Island Flaps in Plastic Surgery

INTRODUCTION: Reconstruction in Plastic Surgery has been revolutionised with the use of flaps with a intact blood supply.Today the reconstuctive plastic surgeon faced with a soft tissue defect has a plethora of options. Major advances in the field of plastic surgery have been made possible by the use of muscle flap,musculocutaneous flap,fasciocutaneous flap and various techniques of microvascular composite tissue transplantation. Application of precise knowledge of anatomy of the skin, muscle, bone and fascia in planning the reconstructive procedure, the surgeon has the ability to restore the form and function in congenital and acquired defects in most topographic region. Modifications and refinements in flap design offer considerable variety and versatility in the technique available for reconstructive surgery. With application of principles of flap design and technique it is possible to simplify the approach to the reconstruction of surgical defect. Cover form and function are the three most important factors in determining the successful outcome. By thorough analysis of each individual surgical defect the most appropriate method of reconstruction can be selected. Island flaps are designed on the principle of transfer of tissue without an intact epitheliazed skin pedicle. Further refinements in design and techniques has reached a point where flaps are transfered on vascular and neurovascular bundles. AIM OF STUDY: The main objectives of this clinical study are 1. To study the role of island flaps in modern plastic surgery. 2. To discuss the types,anatomical regions,planning and tecniques of execution of island flaps 3. To analyse the merits and demerits of island flaps 4. To study the post operative management and complications 5. To assess the outcome of reconstruction on the basis of form, function and aesthesis. 6. To discuss the emerging trends and future prospects for island flaps in reconstructive surgery. MATERIALS AND METHODS: Materials: This work includes the study of 30 patients who underwent reconstruction using island flaps for resurfacing defects from head to foot due to trauma ,congenital lesions or surgical extirpation of tumour. The patients who were admitted to Plastic Surgery, Surgical Oncology and General Surgery wards at Government Rajaji Hospital, Madurai, were studied between September 2005 – April 2008. Methods: The methods include obtaining information from patients, thorough clinical examination and doing necessary investigations for management. All informations were entered in a proforma specially designed for this study. Methodology: The patient’s name,age, sex, history of presenting illness and its duration was obtained. Past history of chronic medical and surgical illness noted. Personal history like smoking, alcohol consumption and diet pattern were obtained. Detailed physical examination of the defect was made and tissue diagnosis was recorded and reconstruction planned accordingly. Basic investigations like blood Hb estimation, urine examination, blood sugar and renal parameters like urea, creatinine were done. Serum protein levels were assessed. X ray chest and ECG were taken. Doppler study was performed to identify and preoperatively mark the perforator vessels in selected cases. Cardiac status was examined by specialist of our institution. Diabetic patients were treated on Diabetologist opinion. Based on the above investigations, patients were assessed for general anaesthesia and managed surgically. Intraoperative, post operative complications were noted and managed accordingly. All the patients were reviewed in our OP department. OBSERVATIONS: Reconstuction using flaps are performed regularily in all operation theatres for defects from head to foot. Out of these 16 interesting island flaps excuted in 60 patient during the period of Sep 2005 to Jan 2008 and were taken up for this study. All cases were in the age group from 6 – 80 years. 60 % cases were male and 40 % were female in our study. Majority of the defects were either due to trauma or post tumour resection. In this study majority of the defects were of the trunk, followed by head and neck region. In this study, an almost equal distribution of all types of flaps were performed. In this study, 4 cases of sensory flap which included Neurovascular island flap, saphenous artery and medial plantar island flap were performed. Almost half of the donor sites in our study were closed primarily. In this study, 13% of patients had haematoma. Wound dehiscence, infection and graft loss were seen in 6.6% each. One patient had flap necrosis which was only partial thickness. As late complications, 13 % each of hypertrophic scar, contour deficit and functional disability like pseudomotor skin changes were noted. 80 % of patients has an excellent aesthetic outcome. CONCLUSION: 1. Island flaps are based on reliable anatomically defined vascular territory with in the flap – blood supply is reliable and robust. 2. The reliability and volume of tissue that can be placed into the defect is markedly greater than any random pattern flap. 3. Delay procedure was unnecessary when moblizing large tissue volumes in a single procedure based on the direct circulation. 4. Arc of rotation is more compared to pedicle flap 5. Inset is complete and satisfactory. 6. Local tissue match - similarity in skin color, texture form contour and aesthesis etc., is excellent. 7. Restoration of function whether motor or sensory is possible in certain flaps. 8. Single stage procedure 9. Most of the donor size can be closed primarily, donor site morbidity also negligeable 10. As good as free flap and minimize the indication for free flap