Simply Local Flaps

This book provides a useful framework for categorizing local flaps on the basis of their composition, blood supply, geometry and means of transfer. The initial chapters are dedicated to the fundamentals – the basic procedures, how to get started, and technical tips – as well as advice on wound care and scar management. These practical pointers are essential for students of plastic surgery, while also offering helpful refreshers for experienced practitioners. The subsequent chapters describe the types of flaps that are traditionally taught and the 10 most common flaps. There is also a practical guide to W-plasty, Z-plasty and their various modifications, which can be applied to both scar revision and the closure of the donor sites. The book also discusses the Keystone Perforator Island Flap (KPIF) and its application to various body sites, offering elegant solutions to some very tricky situations. In turn, the book’s final chapters are focused on assessment, decision-making an d lessons learned – essentially, how to decide if a skin graft is the better choice, matters relating to aesthetics, and dealing with complications. Rather than demonstrate exactly how to execute flaps, the book’s primary goal is to inspire students and trainees to think about the reconstructive problem, consider all patient-related and anatomical factors, and accurately recognize what can feasibly be achieved. Foreword 5 Preface 8 Contents 13 Acknowledgements 11 About the Authors 18 Part I: Fundamentals 20 1: Introduction 21 What Are Local Flaps? 24 Classification of Local Flaps 25 Planning a Local Flap 26 Aesthetic Subunit Principle 26 Scar Considerations 26 Flint’s Circle Technique for Determining the Optimum Scar Lines 28 Anatomical Landmarks 29 Sources of Spare Skin on the Face of Good Donor Sites for Skin Flaps 29 References 30 2: Getting Started: Planning and Drawing 32 Planning with Flint’s Circles 36 References 37 3: Technical Tips for Local Flap Surgery 38 Documentation 38 Local Anaesthesia 38 Sterile Technique 39 Standard Surgical Instruments 40 Gentle Tissue Handling 42 Suture Without Tension 42 Photograph and Measure Everything for the Record, Especially Complications of Treatment 43 Precise Surgical Dissection 43 Designing a Local Flap to Avoid Tension in Hand Wound Defects 46 Managing Patients on Aspirin and Anticoagulants 46 References 46 Part II: Traditional Local Flaps 47 4: Elliptical Excision and Sliding Flap Repair 48 Modifications of the Ellipse 49 Crescentic Ellipse 51 Asymmetrical Ellipse 51 Wedge Excision 52 M-plasty [4, 5] 53 Crown Excision [6] 54 Modifications of the Wedge Excision [4, 5] 55 Dog-ears 57 Summary 58 References 58 5: Advancement Flaps 60 Single Pedicle Advancement Flaps 61 Dorsal Nasal Flap 62 Mucosal Advancement Flap 63 Double Advancement Flap 65 Biwinged Flap 65 Perialar Crescentic Advancement Flaps 67 Double Advancement Flaps 68 H-plasty [5, 6] 68 Flaps Involving V-Y Advancement [5, 6] 69 Nasalis Flap 70 Upper Lip Case 71 Sigmoid Oblique Advancement Flap [10] 72 Double V-Y Flaps 74 Kite Flaps [11, 12] 74 V-Y Technique for Closing Surgical Wounds 75 The V-Y Technique for Releasing Scar Contractures [5, 13] 75 Y-V Advancement [5] 76 Multiple Y-V Advancement Flaps [5] 77 Bipedicle Advancement Flap [5] 78 References 78 6: Rotation Flaps 80 Rotation Flap to Scalp 82 Rotation Flap Requiring a Skin Graft to Repair Flap Donor Site 83 Rotation Flap in the Temporal Area 83 Rotation Flap for Buttock Defects 84 Rotation Flaps on the Face [2] 84 Bilateral Rotation Flaps for Repairing Lower Lip 86 Neurovascular Cheek and Lip Flaps [4] 86 Modifications of the Rotation Flap 87 Subtotal Forehead Flap 88 References 90 7: Interpolated Flaps 91 Paramedian Forehead Flap 92 Interpolated Flap with Buried Pedicle 94 Subcutaneous Pedicle Flaps on Other Parts of the Face [3] 95 Vascular Island Flaps [2] 96 Serendipity Flap 96 The Bipedicle Upper Eyelid Flap 97 References 98 8: Transposition Flaps 99 Postauricular Flap (Inferiorly Based) 101 Postauricular Flap (Superiorly Based) to the Ear 102 Nasolabial Flap (Inferiorly Based) 103 Nasolabial Flap (Superiorly Based) 104 Dorsal Nasoaxial Flap 106 Glabellar Flap [3] 106 Lower Eyelid Flap 107 Rhomboid Flap [5, 6] 109 Square Peg in a Round Hole [7] 112 Dufourmental Flap [6] 115 Comparison of the Rhombic and Dufourmental Flaps [8] 116 Swing-Slide Plasty [9] 117 Banner Flap [11, 12] 120 Hatchet Flap or V-Y-S Closure for a Circular Defect [13] 121 References 122 9: Triangular Flaps That Transpose, Advance and Interdigitate 123 Z-Plasty [2–7] 123 Planning a Scar Revision on the Face 130 Planning Z-Plasties in Three Dimensions 131 Notching of the Lip 131 Bridle Scar 131 Congenital Ring Constriction 132 Modifying the Z-Plasty Flaps 133 Tetrahedral Z-Plasty 133 Finger Web 134 Asymmetrical Z-Plasty 135 Altering Angle Size 135 The Jumping Man Flap 137 Use of Z-Plasty in Flap Repairs 137 The Double Z to Rhomboid Plasty [9] 139 Rhomboid to W-Plasty [10] 139 Triangular Flaps that Advance and Interdigitate [11] 141 W-Plasty 141 The Effects of a W-Plasty 142 References 142 10: Hinge Flaps 143 Cross Finger Flap 147 References 147 11: Recommended Traditional Local Flaps 148 Rotation Scalp Flap 148 Paramedian Forehead Flap 149 Biwinged Excision/Sliding Advancement Flaps 149 Sigmoid Oblique Advancement Flap [1] 150 Nasolabial Flap (Superiorly Based) 150 Dorsal Nasoaxial Flap 150 Glabellar Flap 151 Transposition Cheek Flap 151 Karapandzic Flaps [2] 152 Dorsal Hand Flap [3] 152 References 153 Part III: Modern Local Flaps 154 12: Keystone Flap Concepts 155 Anatomy and Physiology 155 Flap Design 156 Surgical Technique for Keystone Flap 157 References 158 13: Favoured Keystone Flap Applications 159 Cheek 159 Lateral Nose 161 Upper Lip 161 Forehead, Temple and Scalp 162 Neck 164 Shoulder 165 Trunk 166 Lower Limb 168 Hand 169 Foot 171 14: Combination Flaps 172 Keystone Advancement + Chin Rotation Flaps 172 Cervicofacial Rotation + Glabellar Transposition Flaps 173 Forehead Interpolated Flap + Cheek Rotation Flap + Lip Switch Flap 173 Combination Keystone Flaps from Cervical and Cheek Regions 174 Part IV: Judgement, Decision-making and Experience 175 15: Where Skin Grafts Are Better 176 Scalp 176 Frontal Region 177 Nose 178 The Upper Lip 180 16: Aesthetica 181 Bilateral Preauricular Skin Grafts 181 Facelift flaps 184 Type I: Mini Preauricular Facelift Flaps 184 Type 2: Moderate Preauricular Facelift Flap 184 Type 3: Extended Facelift Flap 185 References 186 17: Complications: Their Management and Prevention 187 Haematoma 187 Venous Ischaemia 188 Radiation Necrosis 189 Secondary Viral Infection 190 Hypertrophic Scars 191 Ectropion Deformity 192 Oncological Issues 193 Risk Awareness and Consent 193 18: How to Think Like a Plastic Surgeon 194 Case A 194 Case B 197 Appendix 202 Part V 202 Other Resources Considered for this Book but not Formally Referenced 202 Glossary 203 Index 204 Front Matter ....Pages i-xxii Front Matter ....Pages 1-1 Introduction (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 3-13 Getting Started: Planning and Drawing (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 15-20 Technical Tips for Local Flap Surgery (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 21-29 Front Matter ....Pages 31-31 Elliptical Excision and Sliding Flap Repair (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 33-44 Advancement Flaps (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 45-64 Rotation Flaps (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 65-75 Interpolated Flaps (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 77-84 Transposition Flaps (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 85-108 Triangular Flaps That Transpose, Advance and Interdigitate (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 109-128 Hinge Flaps (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 129-133 Recommended Traditional Local Flaps (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 135-140 Front Matter ....Pages 141-141 Keystone Flap Concepts (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 143-146 Favoured Keystone Flap Applications (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 147-159 Combination Flaps (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 161-163 Front Matter ....Pages 165-165 Where Skin Grafts Are Better (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 167-171 Aesthetica (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 173-178 Complications: Their Management and Prevention (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 179-185 How to Think Like a Plastic Surgeon (Michael F. Klaassen, Earle Brown, Felix Behan)....Pages 187-194 Back Matter ....Pages 195-202 This title provides a useful framework for categorising local flaps on the basis of their composition, blood supply, geometry and means of transfer. The initial chapters are dedicated to the fundamentals - the basic procedures, how to get started, and technical tips - as well as advice on wound care and scar management. These practical pointers are essential for students of plastic surgery, while also offering helpful refreshers for experienced practitioners. The subsequent chapters describe the types of flaps that are traditionally taught and the ten most common flaps. There is also a practical guide to W-plasty, Z-plasty and their various modifications, which can be applied to both scar revision and the closure of the donor sites. The book also discusses the Keystone Perforator Island Flap (KPIF) and its application to various body sites, offering elegant solutions to some very tricky situations