutaneous flaps are available for defects
in need of vascularized bone in addition to soft tissue.
Examples include the trapezius flap with vascularized
clavicle and scapular spine,150,182 pectoralis major flap
with vascularized rib,183,184 iliac osteomusculocutaneous
flap based on the ascending and transverse branches of
the lateral circumflex femoral system167,185 and the
latissimus dorsi–scapular osteomusculocutaneous
flap.163,186
9. The operation should be technically straightforward.
Fascia, fasciocutaneous and perforator flaps
General guidelines for choosing a specific fascia, fasciocutane-
ous flap and basing perforator flaps on known perforators are
similar to those for muscle and musculocutaneous flaps, with
a few exceptions.
The fascia, fasciocutaneous or the perforator flap must be
in the proximity of the defect if a rotational/propeller flap is
planned. The planned flap must be of sufficient size and
bulk to reconstruct the defect. Fascia, fasciocutaneous and
perforator flaps are ideal for areas that do not require bulk.
The vascular supply of the area must be assessed preopera-
tively. If a fasciocutaneous or a perforator flap is planned, the
perforating vessels should be assessed with a Doppler probe
preoperatively so that the skin island can be designed. The
and psychiatrist. Occupational therapy is indicated for
patients unable to return to their jobs. A multi-specialty
approach to patients who have undergone cancer treatment
is essential to provide tumor surveillance and adjuvant
therapy when indicated. Patients at risk for wound recur-
rence, particularly following closure of a pressure sore, and
patients with spinal cord injury require instruction in avoid-
ance of pressure and shear forces at the site of flap reconstruc-
tion and assistance in obtaining devices (i.e., wheelchair with
appropriate padding) to avoid future skin injury.
Although there is no concrete evidence for the use of
postoperative antithrombotic therapy, use of anticoagulation
is still practiced by many surgeons and is usually of concern
in microvascular tissue transplantation.25 Common postopera-
tive regimens include daily aspirin, heparin or dextran.
Aspirin inactivates platelets by blocking cyclo-oxygenase.
Heparin is an antithrombin III inhibitor. Dextran decreases
platelet adhesiveness, inhibits platelet aggregation and
decreases the blood viscosity. The use of these medications
varies among surgeons.
Postoperative monitoring of a flap is a critical component
in patient care after reconstruction. Many techniques have
been developed to monitor flaps and have primarily focused
on those flaps transferred microsurgically. These monitoring
methods assess the patency of the small vessel microanasto-
mosis. The goal is to discover any problem with the anasto-
mosis early enough to salvage the flap. Musculocutaneous or
perforator flaps, which have not been divided from their
vascular pedicle, are generally monitored with clinical obser-
vation. Clinical observation generally involves assessment of
skin color, tissue turgor, temperature, capillary refill, and
pinprick. The ideal monitoring measure should be reliable,
reproducible, sensitive, cost-effective, user-friendly, and con-
tinuous.148 Adjunctive measures such as laser flowmeter,
implantable Doppler, oxygen partial pressure probe, transcu-
taneous oxygen tension, Duplex scans, and hand-held Doppler
can be used to assist the subjective monitoring of the flap.
Selection of specific flaps
Muscle and musculocutaneous flaps
After the decision has been made to use a muscle or muscu-
locutaneous flap, the specific muscle must be chosen. General
guidelines used to assist in the selection of a muscle include
the following:
1. Ideally, the muscle should be adjacent to the defect.
2. The muscle should be of sufficient size and bulk to
cover the defect. The final design of the flap should
occur only after the defect is completely defined. When
tumor exposure or wound debridement is required, the
defect is often much larger and deeper than initially
anticipated. By final design of the flap after
debridement, costly errors in inadequate coverage can
be avoided. If the defect is unstable or the margins are
unclear (tumor pathology not available), wound packing
or temporary skin graft coverage is warranted. One
must also take into consideration that a significant
amount of atrophy occurs if the origin, insertion, or
motor nerve of the muscle is disrupted.
3. The muscle should be expendable. There are often
synergistic muscles that can compensate for the loss of

403
Flap applications
presence or absence of sufficient perforating vessels deter-
mines whether a specific fasciocutaneous or perforator flap
can be used. Following the angiosome principle, only one
adjacent territory should be included to ensure adequate
vascularization of the entire flap.33 For perforator flaps, after
identifying the main perforator, other minor perforators are
eventually transected at the level of the deep fascia. However,
if minor pedicles are dissected together with the source vessel,
the perforator flap will have a better circulation. The donor
defect should be considered. These can generally be closed
primarily (fascial flap) but may require skin graft if the skin
island is large. Restoration of sensation with a fasciocutane-
ous or perforator flap is possible.
Perforator flap (free-style)
In contrast to elevating a flap on a previously identified per-
forator, the skin island can be selected first and the appropriate
perforator located on the flap can be selected in a sequence.
This is the core of the free-style approach and allows efficient
handling of unexpected events which occur during flap
harvest or in cases with anatomical variations.187,188 A specific
donor or source artery does not limit the surgeon. After the
location and dimension of the flap are determined and specific
donor site is selected, the search for the proper perforator
is performed. Although this approach provides maximum
liberty for flap selection, a learning curve is required to be
comfortable with this approach.189
Regional application of flaps
Head and neck reconstruction
Regional flaps:
1. Temporalis
2. Sternocleidomastoid
3. Platysma.
Distant flaps:
1. Pectoralis major
2. Trapezius
3. Latissimus dorsi.
Perforator flaps
1. Facial artery perforator
2. Submental artery perforator.
Radical cancer surgery or traumatic injury can produce
massive defects in the head and neck. Whereas many simple
defects can be adequately treated with direct closure, local
scalp flaps or skin grafts, the more complicated defect requires
a larger reconstruction. The muscle, musculocutaneous and
fasciocutaneous flaps play a major role in these reconstruc-
tions. Historically, large surgical defects of the head and neck
were managed with staged reconstruction. Currently, the
most common reconstruction involves microvascular tissue
transfer.
The primary applications of the muscle or musculocutane-
ous flap in head and neck reconstruction include provision of
tissue bulk for a significant defect (e.g., after hemimandibu-
lectomy); protective coverage of vital structures (e.g., the
carotid artery); provision of skin for intraoral lining and
coverage; and provision of skin for skull, facial, and neck
defects.
The local muscle and musculocutaneous flaps for head and
neck reconstruction include the temporalis, sternocleidomas-
toid, and platysma flaps.
The temporalis muscle is a type III, fan-shaped, bipenni-
form muscle. Transposition of the muscle as a turnover flap
is especially useful for coverage of the orbit, superior maxilla,
and ear.
The sternocleidomastoid is a type II muscle, first described
in head and neck reconstruction by Owens in 1955.190 This
flap has historically been used for intraoral and pharyngeal
reconstruction. Other uses have included augmentation of
soft tissue defects of the upper neck and jaw, protective cover-
age of major vessels, and closure of pharyngocutaneous
fistulas.191–193 However, of all the musculocutaneous flaps used
for head and neck reconstruction, the sternocleidomastoid is
considered the least reliable.20,193
The platysma is a type II, thin, broad, sheet-like muscle
extending over the entire anterior and lateral aspects of the
neck. The use of the platysma as a musculocutaneous flap was
first described in 1887 by Gersuny, who employed it in recon-
structing a full-thickness defect of the cheek.194 The platysma
has been used for intraoral, lip, lower midface, and anterior
neck reconstruction. Because of the thinness of the platysma
muscle, the reconstructive surgeon must be particularly
careful to avoid disrupting the muscle fibers during the dis-
section and placing undue tension on the vascular pedicle
after transposition of the flap.
The distant muscle and musculocutaneous flaps used in
head and neck reconstruction include the pectoralis major,
trapezius, and latissimus dorsi flaps.
The pectoralis major is a type V, large, broad muscle. Its use
as a musculocutaneous flap was first described in 1968 by
Hueston and McConchie as part of a compound deltopectoral
flap.195 In 1977, Brown et al. described the use of the pectoralis
major as a flap in mediastinal coverage.18 In 1979, Ariyan
introduced the pectoralis major musculocutaneous flap for
head and neck reconstruction (Figs. 22.49 & 22.50).20 During
the ensuing years, the pectoralis major musculocutaneous
flap proved more valuable than the deltopectoral flap and
supplanted it as the primary flap (other than microvascular
tissue transplantation) in head and neck reconstruction.
The common applications of the pectoralis major musculo-
cutaneous flap in head and neck reconstruction include the
following: external resurfacing of the skin of the face and
neck; intraoral and pharyngeal lining; carrying vascularized
rib and skin in mandibular reconstruction; and reconstruction
of the esophagus.196–200 Historically, the pectoralis major mus-
culocutaneous flap has been one of the most versatile flaps
used in head and neck reconstruction.
The trapezius, a type II muscle, is less widely used than the
pectoralis major muscle, yet its superior location and wide
anterior arc of rotation make it a valuable musculocutaneous
flap.14,22 Modifications in design have enabled the trapezius
muscle to be used as distinctly different upper and lower
musculocutaneous flaps.201 The various clinical applications
of the trapezius flap have included lower facial reconstruc-
tion, especially the ear and parotid regions; lateral upper face
and scalp (occipital and temporal) repair;202 anterior and
posterior neck reconstruction;203 orbital reconstruction with
the use of an extended flap;204,205 and pharyngoesophageal

404
CHAPTER 22 • Flap classification and applications
Fig. 22.49  Pectoralis major flap. Standard arc to middle third of face.
Fig. 22.50  (A–C) Pectoralis major flap for head and neck reconstruction.
A
B
C
reconstruction. Historically, the trapezius has also been used
as an osteomusculocutaneous flap, incorporating either the
lateral aspect of the clavicle or the spine of the scapula (Figs.
22.51 & 22.52).206
The latissimus dorsi is a type V muscle originally described
as a superiorly based flap by Tansini in 1896.207 Since the first
Fig. 22.51  Trapezius flap. Arc to face and anterior neck.
description, there have been numerous modifications and
refinements of the flap. Historically, the latissimus dorsi
musculocutaneous flap has been used in head and neck
reconstruction for large defects or when previous irradiation
or surgery precluded the use of other flaps. Since Quillen et al.
reported the use of the latissimus dorsi as a transposition
island flap in 1978 to cover the mandible and neck after resec-
tion of a tumor; various other clinical applications of the
muscle have been described.208 In fact, the latissimus dorsi
musculocutaneous flap was used frequently in intraoral and
pharyngeal reconstruction.209 Other uses of the latissimus

405
Flap applications
(Fig. 22.54).211,212 The pedicle can be long as 8 cm, reaching
temporal, midface, lower face as well as the oral cavity.213
Depending on the laxity of the skin, it can be closed primarily
and the scar well hidden in the cervicomental angle.
Breast reconstruction
Regional flaps:
1. Pectoralis major
2. Serratus anterior
3. Pectoralis minor.
Distant flaps:
1. Rectus abdominis
2. Latissimus dorsi.
Perforator flap:
1. Lateral intercostal artery perforator
Muscle and musculocutaneous flaps have had a tremendous
impact on breast reconstruction and have provided women
dorsi muscle in head and neck reconstruction have included
reconstruction of defects of the posterior neck, shoulder,
anterior neck, lower face, occipital scalp, and intraoral–
pharyngoesophageal regions.
The main impact of perforator flaps in the head and neck
region is the increased capability of these flaps to accommo-
date complex reconstructions. The addition of perforator flaps
with enhanced knowledge of vascular anatomy has allowed
increased versatility in choosing an appropriate flap. The
facial artery perforator flap is an example of increased choice
for reconstruction of head and neck.210 It is an evolved form
of nasolabial flap and overcomes the limitations by providing
a thinner flap, does not need a second procedure of dividing
the flap, and provides a better rotation and mobility (Fig.
22.53). The second advantage of perforator flaps in the head
and neck is the increased availability of donor site options.
The submental perforator flap based on the perforator of the
submental artery provides excellent texture, color match and
hair-bearing properties ideal for head and neck reconstruction
Fig. 22.52  (A–E) Vertical trapezius
musculocutaneous flap for head and neck
reconstruction.
A
B
C
D
E

406
CHAPTER 22 • Flap classification and applications
Fig. 22.53  The facial artery perforator flap is an
evolved form of nasolabial flap and overcomes the limit
by providing a thinner flap, does not need a second
procedure of dividing the flap and provides a better
rotation and mobility of the flap.
Fig. 22.54  The submental perforator flap based on the perforator of the submental
artery provides excellent texture, color match and hair-bearing properties ideal for
head and neck reconstruction.
approach has resulted in smaller defects and more local tissue
available for use in reconstruction. In addition, more women
with pre-malignant disease or with a family history of breast
cancer are undergoing prophylactic mastectomy and immedi-
ate reconstruction.
Local muscles available in breast reconstruction are
the pectoralis major, pectoralis minor and serratus ante-
rior. These muscles are especially important for patients
who undergo prosthetic implant or expander insertion.
For patients with an intact pectoralis major muscle and
adequate overlying skin, the submuscular (subpectoral or
subserratus–pectoral) placement of a prosthetic implant is
a common reconstructive technique.214 The pectoralis minor
and serratus muscles can also assist in implant coverage
and are generally used in addition to the pectoralis major
muscle.215–217
The distant muscles available in breast reconstruction
include the latissimus dorsi, rectus abdominis and a variety
of other muscles transferred microsurgically including the
gluteus, and fasciocutaneous perforator flaps (deep inferior
epigastric perforator, superficial inferior epigastric artery and
transverse upper gracilis). Distant musculocutaneous or fas-
ciocutaneous flaps are usually indicated for patients with
inadequate local tissue, unacceptable overlying skin, or radia-
tion damage.
with superior cosmetic results after mastectomy. Less aggres-
sive surgical treatment of breast cancer such as the modified
radical mastectomy, skin or nipple-sparing mastectomy, and
lumpectomy have replaced the classic radical mastectomy as
the treatment of choice for breast cancer. This change in

407
Flap applications
Tansini described the earliest version of the latissimus
flap.207 Since then, this muscle has become one of the most
versatile flaps in plastic and reconstructive surgery. The
advantages of the latissimus flap are that it has a reliable
vascular supply and skin island and ultimately provides an
acceptable cosmetic result.218 The major drawback in using the
latissimus dorsi muscle for breast reconstruction is that a
prosthetic implant is usually required to provide adequate
projection, as the musculocutaneous flap by itself is generally
too thin.219 Given this, the extended latissimus dorsi flap has
been described; it provides additional soft tissue, thus obviat-
ing the need for implants.220 In addition, the latissimus dorsi
donor scar is often unsightly and the seroma rates high.221
The rectus abdominis is a type III muscle that commonly
supplies a generous amount of abdominal fat and overlying
skin. As a musculocutaneous flap, the rectus abdominis has
proved to be one of the most valuable options for breast
reconstruction. Variations in flap design have produced dif-
ferent types of rectus abdominis musculocutaneous flaps (e.g.,
vertical, transverse, bipedicled, superiorly based, and inferi-
orly based flaps). The flap was initially described based on its
superior pedicle, the superior epigastric artery and venae
comitantes, with a vertical skin island. Subsequently, its use
based on the inferior pedicle, the deep inferior epigastric
artery, was reported.222 In 1982, Hartrampf et al. described a
technique that changed the entire approach to breast recon-
struction.223 By alignment of the skin island in a transverse
direction, between the umbilicus and pelvis, the rectus
abdominis musculocutaneous flap provided skin and soft
tissue for breast reconstruction with improved abdominal
contour. The transverse rectus abdominis musculocutaneous
(TRAM) flap is now considered the musculocutaneous flap of
choice for breast reconstruction (Fig. 22.55).
The indications for using the TRAM flap in breast recon-
struction include a patient in need of additional soft tissue
and overlying skin who has a moderate amount of lower
abdominal tissue; a patient who prefers autologous tissue
reconstruction without the use of a prosthetic implant; a
patient who prefers a lower abdominal donor scar rather than
a back scar; and a patient who has had an unacceptable result
after undergoing other reconstructive methods (Fig. 22.56).224
The relative contraindications to using the TRAM flap
include an extremely thin patient who has little lower abdomi-
nal tissue, a nulliparous patient in her child-bearing years, a
patient with a history of abdominal wall hernia, an extremely
obese patient, a heavy smoker, and a patient with lower
abdominal scars. An absolute contraindication for a superiorly
based transposition TRAM flap for breast reconstruction is
prior division of its superior pedicle, usually related to a
superior transverse laparotomy incision.
The advantages of the TRAM flap include the following:
1. It provides sufficient bulk so that a prosthetic implant
usually is not required.
2. The suprapubic horizontal donor scar is aesthetically
acceptable.
3. Transposition of the flap can be performed with the
patient in a single operative position.
4. The skin dimensions are larger than those available with
the latissimus dorsi flap.
5. A simultaneous abdominoplasty is accomplished with
direct donor site closure.
The major disadvantage of the TRAM flap is that there is a
potential risk of abdominal hernia or weakness after the use
of the unilateral or bilateral rectus muscles for flap harvest.225
The long-term effect of the loss of one or both rectus
abdominis muscles has been the subject of many investiga-
tions.226 Most studies report qualitative rather than quantita-
tive data with regard to the postoperative strength of the
abdominal wall. However, studies are beginning to show
qualitative deficits of abdominal wall muscle loss.227 Overall,
the majority of patients resume normal activities, without
physical limitations, after breast reconstruction with the
TRAM flap.
For breast reconstruction, TDAP (thoracodorsal artery
perforator), AICAP (anterior intercostal artery perforator),
LICAP (lateral intercostal artery perforator), and SEAP (supe-
rior epigastric artery perforator) flaps can be used as regional
flaps. These regional flaps may serve to reconstruct the breast
after partial mastectomy. The LICAP flap is frequently used
for reconstruction for lower lateral quadrant partial mastec-
tomy defects. They can be a simple alternative to pedicled
latissimus dorsi flaps or TDAP flaps.228 The LICAP flap is
supplied by the lateral branch of posterior intercostal artery
found at the junction of the midaxillary line and the lower
border of the corresponding rib. Perforators rising between
the fourth and sixth intercostal are ideal options for partial
breast reconstruction (Fig. 22.57).
Mediastinum
Regional flaps:
1. Pectoralis major.
Distant flaps:
1. Rectus abdominis
2. Latissimus dorsi
3. Omentum.
The most common reason for reconstructing the mediastinum
is infection after median sternotomy. Although the incidence
of infection following median sternotomy is low, reported
from 0.4% to 6.9%, the morbidity and mortality are signifi-
cant.229 The treatment of an infected median sternotomy
wound depends on the extent of the infection and the amount
of tissue necrosis. Historically, the standard therapy for an
infected median sternotomy wound included debridement
and closed tube irrigation. Muscle flap coverage was gener-
ally reserved for wounds recalcitrant to standard therapy.
Now, it is generally accepted that early muscle flap transposi-
tion decreases morbidity, and therefore the use of a muscle
flap should always be considered for the treatment of median
sternotomy wounds.
The preferred local muscle for mediastinal coverage is the
pectoralis major. In 1980 Jurkiewicz et al. described the use of
the pectoralis major muscle flap to obliterate the sternal–
mediastinal dead space.230 The pectoralis major can be mobi-
lized in several ways. The muscle can be transposed either on
the dominant thoracoacromial pedicle or as a turnover flap
on the segmental secondary vascular pedicles (perforating
vessels from the internal mammary artery and vein). Nahai
et al. described a modified technique of the turnover flap
that preserves the lateral one-third of the muscle based on the
dominant vascular pedicle and its motor nerves.231 The advan-
tage of this technique is the preservation of the anterior

408
CHAPTER 22 • Flap classification and applications
Fig. 22.55  Various designs of superiorly pedicled
TRAM flaps.
Mathes 1977
Drever 1970
Robbins 1979
Marino 1981
Hartrampf 1982
Dinner 1982
Lejour 1982
Hartrampf 1982
Gandolfo 1982
Hartrampf 1982
Elliot 1983
Dinner 1983

409
Flap applications
along with the pectoralis major muscles to cover the inferior
aspect of the wound.236 Used as either a muscle or musculocu-
taneous flap, the rectus abdominis muscle is a reliable source
for inferior mediastinal coverage; in addition, it provides the
ability to fill a large dead space.237,238 In considering the use of
the rectus abdominis muscle, it must be noted that the superior
epigastric artery is the continuation of the internal mammary
artery inferior to the sternum that should be avoided during
debridement of the sternal wound. Furthermore, the use of the
internal mammary artery as a coronary artery bypass graft
may adversely affect perfusion of the superiorly based rectus
abdominis flap, which precludes the use of the rectus flap on
that side. Collateral circulation to the internal mammary
vessels distal to the site of ligation during coronary bypass will
generally allow adequate perfusion through the superior
epigastric artery and vein for superior transposition to the
mediastinum (Figs. 22.58 & 22.59).
The omentum is an alternative source of tissue available to
be transferred for mediastinal reconstruction; it may be used
solely or in combination with another flap.239 The omentum
can be based on the right or left gastroepiploic vessels. In view
of the risk of exposing the peritoneum to a contaminated field,
however, the omentum is generally reserved for patients in
whom the pectoralis major and rectus abdominis muscles
are unavailable.240 The harvest of the omentum has been
achieved laparoscopically to lower the potential abdominal
wall morbidity.241
The latissimus dorsi provides another alternative muscle
or musculocutaneous flap for coverage of the upper media­
stinum.242 Its use is usually indicated when the pectoralis
major is absent or damaged by previous incisions or radiation
therapy.243 The advantage of using the latissimus dorsi muscle
or musculocutaneous flap is that the vascular pedicle and the
donor site are distant to the infected area.244 The disadvantages
include the inconvenience of obtaining a muscle flap from the
back and that the latissimus dorsi muscle may be too thin for
the deeper, more extensive mediastinal defects. The latissimus
dorsi can also be transferred microsurgically to sternal wound
defects.245
Chest wall and pulmonary cavity
Regional flaps:
1. Pectoralis major
2. Latissimus dorsi
3. Serratus anterior.
Distant flaps:
1. Rectus abdominis
2. Omentum.
Perforator flaps
1. TDAP (thoracodorsal artery perforator)
2. Keystone flaps.
Reconstruction of the chest wall is challenging. Ablative
surgery for neoplasm, infection, radiation, and trauma can
produce extensive full-thickness chest wall defects. Further-
more, many of the patients in need of reconstruction
have previously undergone some form of chemotherapy or
high-dose irradiation for their primary disease. Wound
healing can therefore be severely compromised at the time of
reconstruction.
Fig. 22.56  (A–C) TRAM flap breast reconstruction.
A
B
C
axillary fold. The pectoralis muscle flap remains the mainstay
of treatment in both adults and children with sternal wound
infections.232–234
Depending on the size of the defect, the surgeon can use
one or both pectoralis major muscles for coverage.235 If addi-
tional coverage is needed, the rectus abdominis can be used

410
CHAPTER 22 • Flap classification and applications
viable muscle at the wound bed can be managed with skin
grafting; larger full-thickness defects require flap reconstruc-
tion. In addition to flap reconstruction, Prolene® mesh is
indicated for chest wall reconstruction to provide stability and
support for the overlying flap when there is significant loss
of chest wall continuity.246,247
The pectoralis major and latissimus dorsi muscle and
musculocutaneous flaps are the most commonly used in chest
wall reconstruction. Larson and McMurtrey stated that the
pectoralis major musculocutaneous flap is the flap of choice
for defects of the lower neck and upper third of the sternum,
whereas the latissimus dorsi musculocutaneous flap is pre-
ferred for wounds of the anterior chest wall that will require
removal of two or three ribs and resection of <8 cm of skin.
In these authors’ series of 53 flaps in 50 patients, the muscu-
locutaneous flap alone provided adequate support and stabil-
ity. Fascia, ribs, and prosthetic mesh were not needed for
support.248
The use of the latissimus dorsi flap in a patient who has
previously undergone a thoracotomy decreases the reliability
of the pedicle and safety of subsequent ipsilateral flap trans-
position although previous thoracotomy is not an absolute
contraindication. In fact, Scheflan et al. reported that a stan-
dard anterolateral thoracotomy, which separates the latissimus
Historically, methods of chest wall reconstruction consisted
of various random and tube flaps that often required several
stages before completion. Currently, the reconstruction of the
chest wall is successfully accomplished without the need for
delay or staged procedures. Partial thickness defects with
Fig. 22.57  The LICAP flap is supplied by the lateral branch of the posterior
intercostal artery found at the junction of the midaxillary line and the lower border
of the corresponding rib. Perforators rising between the fourth and sixth intercostal
are ideal options for partial breast reconstruction.
Latissimus
dorsi
Latissimus
dorsi
Pectoralis major
Serratus anterior muscle segments
Serratus
anterior
Posterior
intercostal
vessels
Anterior branch of
lateral intercostal
artery
Rib
Fig. 22.58  Pectoralis major flap. (A) Standard flap to anterior mediastinum based
on thoracoacromial pedicle. (B) Turnover arc to anterior mediastinum based on
perforator vessels from internal mammary artery and associated veins.
A
B

411
Flap applications
reconstruction. The serratus muscle has a constant and reli-
able vascular pedicle and a long arc of rotation.259 Arnold et al.
described its use in reconstructing the chest wall, closing
bronchopleural fistulas, and reinforcing tracheal reconstruc-
tions.260 The serratus may be surgically split thereby utilizing
only a portion for reconstruction.44
The rectus abdominis muscle is a distant muscle or muscu-
locutaneous flap for chest wall reconstruction. Larson et al.
showed that the rectus abdominis musculocutaneous flap is
particularly useful for large chest wall defects.248 The avail-
ability of the flap is dependent on the status of the internal
mammary arteries. Miyamoto et al. favored the rectus
abdominis musculocutaneous flap over the latissimus dorsi
in chest wall reconstruction because of its convenience (the
patient can remain in one position intraoperatively), ease of
elevation and subsequent closure of the donor site.261 In
addition, it is thought that in situations when up to three
ribs are removed and reconstructed with mesh, the rectus
shows a distinct advantage given its thickness which
dorsi into an upper third and lower two-thirds, does not
preclude the subsequent use of the muscle as a flap.249 More
recently, the latissimus dorsi muscle has been used success-
fully in patients who had undergone previous posterolateral
thoracotomy.250 The upper third of the latissimus dorsi muscle,
based on the thoracodorsal pedicle, may be used to cover
superior anterolateral chest wall defects. The lower two-thirds
of the muscle, based on its secondary pedicles from the para-
spinal perforators, can be used as a reverse latissimus dorsi
flap with or without the overlying skin to cover inferolateral
and posterior chest wall defects. Early work by McCraw et al.
and Bostwick et al. was instrumental in the development of
the reverse latissimus dorsi flap.251,252 Latissimus dorsi muscle
and musculocutaneous flaps have proved invaluable in the
treatment of numerous chest wall and pulmonary cavity
disorders including Poland syndrome,253,254 spina bifida
defects,255,256 and diaphragmatic hernias.257,258
The serratus anterior muscle can also be useful as a
local muscle flap for chest wall and pulmonary cavity
Fig. 22.59  (A–E) Bilateral pectoralis muscle flaps for
mediastinal reconstruction.
A
B
C
D
E

412
CHAPTER 22 • Flap classification and applications
minimizes the risk of creating a flail chest wall.262 Large defects
of the chest wall within the arc of rotation of the rectus can be
reconstructed. The rectus abdominis muscle may be used as
a transverse or vertically oriented musculocutaneous flap.263
If the internal mammary vessels have been manipulated
the rectus flap is often transferred microsurgically.264
The omentum is also utilized for chest wall reconstruction.
The omentum can be harvested laparoscopically, obviating
the need for a large abdominal incision. When used as a
transpositional flap, the omentum can be based on either the
right or left gastroepiploic vessels. The omentum has a large
surface area, obliterates dead space, is pliable, and contains
angiogenic and immunogenic properties. The use of the
omentum in chest wall reconstruction secondary to osteo­
radionecrosis, cancer ablation, and chronic wounds is well
established.79
The regional perforator flaps are often with short pedicle
around the chest. The TDAP flap does have a long pedicle
making reconstruction possible in the upper two thirds of the
chest wall. However, the frequent presence of dead space may
require additional muscle mass favoring the latissimus mus-
culocutaneous flap. The keystone island flap based on fascio-
cutaneous and musculocutaneous perforators offers robust
vascularity of perforator flaps and the ease and speed of
simple local flap advancement.32
Abdominal wall
Regional flaps:
1. Rectus abdominis
2. External oblique.
Distant flaps:
1. Tensor fascia lata
2. Latissimus dorsi
3. Rectus femoris.
Perforator flaps:
1. Anterolateral thigh (ALT)
2. Deep inferior epigastric artery perforator (DIEAP)
3. Deep superior epigastric artery perforator (DSEAP)
4. Propeller.
In reconstructing abdominal wall defects, the surgical objec-
tive is to provide soft tissue coverage in addition to
re-establishing the abdominal wall integrity. To plan safe and
reliable techniques for wound closure, it is helpful to classify
complex wounds by location and the status of the overlying
skin and soft tissue coverage. In regard to location, the
abdominal wall is divided into four zones: zone 1A, upper
midline defects with extension across the midline; zone 1B,
lower midline defects with extension across the midline; zone
2, upper quadrant defects; and zone 3, lower quadrant defects
(Fig. 22.60, Table 22.14).
The two muscles available for local flaps are the rectus
abdominis and the external oblique. The rectus abdominis
muscle or musculocutaneous flap is the flap of choice for
unilateral abdominal wall defects. In 1977 Mathes and Bost-
wick described the use of the rectus abdominis musculocuta-
neous flap for reconstruction of an abdominal wall defect.222
Parkash and Ramakrishnan reported the use of a rectus
abdominis musculocutaneous island flap for coverage of an
extensive radionecrotic abdominal wall ulcer that had been
Fig. 22.60  Reconstructive zones of the abdomen.
3
3
2
1B
1A
2
Table 22.14  Flaps for abdominal reconstruction by location
(zone)
Flaps
Zones
1A
1B
2
3
Latissimus dorsi
X
Rectus abdominis
  Superiorly based
X
X
  Inferiorly based
X
X
  Advancement
X
X
External oblique advancement
X
Tensor fascia lata
  Transposition
X
X
  Expansion
X
X
X
X
Rectus femoris
X
X
(Modified from Mathes SJ, Steinwald PM, Foster RD, et al. Complex abdominal
wall reconstruction: a comparison of flap and mesh closure. Ann Surg.
2000;232:586–596.)
resistant to conservative therapy.265 In 1983, Taylor et al.
described the extended deep inferior epigastric flap, which
consists of an inferiorly based rectus abdominis musculocu-
taneous flap with a superolateral fasciocutaneous extension.
With this larger skin territory, extensive defects of the
abdomen, as well as those of the groin and thigh, have been
successfully treated.266
The rectus may be released from its lateral attachments to
achieve midline abdominal wall closure. Several variations
have been described. One variety, termed separation of com-
ponents, involves separation of the external oblique fascia
with an incision just lateral to the linea semilunaris allowing
a plane to develop between the external and internal oblique
muscles.267 This permits medial mobility of the rectus abdomi-
nis muscle. Other variants of sliding myofascial partitions
or releases have been used successfully to reconstruct the
abdominal wall.222,268 Alternatively, the rectus may be used as
a turnover flap to achieve closure.269
The external oblique muscle may be used to reconstruct
absent or deficient rectus fascia.270 The external oblique mus-
culocutaneous flap is an alternative local flap, useful for

413
Flap applications
Groin and perineum
Regional flaps:
1. Sartorius
2. Pudendal thigh flap.
Distant flaps:
1. Gracilis
2. Tensor fascia lata
3. Rectus femoris
4. Rectus abdominis
5. Gluteus maximus.
Perforator flaps
1. Free-style perforator.
Reconstruction of the groin and perineum is often indicated
for defects due to trauma, tumor resection and infection. The
wounds can be extensive and, because of their proximity to
the anus and urethra, are susceptible to fecal and urinary
contamination. In addition, wounds involving the groin may
expose the femoral vessels. Vascular prosthetic grafts and
adjunctive radiation therapy in the cancer patient can further
compound the problem.
The sartorius is a type IV muscle with multiple segmental
vascular pedicles that limit its arc of rotation. The division of
one or two of the most proximal pedicles, however, enables
the superior aspect of the sartorius muscle to be transposed
medially into the groin. This technique is used for coverage
of exposed femoral vessels and prosthetic vascular grafts.296
The pudendal thigh flap is an axial pattern, sensate fascio-
cutaneous flap based on the terminal branches of the internal
pudendal artery.297,298 Variants of this flap are gluteal fold
flaps, lotus flaps, and Singapore flaps.297,299,300 Various designs
can be used: along the longitudinal axis in the line of the
internal pudendal artery in the gluteal fold, a V–Y advance-
ment, and a rhomboid-style flap.
The gracilis is a type II muscle that has both an anterior
and posterior arc of rotation. Anteriorly, the muscle can be
used for groin and perineal reconstruction; posteriorly, ischial
and perirectal defects can be reconstructed.301–303 Other
common uses of the gracilis muscle and musculocutaneous
flap include reconstruction of the vagina, penis, scrotum, and
anal sphincter (Fig. 22.63).294,304–306
The tensor fascia lata (TFL) is particularly useful for groin
and perineal reconstruction.307,308 It can be used as either a
musculocutaneous flap or a musculofascial flap. The TFL is
also used in vulvar reconstruction and recurrent inguinal
hernia reconstruction.284
The rectus femoris is useful for coverage of the groin and
perineum.309,310 It is a large, bulky muscle that has an arc of
rotation similar to that of the tensor fascia lata. Despite its
reliability and desirable muscle bulk, this muscle is generally
used as an alternate flap in the ambulatory patient, given the
potential functional deficit associated with its harvest,
although more recent evidence suggests that the results of the
reconstruction appear to outweigh the loss of strength.284,311
The rectus abdominis muscle or musculocutaneous flap
based on its inferior pedicle provides a reliable flap for
defects of the anterior pelvis and groin.222,294,312 Its wide arc of
rotation and abundant blood supply through the inferior
epigastric vessels make it an excellent reconstructive flap for
this region. The vertical rectus abdominis musculocutaneous
reconstructing small, full-thickness upper abdominal wall
defects.271–273 The external oblique musculofascia may also be
expanded and advanced centrally to repair abdominal wall
defects.274,275
The distant muscle and musculocutaneous flaps used in
abdominal wall reconstruction include the latissimus dorsi,
tensor fascia lata, and rectus femoris flaps. Transposition of
the latissimus dorsi musculocutaneous flap is a reliable tech-
nique that is particularly useful for superolateral abdominal
wall defects.276,277 This flap is particularly useful in traumatic
defects, burn injuries and post-extirpative defects.278–280 The
latissimus dorsi can also be transferred microsurgically to
cover central abdominal defects.281 This flap may also be rein-
nervated and has shown enough contractile capacity and
strength to adequately replace the function of the missing
abdominal wall muscles.282
The use of the tensor fascia lata (TFL) as a musculocutane-
ous and musculofascial flap is indicated for lower abdominal
wall reconstruction. Wangensteen initially described use of
this flap for lower abdominal wall closure.283 The unique
qualities of the tensor fascia lata flap include the large amount
of vascularized fascia and skin and the low donor site
morbidity.284–286 The TFL is most commonly used as a rotational
flap, although success as a free flap has been demonstrated.287
As a rotational flap, the arc of rotation is limited to the lower
abdominal wall, whereas when used as a free flap, any region
of the abdominal wall may be reconstructed.288
The rectus femoris musculocutaneous flap is a dependable
alternative flap for abdominal wall reconstruction.289,290
Variations of the rectus femoris flap, including the use of
fascial extensions and tissue expansion, have been described
to extend its arc of rotation.291,292 However, it tends to be
bulkier than the TFL and has greater donor site morbidity.
Leg extension may be adversely affected with the use of this
flap although subsequent studies show no appreciable
effect.291,293 In certain instances the rectus femoris is preferred
to the TFL flap. An example would be the use of the rectus
femoris to treat a radionecrotic ulcer involving the lower
abdominal wall, given the need for muscle bulk to fill the
defect (Fig. 22.61).294
There can be many options for perforator flaps to cover the
abdomen. For moderate or small-sized wounds, a perforator
can be found near the defect and the flap can be rotated as a
propeller flap to cover the skin defect of the abdomen. This
rotation based on the perforator allows rotation of the flap
without violating the structures beneath the deep fascia.58 For
larger and complex wounds, a larger perforator flap or a
flap with composite tissue can be used. Fig. 22.62 divides the
abdomen into five zones showing the preferred perforator
flap for reconstruction.58 The DIEP flap can be rotated as a
propeller to cover the lower abdomen as well as the mid
abdomen. If there is a scar within the flap territory, it may
jeopardize the flap circulation after elevation. A pedicled ALT
flap can be harvested with large dimensions able to reach
the low and lateral abdomen. The ALT can be elevated with
a deep fascia as a composite flap to restore the integrity of
the abdominal wall.295 The DSEAP flap can be designed hori-
zontal and slightly obliquely parallel to the costal margin. A
propeller-style harvest and rotation can be done to reconstruct
the upper abdominal region.58 When elevating this flap, one
should always confirm the presence of the internal mammary
artery as this is the main source vessel of the perforator.