Considerations in Flap Selection

Introduction

A meticulous preoperative problem analysis leading to the selection of the proper strategy for solving the given wound, defect, or deformity can be a difficult task, yet certainly as critical as the actual surgical procedure that may be required. If a vascularized tissue transfer is indicated, there can then be little question that the selection of the correct flap is imperative as, if chosen improperly, the entire reconstructive endeavor may be doomed to failure – no matter how careful the subsequent surgical execution. This initial phase of planning should be appreciated as the most intellectually stimulating and challenging stage, as sometimes the hours spent in the operating room afterwards may seem actually too much like “work.” Unfortunately, if simplicity were the only goal, unlike the early days of plastic surgery, when the only option was to use some variation of the random flap, now an almost overwhelming cornucopia of flap alternatives is available. A “laundry list” of all the available flaps and their indications would be an impossible job, even if limited to the “workhorse” flaps outlined in the other chapters in this book ( Fig. 3.1 ); but a brief dissertation on basic principles to follow in completing this selection process may prove invaluable. An appreciation of the attributes and limitations of the many available flaps ( Tables 3.1–3.6 ) and their specific indications for use ( Tables 3.7–3.9 ) is critical before a decision can be made as to which is most appropriate for the task at hand.

Table 3.6

Comparison of attributes for “workhorse specialized” tissue flaps

	Colon	Glabrous skin	Jejunum	Joints	Nail beds	Toe
Ease of dissection	Simple	Not easy	Easy	Moderate	Difficult	Moderate
Anatomic anomalies	No	Usually	No	Common	No	Common
Potential for harvest as compound flap/component tissues that can be included	No	No	No	Yes/bone, skin	Yes/any part of toe	Yes/any part of foot
Contour (thin → bulky)	Bulky	Thin	Moderate thickness	N/A	N/A	N/A
Implant osseointegration	N/A	N/A	N/A	No	N/A	Yes
Donor site morbidity	Laparotomy needed	Minimal	Laparotomy needed	Can be minimal	Loss of nail	First toe, yes; Second toe, minimal
Bone length	N/A	N/A	N/A	Shorter	Variable	Short
Vascular pedicle caliber	Large	Small	Very large	Large	Small	Large
Vascular pedicle length	Long	Short	Very long	Medium	Short	Medium
When used as pedicled flap
Arc of rotation	Wide	Limited	Moderate	N/A	N/A	N/A
Reliability	Good	Moderate	Good	N/A	N/A	N/A
Potential for harvest as distally based	N/A	Yes	N/A	N/A	N/A	N/A

N/A, not applicable.

Table 3.7

Typical and atypical indications for the free and pedicled version of “workhorse” flaps harvested from the head and neck, chest, abdomen, and back regions

Flap	Free microvascular transfer		Pedicled
Flap	Typical indication	Atypical indications	Typical indication	Atypical indications
Temporoparietal fascia	Thin, gliding surface to cover tendons, especially hand	Hair transplant	Ear salvage	Beard or eyebrow reconstruction
Pectoralis major	None	None	Closure of chest or facial wounds	Repair of esophagus or trachea
Deltopectoral	None	None	Oropharynx	Chest wounds
Rectus abdominis	Breast reconstruction	Lower extremity	Breast reconstruction	Groin
Jejunum	Cervical esophagus	Oropharynx lining	N/A	N/A
Trapezius	None	None	Midline posterior neck coverage	Lateral face
Scapular and parascapular	Large defects	Bone flap	Axillary contractures	Head and neck coverage
Latissimus flap	Large defects	Quadriceps function restoration	Breast, chest wounds, thoracic spine	Axillary contractures, head and neck, dynamic upper extremity

N/A, not applicable.

Table 3.8

Typical and atypical indications for the free and pedicled version of “workhorse” flaps harvested from the upper extremities, pelvis, groin, buttock, and lower extremities

Flap	Free microvascular transfer		Pedicled
Flap	Typical indication	Atypical indications	Typical indication	Atypical indications
Lateral arm	Small defect of arm or leg	Short segment bone or tendon defect	Elbow coverage	Axilla
Radial forearm	Oral lining	Foot or distal third leg	Hand coverage	Elbow coverage
Iliac	Mandible	Long bone segmental defects	Pubis	Sacrum
Groin	Large defect if cosmetic donor site imperative	Extremities	Thigh or abdomen	Staged upper extremity pedicle flaps
Gluteus	Breast reconstruction	None	Sacral or ischial pressure sores	Lumbar pressure sores
Tensor fascia lata	Vascularized fascia, Achilles repair	Abdominal wall	Abdominal wall	Groin
Gracilis	Small extremity wound, facial reanimation	Breast reconstruction	Groin, perineum or vagina	Scrotum, penis
Gastrocnemius	None	Pressure sore	Knee wound	Cross-leg flap
Soleus	None	None	Proximal leg	Distal leg
Fibula	Mandible or large bone segmental gap	Pelvis	Knee arthrodesis	Ipsilateral tibia segmental gap
Glabrous skin	Hand	Foot	Foot	None
Toe	Hand	Nail transfer	N/A	N/A

N/A, not applicable.

Table 3.9

Typical and atypical indications for the free and pedicled version of “workhorse” perforator flaps

Flap	Free microvascular transfer		Pedicled
Flap	Typical indication	Atypical indications	Typical indication	Atypical indications
Deep inferior epigastric artery perforator flap	Breast reconstruction	Large soft tissue defect	Groin coverage	Abdomen
Superficial inferior epigastric artery perforator flap	Breast reconstruction	Extremity defect	Groin	Staged upper extremity coverage
Superior gluteal artery perforator flap	Breast reconstruction	None	Sacral pressure sores	Lumbar pressure sores
Inferior gluteal artery perforator flap	Breast reconstruction	None	Ischial pressure sores	Perineum
Anterolateral thigh (ALT) flap	Large soft tissue defect	Achilles tendon	Thigh wounds	Abdomen
Anteromedial thigh flap	Large soft tissue defect if ALT flap unavailable	None	Thigh wounds	Groin
Thoracodorsal artery perforator flap	Large soft tissue defects	Breast reconstruction	Breast reconstruction	Axilla
Posterior tibial artery perforator flap	Thin contour required	None	Distal lower extremity	None

Table 3.1

Comparison of attributes of the basic flap subtypes

	Bone	Cutaneous non-perforator based	Cutaneous perforator	Intestine	Muscle	Toe
Ease of dissection	Somewhat difficult	Easy	Difficult	Requires laparotomy	Easy	Moderately difficult
Anatomic anomalies	Occasional	Rarely important	Expected	Rare	Rare	Common
Availability	Always	Always	Usually	Always	Always	Possible
Potential for harvest as compound flap	Sometimes	Sometimes	Always	Never	Usually	Sometimes
Contour (thin → bulky)	N/A	Variable	Variable	Moderate thickness	Relatively thin	N/A
Potential for thinning	No	Secondarily	Immediate	No	Yes	No
Donor site morbidity	Potential	If skin graft necessary	If skin graft necessary	Requires laparotomy	Loss of function	Potential, especially great toe
Dynamic transfer	No	No	No	No	Yes	No
Expendability	Maybe	Yes	Yes	Yes	Maybe	Maybe
Reliability (blood supply)	Usually good	Can be precarious	Usually good	Always	Best	Sometimes
Sensibility	No	Yes	Yes	No	No	Yes
Surface area	N/A	Small	Very large	Moderate	Large	N/A
Vascular pedicle caliber	Large	Variable	Can be large	Very large	Large	Large
Vascular pedicle length	Short	Variable	Exceedingly long	Very long	Medium	Medium
When used as pedicled flap
Arc of rotation	Short	Limited	Wide	N/A	Wide	N/A
Reliability	Usually good	Can be precarious	Usually good	N/A	Best	N/A
Need for supercharge	Sometimes	Usually not possible	Sometimes	N/A	Not possible	N/A

N/A, not applicable.

Table 3.2

Comparison of attributes of “workhorse” muscle-free and pedicled flaps

	Gracilis	Gastrocnemius	Gluteus	Latissimus dorsi	Pectoralis major	Rectus abdominis	Soleus	Trapezius
Ease of dissection	Easy	Minimal difficulty	Moderate difficulty	Easy	Easy	Easy	Minimal difficulty	Moderate difficulty
Anatomic anomalies	Not important	Not important	No	No	Not important	No	Not important	Sometimes
Potential for harvest as compound flap/component tissues that can be included	Yes/skin	Yes/skin, tendon	Yes/skin, bone unusual	Most versatile/skin, rib, scapula bone	Yes/skin, rib	Yes/skin	Not usually	Yes/skin, scapula bone
Contour (thin → bulky)	Moderately thin	Moderately thick	Thick	Moderately thick	Moderately thick	Thin	Moderately thick	Thin
Potential for thinning	Yes	Yes	Yes	No	No	Difficult due to inscriptions	Yes	No
Dynamic transfer	Best	Pedicle transfer	No	Minimal value	Minimal value	Segmental innervation	Pedicle transfer	Yes, for shoulder
Donor site morbidity	None	Some, if athletic	Significant, if ambulatory	Minimal	Limited	Can be significant	Some, if athletic	Possible, shoulder drop
Surface area	Narrow	Moderate	Small	Largest	Moderate	Small	Moderate	Moderate
Vascular pedicle caliber	Moderate	Moderate	Large	Large	Moderate	Large	Small	Moderate
Vascular pedicle length	Medium	Medium	Short	Long	Short	Long	Variable	Medium
When used as pedicled flap
Arc of rotation	Moderate	Limited	Limited	Great	Great	Wide	Limited	Great
Reliability	Very good	Always	Usually	Always	Very	Usually	Usually adequate	Usually
Need for supercharge	No	No	No	No	No	Possible	No	Possible
Potential for harvest as distally based	No	Unusual	No	Yes, on secondary pedicles	Yes, on secondary pedicles	Yes, has two dominant pedicles	Only if distal perforator present	No
Need for delay procedure	No	No	No	No	Sometimes, if composite flap	Sometimes, if composite flap	No	No
Splitting into subportions	Maybe	No	Yes	Yes	Yes	No	Yes	Maybe