Local Flaps, Regional Flaps, and Free Tissue Transfer

Daphne A. Bascom

• Local flaps are classified by blood supply and tissue movement.
  
• Random flaps are the type most commonly employed in the head and neck and are based on the rich perforating vascular plexus of the skin. The survival of random pattern flaps is unpredictable because of their blood supply.
  
• Axial pattern flaps derive their blood supply from a direct cutaneous artery or named blood vessel. Axial flaps can be of greater length-to-width ratios than random flaps because of their more predictable blood supply.

• It is often helpful to use a template to determine the best donor site.
  
• Before incising the flap, carefully undermine the defect site to ensure that primary closure is not possible.
  
• Incise and undermine the flap, then rotate, advance, or transpose it into the defect.
  
• Stabilize the flap with several key sutures, then inspect the flap perfusion.
  
• Close the donor site to minimize tension at the defect site.
  
• Remove any tissue redundancies after the flap is inset.
  
• Once adequate coverage, perfusion, and location have been ensured, sequentially remove the tacking sutures and begin final closure.

• The rotation flap is curvilinear in shape and is designed to rotate about a fixed axis into the defect.
  
• A standing cutaneous deformity at the base of the flap is common.
  
• This can be addressed with a Burow’s triangle; in some cases, over time, tissue contraction alone will eliminate the “dog ear.”

• Transposition flaps are harvested at one site and transferred to a site immediately adjacent to the base of the flap.
  
• These differ from rotation flaps in that their final axis is linear, whereas the rotation flap has a curvilinear axis.
  
• The most important element of design of a transposition flap is the location of the pivot point.

• The rhomboid flap is based on four equal sides with corresponding 60 and 120 degree angles.
  
• The Dufourmentel flap is one of several modifications of the rhomboid flap has angles varying from 60 to 90 degrees.
  
• Based on the flap design, there are four potential donor flaps from which to choose in order to align the final scar in an inconspicuous fashion.

• Bilobed flaps are double transposition flaps that share a single base.
  
• The primary flap is used to repair the surgical defect and the secondary flap to repair the flap donor site.
  
• Arcs of transposition of 90 to 110 degrees help to decrease the resulting deformity.
  
• A disadvantage of the bilobed flap is that the resulting scar may be unable to follow skin tension lines.