Flaps can be classified in several ways: (1) By circulation/blood supply - direct or indirect, axial or random; (2) By composition - skin, fascia, muscle, bone, or visceral; (3) By contiguity - local, regional, or free. Perforator flaps allow for minimal donor site morbidity.

1. CLASSIFICATION OF FLAPS
Dr. Prabhu Dayal Sinwar
Resident Plastic and Reconstructive
Surgery

2. Introduction
• Flap consists of a tissue that is mobilized on the
basis of its vascular anatomy.
• It may consists of simple skin tissue, muscle,
fascia, bone.
• The purpose of classification is to understand the
anatomy and features that each flap provides.
• It also provides easy communication with peers
and patients to achieve a common goal of
reconstruction.

3. Timeline of the development of flap surgery
• 600 BC Sushruta Samhita Pedicle flaps in the face and forehead for nasal
reconstruction
• 1597 Tagliacozzi Nasal reconstruction by tubed pedicle flap from arm; described
“delay” of pedicle flap
• 1896 Tansini Latissimus dorsi musculocutaneous flap for breast reconstruction (post-
mastectomy)
• 1920 Gillies Tubed pedicle flap
• 1946 Stark Muscle flaps for osteomyelitis
• 1955 Owens Compound neck flap
• 1963 McGregor Temporalis flap
• 1965 Bakamjian Deltopectoral flap
• 1971 Ger Lower extremity musculocutaneous flap
• 1972 McGregor and Jackson Groin flap
• 1972 Orticochea Musculocutaneous flaps
• 1977 McCraw et al Musculocutaneous territories
• 1981 Mathes and Nahai Classification of muscle flaps based on vascular anatomy
• 1981Ponten described fasciocutaneous flap

4. Atomic Classification of Tolhurst
(Modified by Hallock ,2004)
Conditioning
Conformation
Contiguity
Construction
Constituents
Circulation

5. Basis for flap classification
1. Circulation (blood supply)
Direct
vessels
Axial
Septo-
cutaneous
Endosteal
Indirect
vessels
Myo-
cutaneous
Periosteal

6. 2.
Constitution
(Composition
)
Skin (with
subcutane
ous fat )
Facio-
cutaneous /
Fasia
Musle /
Musculocu
taneous
Visceral
Nerve
Bone
Cartilage
Lymph
node (with
subcutaneo
us fat )

7. 3. Contiguity
( Destination)
Local Regional Distant (Free)

8. * Pedicle usually drain single source(unipedicle) and antegrade /
orthograde flow
4. Construction (Flow)
Bipedicle
Retrograde
Turbocharged
Supercharged
Arterialised
venous

9. 5.
Conditioning
Delay
Tissue
Expansion
Prefabrication
Sensate
(sensory
nerve)
Functional
(motor nerve)

10. 6. Conformation
Special
shapes
Tubed
Combined
flaps

12. Fascial plexus : divided into
1) Subfascial plexus :
• plexus lying on the under surface of the fascia .
• relatively minor plexus .
• incapable of sustaining a fascial flap .
2) Prefascial plexus : dominant distribution system .
3) Subcutaneous Plexus
• Network of vessels which divide subcutaneous fat into
deep (loose) and superficial (dense) layers.
• More developed in torso than in extremities.
• Supplied by both septo-cutaneous and Musculo-
cutaneous arteries.

13. 4) Sub dermal Plexus :
• Located at junction between reticular dermis and subcutaneous fat.
• Vessels have a continuous arterial muscular wall.
• Primary blood supply to the skin.
• Primarily distributor function.
• Corresponds with “dermal bleeding” at the edge of the flap.
5) Dermal Plexus
• Present at lower limits of dermal papillary ridge.
• The Vessel in the plexus are arterioles and wall contains isolated
muscular elements .
• Primarily thermoregulatory function.
6) Sub epidermal Plexus
• Located at dermoepidermal junction.
• Consists mostly of capillaries having no muscle in their wall.
• Therefore they serve to have primarily nutritive function.

14. RANDOM FLAP AXIAL FLAP
• Based on the rich sub -
dermal vascular plexus of
the skin.
• Derive their blood supply from a direct
cutaneous artery or named blood
vessel .
• Most of the local flap are
random flaps. E.g Bipedicle flap, VY
advancement flaps, rotation or
advancement flaps
• Examples :
Nasolabial flap (angular artery) ,
Forehead flap(supratrochlear artery).
• Maximum length : breadth ratio of
1 : 1 in the lower extremity.
Up to 3 : 1 in the face.
• The surviving length of an axial pattern
flap is entirely related to the length of the
included artery.

15. Random flaps
Z plasty
• Four flap plasty
• Five flap plasty
• W plasty
Advancement flaps
• Simple
• Modified
• V-Y
• Keystone
• Bipedicle
Pivot flaps
• Transposition
• Interpolation
• Rotation
• Bilobed

16. Flap based on Constituents
• Muscle and Musculocutaneous flaps
1981, Mathes and Nahai classification
Five vascular pattern

18. Advantages of muscle,
musculocutaneous flap
• Vascular pedicle are specific and reliable.
• Vascular pedicle often located outside surgical defect.
• Muscle provide bulk for deep extensive defect and
protective padding for exposed vital structure.
• Muscle is malleable and can be manipulated.
• Well vascularised muscle resistant to bacterial infection
and inoculation.
• Often one stage procedure.
• Restoration of function possible with certain flap.

19. Disadvantages of muscle,
musculocutaneous flap
• Donor defect may lose some degree of
function.
• Donor defect may be aesthetically
undesirable.
• May provide excessive bulk or may atrophy
over time.
• May result in contour deformities at the donar
site.

20. Fascia and Fasciocutaneous flaps
• Fascial flap consist of fascia detached from its normal origin
or insertion and transposed to another location.
• Fasciocutaneous flap consist skin, subcutaneous tissue and
underlying fascia.
• 1975, Schafer found three major vascular system for deep
fascia
• Perforating arteries
• Subcutaneous arteries
• Subfacial arteries
• 1981, Ponten for lower extrimity reconstruction
• 1983,Tolhurst for trunk and axillary reconstruction.

21. MATHES AND NAHAI
• On the basis of the source of the pedicle
Examples
•Groin fascio-
cutaneous flap
•Superficial inferior
epigastric flap
Examples
•Scapular and
para-scapular
flap
•Lateral arm
flap
Examples
•Median
forehead flap
•Antero-lateral
thigh flap

22. • CORMACK AND LAMBERTY
Examples
•Lower leg flaps
described by Ponten
Examples
•Scapular and
Parascapular flap
Examples
•Radial
forearm flap
•Lateral arm
flap
Also TYPE D flaps are osteomusculofasciocutaneous flaps with vascular supply similar
to Type C

23. Nakajima classification

24. Advantages of fascia, fasciocutaneous
flap
•Thin and pliable
•Blood supply is reliable and robust.
•Donor site morbidity is minimal.
•They are muscle sparing.
•Have ability to restore sensation.
•There are many potential donor site.

25. Disadvantages of fascia,
fasciocutaneous flap
•Lack of bulk for deep defect.
•Technically more challenging.
•There are size limitation.
•Arc of rotation sometimes limited.
(though often better than similar muscle
flap.)
•Donor site may require skin graft closure.

26. Perforator flap ( Skin with fat and
with or without fascia )
• Skin flap with or without fascia based on single
perforator.
• Evolved from musculo-cutaneous and fascio-
cutaneous flap without the muscle and fascial
carrier.
• Aiming to minimizing donor morbidity.

27. Perforasome theory
• Given by Saint-Cry
• Reported four major characteristic
1. Each perforosome linked with adjacent perforosome.
2. Flap design and skin paddle orientation should be
based on direction of linking vessel.
3. Filling of perforosome occur within perforosome of
same source artery first.
4. Mass vascularity of a perforator found adjacent to an
articulation is directed away from the same
articulation.

28. Types of perforator based on surgical
dissection
• Type 1: Direct perforators perforate the deep
fascia only
• Type 2: Indirect muscle perforator predominantly
supply subcutaneous tissue.
• Type 3: Indirect perforator predominantly supply
the muscle
• Type 4: Indirect perimyceal perforator
• Type 5: Indirect septal perforator

29. • Propeller flap, an island flap is a type of
perforator based local flap that reaches the
recipient site via an axial rotation of upto 180
degrees around the perforator.

30. Advantages of perforator flap
• Reduced donor site morbidity
• Versatility of flap design
• Muscle sparing
• Improved post operative recovery of
patient

31. Disadvantages of perforator flap
• Meticulous dissection needed
• Increased operative time
• Variability in size and position of
perforator vessels
• Steep learning curve

32. Visceral flap
Jejunum To reconstruct esophagus
Colon / Jejunum Vaginal reconstruction
Appendix Urethra and voice
reconstruction
Omentum To reconstruct a wide range of
extraperitoneal defect
Also have immunologic and
angiogenic property

33. Bone flap ( Vascularised bone,
osseous-periosteal flap)
Flap Based on
Fibula Peroneal Artery
Iliac crest Deep circumflex iliac artery
Scapula Circumflex scapula or thoraco-dorsal
artery
Radius Radial artery
Calvarial osseous flap Superficial temporal artery or occipital
artery
Genicular osseous-periosteal flap ( Medial
femoral condyl flap )
Articular branch of decending genicular
artery

34. Nerve flap
• Sensory nerve supplied by extrinsic and
intrinsic blood supply.
• Extrinsic blood supply : From arteria nervorum from
perforating vessels.
• Intrinsic blood supply : From longitudinal oriented
arteriole.
• Nerve flap can harvested from superficial
located sensory nerve based on perforating
vessels.

35. Nerve Based on
Superficial radial nerve flap Radial artery and
accompanying vein
Saphanous nerve flap Femoral artery (proximally)
Saphanous artery (distally)
Sural nerve flap Superficial / medial sural
artery
* Lesser saphanous vein
can be arterialised if
perforator are missing.

36. Lymph node flap
• Offer a solution in Lymphoedema patient.
• Require supermicrosurgery technique for
anastomosis extremly small vessels.
• Source vessels are superficial inferior
epigastric artery, superficial circumflex iliac
artery and supraclavicular artey.

37. Flap based on Contiguity
(Destination)
Flaps can be classified as
1. Local flaps (Tissue adjacent to the flap)
2. Regional flap (Tissue from the same region of
the body as the defect) e.g. Radial forearm flap
for a defect on the dorsum of hand.
3. Distant flaps
• Pedicled from a distant part of the body
staying attached to its original vasculature
• Free flaps are completely detached from the
body and anastamosed to recipient vessels
close to the defect

38. Flap based on construction / flow
• Unipedical flap: Pedicle usually drains into
single source.
• Bipedical flap: Flap with dual pedicle.
• Random pattern skin flap to cover a defect on
extremity,
• Transabdominal bipedicle flap to provide coverage on
dorsum of hand.

39. • Retrograde flow flap:
• When orthograde pedicle ligated proximally than flow
of flap become reversed and flap based on distal part of
major pedicle.
• First reported by Bostwick et al using a reverse flow
temporal artery island flap.
• Other are
– Distally based radial forearm fasciocutaneous flap,
– posterior interosseous flap,
– Reversed first dorsal metacarpal artery flap used in hand
reconstruction.
– Sural fasciocutaneous flap
– Lateral calcaneal flap
– Reverse flexor hallucis longus flap

40. • Supercharged flap:
• 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.
• Superior unipedicled transverse rectus
abdominis musculocutaneous flap.

41. • Turbocharging:
• Using main vascular source to connect to
an additional pedicle from same flap
create a direct flow to vascular territory
of the connected branch.
• Connecting ipsilateral and contralateral
deep inferior epigastric vessel of TRAM
flap to improve vascular supply of whole
TRAM flap.

43. • Venous flaps (Arterialised venous flap):
• Using subcutaneous vein for arterial
inflow and venous outflow.
• Does not require a donor site artery.
• Widely used for soft tissue repair on
hands and fingers.

44. • Woo’s classification of arterialised venous flap
for hand and finger reconstruction based on
presence of intervenous valve, venous
network of donar site, location, number of
vein at recipient site.
• Type I: Through and along valve
• Type II: Against valve
• Type III: Mixed pattern (through and against
valve)

45. Flap based on conditioning
1. Delay
• “ preliminary surgical intervention wherein a portion of the
vascular supply to a flap is divided before definitive elevation
and transfer of the flap”.
• In 16th century Tagliacozzi delayed his upper arm flap by
making parallel incision.
• In 1921 Blair introduced the term ‘Delay transfer’.
• In 1965, Milton investigated four different method of delaying
a flap (in pig model).
• Goal are to enhance flap circulation, ensuring flap servival after
advancement, transposition, or transplantation to a defect site.

46. • Two theories that describe potential mechanism by
which delay phenomenon prevent skin necrosis.
1. Delay acclimatizes flap to ischemia (tolerance)
: vascular delay cause adaptive metabolic
changes at cellular level within the tissue.
2. Delay improve vascularity by increasing flow
through preexisting vessels, reorganizing the
pattern of blood flow to more ischemic area.
*May result in part from sympatholytic state that
result from cutting of sympathetic innervation
and subsequent vasodilation.

47. 1.STANDARD DELAY : 2. STRATEGIC DELAY :
With an incision at the periphery of the
cutaneous territory or partial flap
elevation.
Flap is then elevated after 10-14 days.
With division of selected pedicles to the
flap to enhance perfusion through the
remaining pedicle or pedicles .
Flap elevation after 2 week period.
Surgical flap delay is accomplished in two ways:

48. 2. TISSUE EXPANSION
•1957 : Neumann is credited with the first modern report of this
technique.
•1976 : Radovan further described the use of this technique for
breast reconstruction.
•Although immediate skin expansion is possible, delayed expansion
is usually performed prior to flap elevation.
•During a selected time interval, usually 6 week to 3 months,
expander is injected with saline at weekly interval till the desired
amount of expander achieved.
Advantages :
1. Reconstruction with tissue of a similar color, texture and contour.
2. Reconstruction with sensate skin containing skin appendages.
3. Limited donor-site deformity.

49. 3. Prelaminated and prefabricated
flap
• Flap prelamination: Surgical manipulation of
flap that requires partial or complete flap
elevation and suturing of flap to form
structure at the site of reconstruction.
• When these structure at donar site healed,
flap transposition or transplantation
performed.
• Commonly done in flap used in head and neck
reconstruction.

50. • Prefabrication: Provide a new dominant
vascular pedicle to structure for subsequent
transposition or transplantation.
• Large pedicle of adjacent muscle is selected
and inset beneath the proposed flap site.
• In 6 weeks this flap based on new vascular
pedicle is elevated and transposed or
transplanted.

51. 4. Sensory flap
• Cutaneous nerves are incorporated in the flap
base or senory nerves of the the flap may be
coapted to the suitable nerve at the donor site
to retain protective sensibility to hands, feet
and other weight bearing areas
• Another common area in which sensate flap
are used is oral cavity and this potentially
improve postoperative intraoral function.

52. 5. Functional muscle flap
• For function to be preserved:
– Motor nerve must be preserved along with
dominant vascular supply
– Muscle must be reattached to a new bone or
tendon across a joint.
– Muscle must exert a direct force on its new point
of attachment.
• Eg. Latissimus, gluteus maximus (segmental),
gracilis, gastrochnemius and serratus muscle.

53. Flap based on conformation
Conformation of flap frequently combine
multiple flap.
Tubed flaps – flaps rolled over to allow easy
movement from one region to another e.g. facial
reconstruction.
Compound flaps consist of multiple tissue
components linked together in a manner that
allows their simultaneous transfer and
consequent more effective reconstruction.

54. Compound flaps HALLOCK’S CLASSIFICATION
1. Solitary Compound Flap – composite flaps based on a single source
of circulation
2. Combined compound Flap – compound flap with multiple sources
and combined vascularisation
2a. Conjoined Flaps – At least two anatomically distinct territories
each preserving their individual blood supply but joined by means
of some common physical territory.
• Two subgroup- Perforator based or branch based(independent
or common type).
2b. Chimeric Flaps – Multiple otherwise independent flaps each
having an independent blood supply but in turn all pedicles are
linked to a large common source vessel.
• Three subclasses: perforator based, branch based and
fabricated(sequential type or internal type).

56. THANKS