What Are Different Types Of Flap Surgeries.

: Admin : 2022-03-11

What are the layers of skin?

Skin is the largest organ of the body. It forms the outermost protective layer covering the entire body parts. Skin gets its colour from melanin pigment lying underneath its different layers. It has definite texture and thickness throughout the body.

Skin is formed of three layers. Every layer has certain definite functions to play. The epidermis is the outermost protective layer on the skin. It is formed of three different types of cells. Melanocytes containing melanin pigment that gives colour to the skin are found at the base of the epidermis. The dermis is a layer found beneath the epidermis. It contains blood vessels, lymph vessels, hair follicles, sweat glands, fibroblasts, nerves and sebaceous glands.  It gives strength and flexibility to the skin. Pain and touch receptors are found in this layer. A subcutaneous layer of fat called hypodermis is the third deepest layer of skin. It protects the body from injury and conserves the body's heat. 

What are different skin conditions?

Skin is an external cutaneous coating on the body. As it is in continuous contact with the environment, it is the foremost tissue to be affected or damaged from external harmful irritants or sources. Injuries are common in all age groups.  A deep harsh bruise may cut the skin that may damage all layers of the skin. The organs lying beneath the skin may also get damaged. People who encounter road accidents or even at work or while doing physical activities like sports are affected by cuts and injuries.  When the wound is very deep, it requires a surgical treatment procedure.

Accidental burns are also caused by deep-rooted skin damage and necrosis of tissues. Patients who have disfigured, destructive, indistinct skin lesions, lacerations from burns need surgery to restructure normal physical appearance. In third-degree burns, a large area of skin is affected which needs a large amount of tissue to reconstruct the damaged lesions. It is an extensive cosmetic surgical treatment procedure. An expert panel of doctors from a plastic or cosmetic surgeon to skin specialists, general physicians and orthopaedic surgeons manage these critical cases of accidents and burns.

Skin is also damaged with loss of skin tissues in certain infections. Loss of skin is observed in skin cancers, necrotizing cellulitis, lupus and certain skin infections. When an extensive area of skin shows necrosis of tissues, it requires surgery.

Metabolic syndrome-like chronic diabetes mellitus cause extensive skin ulcers which might not heal causing necrosis of skin tissues.  Gangrene is also a common complication of chronic diabetes mellitus. Venous ulcers, pressure ulcers from bedsores cause damage to the skin. These are different skin conditions where the loss of skin is to a remarkable extent. Although skin cuts and minor wounds heal after a certain period of time, major deep injuries, deep skin cuts, large wounds require surgical intervention.

What is the role of plastic surgery in treating traumatic skin conditions?

Skin being a protective shield all over the body is studied extensively by medical professionals.  Research-based studies have proved that skin specialists can treat different diseases of skin but more skilled expertise is needed to treat wounds and skin lesions. A more qualified plastic surgeon who has experience is professional in tissue reconstructive surgery performs this surgical procedure on patients who have damaged skin conditions.  The history of plastic surgery or reconstruction of damaged tissue dates back around 600 BC. After the first world war, several innovative techniques were developed by surgeons to treat wounded soldiers. Later more structured, planned well defined creative and complex reconstructive surgeries were invented.

Plastic surgery is ceaseless, a perennial advanced procedure that requires anatomical dissection of different layers of tissues, profound understanding of neurovascular physiology, purposeful diligent efforts and improvement in surgical instrumentation techniques. The novel, modern technology-driven methods have been introduced in plastic surgery treatment that has revolutionized reconstructive procedures. These advanced theories have proved useful in giving the best outcomes or results in reviving and remodelling skin tissues. With the advent of plastic surgery, the potential of medical science has paved a way to replenish, restructure damaged skin conditions. Patients at times are depressed from skin lesions that ruin, distort external appearance. In serious, grave critical cases of burns and accidents, patients do not have any desire to live due to deformed skin. Plastic surgery comes to a rescue that redevelops, reforms and reshapes extensive tissue destruction.

Breast reconstruction, large wounds and cleft palate repairs are done using flap plastic surgeries.

What are skin flaps?

Skin, the prime external organ of the body, is affected by all kinds of superficial, extrinsic, foreign impressions that need surgical treatment procedures. A skin flap is a common method used to repair large wounds or extensive damaged area of skin that requires surgical repair. A flap of healthy skin with blood vessels is resected from the donor's site to cover a localised wound. A flap also contains cartilage, muscle and fatty tissue depending upon the extent of the area that is damaged across the skin. The damage of tissues occurs from wounds or deep cut injuries as seen in fractures, cancers, infections and severe burns. 

A plastic surgeon performs the surgery in a hospital under general or local anaesthesia depending upon the extent of damage of tissues or area affected by trauma. A surgeon may ask the patient to routine laboratory investigations like urine tests, blood tests, chest X-ray, ECG, Doppler study, MRI and CT angiogram to understand the extent of skin damage and blood supply. A detailed history of the patient is recorded. Admission to the hospital is usually done a day prior to the surgery being scheduled. The donor site of the surgery is well marked. The type of flap surgery to be performed is decided by the surgeon according to the damaged site.

What are the different types of flap surgeries?

There are two main types of flap surgeries.

FREE FLAP – An entire flap of skin along with its blood vessels is dissected from the donor's site and attached to the blood vessel at a recipient area.

PEDICLED FLAP -  A flap with at least one artery and one vein blood supply is grafted on the recipient's damaged skin area.

Pedicled flaps are further classified into local flaps. These flaps are used from adjacent tissues for local medium-sized skin exfoliation and defects. The area which is affected, the flap is made to advance or is rotated or is transported in relation to the position of the defect. Regional flaps are another type of pedicled flaps. They are in close vicinity or immediately found next to the recipient's site. The flap is moved under the tissue to adhere to the recipient's site. New blood vessels soon form near the donor's site. A distant flap is one that is placed from a distant area of the body. These are complex flaps connected to both donors and recipient sites thereby forming a bridge in between both areas.

The source of blood supply determines the nature of flap surgery.  Random flaps are those where blood supply comes from unrecognised blood vessels. Axial flaps are those from where blood supply comes from a known artery or vein. Perforator flaps have smaller blood vessels that have their origin from a larger main vessel. Reverse flow flaps are those where the blood supply of the artery is cut therefore backward flow of blood occurs in different directions to maintain the balance of adequate flow to keep the skin tissues alive. 

The skin flaps selected for surgery contain a single type or multiple types of tissues. Fasciocutaneous tissue contains skin and fascia. Adipofacial tissue contains both fats and fascia. Mucocutaneous layers of flaps contain both muscles and skin. The Osseocutaneous layer contains both bones and skin grafts. Tendocutaneous flaps contain tendons and skin. Flaps are used in the mouth during oral surgeries for treating gum disease. Different shape flaps are articulated like trapezium, triangular, envelope, semilunar and pedicle.

Flap surgery is more commonly done than graft implants because flaps have their own blood supply. Flaps are more strong providing texture and tone to skin tissues. When a mass of tissue destruction is in bulk, a large flap gives resilient support to damaged areas of skin to keep it alive.

What are advancement flaps?

Advancement flaps are random pattern flaps commonly used in the reconstruction of surgical defects of the face after treatment of skin cancer. It is a cosmetic aesthetic procedure where meticulous planning and skill is required for desired results. Advancement flaps are also used for large wound repair.

Advancement flaps are modified linear closure grafts with both apical standing cones moved to the side. These flaps give a linear repair graft over eyelids, lips, nasal sidewalls, infraorbital cheeks, forehead and temples. They are used to camouflage scars.  Patients are counselled before the surgical procedure. Preoperative cleansing of the area is done to make it sterile. Depending upon the extent of damage, the technique is determined by the surgeon.

Tension vector is one method used for wound closure. Primary tissue motion is one in which the flap slides towards the defect. The countermovement of the surrounding tissue to connect to the adjacent flap is termed secondary tissue motion. This anchor the flaps under a specific magnitude of tension for linear closure of wounds and damaged skin areas.

Standing cones created by advancement flaps can be laterally moved in one or two directions. A linear resection or reconstruction of skin tissues can be done to rectify a damaged wound. The blood supply to these flaps is balanced while the surgery is performed maintaining oxygen levels on the edges of the flaps.

A V- Y advancement flap is a triangular-shaped skin supported by a subcutaneous tissue pedicle. It is placed deep inside the wound, the pedicle allows tension-free movements. The flap used is segmented in uniform depth that closes the site of the wound according to its area of thickness. The aim behind every technique is to maintain homeostasis.

Dressing of the surgically implanted flap areas is done post the procedure is performed. Patients are given guidelines regarding post operative care.

Advancement flap surgeries hold a very advantageous place where plastic reconstructive surgeries are performed. Anal fistulas leave a gap or lesion which is repaired by advancement flap surgery. It is a standard method to heal the damaged area around the anal fistula. Mucosal and submucosal advancement flap is the method done to repair anal fistulas.

It takes about six to eight weeks to heal post-surgery. There may be minor postoperative complications, but these are resolved or treated during follow up visits.

In an era where medical science has multifaceted, diversified, voluminous research-based treatment procedures for every diseased state that causes agony and distress to mankind especially traumatic wounds, cancers, plastic reconstructive surgeries using skin flaps have healed and saved lives of people all across the world.

Loss of skin tissues during accidents or chronic malignant diseased conditions where uncontrolled damage to the skin is observed, patients' life can be rescued to a more healthy living by means of reconstructive surgeries using skin flaps. The flaps replace the loss of skin tissues. It provides a skin coverage area where later the treatment of the lesions can be done on a wider plane. Skin flaps act like a pad, a cushion over bony prominences and aid in faster repair of a fractured bone. Skin flaps have their own connective tissues. As it has a large proportion of blood vessels, it forms support to the poor or inadequate vascularised beds of tissues.  Sensation and physiological functions surrounding the damaged skin tissues and organs improve considerably post reconstruction surgery. The muscle or bone that suffers from traumatic wounds or damaged diseased condition, regains its normal vasculature along with shape and texture to resume different functions.

On account of the above healing properties, skin flaps are more popular surgical treatment aids in comparison to normal skin grafts. Patients have been treated through skin flap surgeries without any future relapse or major complications at the site of the reconstructive treatment procedures. A skin flap plastic surgery is thus a revolutionary bestowal in the field of medicine.