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Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 334 - файл
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3 Basic Flaps
a
e
bc d
f
gh
Fig. 3.6 Island aps. (a) Markings for excision and ap, (b) Excision defect and ap incisions, (c)
Flap moved into defect maintaining subcutaneous pedicle, (d) Final closure, (e) Markings for excision, (f) Markings of ap and modication of excision margins, (g) Excision defect, (h) Flap incisions, (i) Maintaing a subcutaneous pedicle, (j) Flap moved into defect, (k) Final closure, (l)
Markings for excision and ap, (m) Excision defect and ap incisions of varying depth, (n) Flap
moved into defect, (o) Final closure, (p) Markings for excision and ap, (q) Final closure
lm
Island Flap
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i
j
k
n
Fig. 3.6 (continued)
o p
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q
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Fig. 3.6 (continued)
3 Basic Flaps
Rhombic Flap
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Rhombic Flap
The rhombic ap is a type of transposition ap, rst described by Limberg following work on paper models. The defect and the ap are based on very specic geometric designs.
The defect is converted into a rhombus, with 60° and 120° internal angles. A
rhombus is similar to two equilateral triangles, whose bases are placed on each
other. This results in a defect in which all the sides and the short diagonal are of
equal length. The ap is designed by extending the short diagonal to a distance
equal to one of the sides, and a further line is drawn from its extremity, parallel to
the adjacent side of the defect, again of equal length. It is possible to harvest four
aps for each rhombic defect. The ap is raised in the subcutaneous plane and
mobilised into the defect. The wound margins of the wound are undermined and the
defect closed in layers. An orderly sequence of closure is advised, with closure of
the secondary defect carried out initially followed by that of the primary defect. The
dog ear is corrected last (Fig.3.7a–q).
Tips: For any rhombic defect, four potential aps can be harvested. The nal
decision is based on the availability of tissue laxity, the best placement of scars and
avoiding distortion of the adjacent structures. In practice, it is often possible to
minimise or avoid excision of additional tissue to achieve the rhombic conguration, when using this ap. This often results in a dog ear at the base that might have
to be corrected. Similarly, angulating the short diagonal can increase the tissue
availability to cover the distal end of the defect.
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gh
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abc
3 Basic Flaps
d
Fig. 3.7 Rhombic (Limberg) ap. (a) Markings following modication of excision margings and
ap design, (b) Excision defect and ap incisions, (c) Flap raised and closure od secondary defect,
(d) Sequentail closure of primary defect, (e) Final closure, (f) Lesion marked with excision margins, (g) Markings with modication of excision margins and planned ap, (h) Excision defect and
ap incisions, (i) Trial transfer of ap into defect, (j) Wide undermining of surrounding tissues, (k)
Closure of secondary defect, (l) Sequential closure of primary defect, (m) Resultant dog ear, (n)
Marking for excision of dog ear, (o) Dog ear elevated, (p) Dog ear delineated for excision, (q)
Final closure
e f
Rhombic Flap
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ii
k
j
l
mn
Fig. 3.7 (continued)
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o
p
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3 Basic Flaps
q
Fig. 3.7 (continued)
Dog Ear Correction (Standing Cutaneous Deformity)
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Dog Ear Correction (Standing Cutaneous Deformity)
A dog ear (standing cutaneous deformity) often develops at the base of a transposition, rotation ap and at the extremity following excision of lesion planned for primary closure.
Excision of the dog ear should follow an orderly sequence. The wound is sutured
till the dog ear appears. A skin hook/toothed forceps is placed into the summit of the
dog ear to dene it fully. An incision is made along the one of the bases of the dog
ear and the tissue brought across the wound, to accurately dene the excess. The
excess tissue is then removed, and the wound is closed in layers. The excess tissue
to be removed is designed to be on the “away” rather than on the “ap” side, to
avoid compromising the vascularity of the ap pedicle (Fig.3.8a–h).
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3 Basic Flaps
a
d
f
bc
e
g
h
Fig. 3.8 Dog ear correction. (a) Dog ear delineated with a skin hook and an incison made along
its base, (b) The excess tissue is spreadover the incision line and the excess trimmed appropriately,
(c) Final closure, (d) Dog ear following developing with closure, (e) Excision of dog ear marked
along its base, away from ap, (f) Excess dog ear tissue delineated, (g) Tissue laid across the incision to delineate appropriate excision, (h) Final closure
Decision-Making Process
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The principal aim of reconstruction is to replace lost tissue with tissue with the best
match in terms of size, shape, contour, colour and if possible function. This will
require the ap/graft to be harvested from a site, which fulls the above characteristics and places the secondary defect in the most advantageous position.
In the head and neck region, the ap is often harvested from a site adjacent to the
defect for the “best” match. This requires sourcing aps from areas with adequate
tissue laxity and placement of scars along RSTLs, without causing distortion of the
adjacent structures and landmarks.
The assessment of the defect will have to take into consideration the.
1. Size of defect
2. Site of the defect
3. Shape of the defect
4. Thickness of defect
5. Components of the defect (skin, cartilage, bone, mucosa, combinations)
6. Vascularity of the base (in case a graft)
4
Assessment of the ap, in addition will have to take into consideration.
1. Vascularity
2. Tissue laxity to facilitate closure of the secondary defect
3. Placement of scar along RSTL/aesthetic boundaries
4. Avoid distorting adjacent landmarks
5. One/multi-stage reconstruction
6. Injury to adjacent neurovascular structures
© Springer Nature Switzerland AG 2024
V. Ilankovan et al., Local Flaps in Facial Reconstruction,
https://doi.org/10.1007/978-3-031-49464-2_4
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