Common Flaps Used in Microsurgery

There are more than thirty-three donor areas to choose free flaps from, with multiple combinations of flaps possible, enhancing the number of flap combinations greatly.  

The figure above shows a frontal view of some of the more common skin/fasciocutaneous flaps in yellow, muscle flaps in red and bone flaps in blue.  Click on the thumbnail below for a view of the back.

Skin/Fasciocutaneous/Musculocutaneous Flaps

• TRAM – Transverse rectus abdominus myocutaneous flap.  This is the most common flap used for microvascular breast reconstruction.  It is based on the deep inferior epigastric vessels.

• DIEP - This is an abdominal skin and fascia flap that spares the muscle that is harvested in the TRAM flap.  It is often a better choice for a free flap in breast reconstruction because it spares the rectus muscle.

• Radial forearm – A flap based on the radial artery it uses the skin and subcutaneous tissue from the palmar side of the forearm.  The donor site often needs to be skin grafted unless a very small flap is used.

• Scapular, parascapular – A skin and fascial flap based on the circumflex scapular vessels.  The donor site leaves a scar on the back.  The skin and fat can be quite thick.

• Dorsalis pedis – Harvested from the dorsum of the foot and based on the first dorsal metatarsal artery and dorsalis pedis artery.  The skin is very thin, but the donor site tends to heal poorly and usually needs skin grafting.

• Lateral arm – This workhorse flap has skin and fat and leaves a relatively inconspicuous scar for anyone who wears even a short sleeved shirt.  It is based on the posterior radial collateral artery. 

• Groin flap – Much less popular now, but one of the original clincical microvascular transplants, it is based on the superficial circumflex iliac artery.  The vascular supply can sometimes be quite tenuous.

• BIEF – The bilateral inferior epigastric artery flap is based on the bilateral superficial inferior epigastric arteries or deep inferior epigastric vessels.  The deep system is more reliable and essentially a double barrel DIEP flap.

• Deltoid flap – This flap is rarely used and tends to scar poorly.  It is based on the posterior circumflex humeral artery.

• Superior gluteal flap – Mostly used for breast reconstruction now, but infrequently, it is based on the superficial and deep branches of the superior gluteal vessels.  The donor scar has been criticized for its prominence and tendency to distory the donor area.

 Muscle Flaps

• Rectus – A very consistent and reliable donor, it is based on the deep inferior epigastric vessels.  This muscle has a fairly long pedicle and good length.

• Latissimus*- Another consistent and reliable donor, it is based on the subscapular-thoracodorsal vessels.  It is the largest muscle available and is an excellent choice in many cases where a large defect must be filled.

• Serratus* - It is based on the subscapular-thoracodorsal vessels as well.  The long pedicle and moderate size of the muscle tends to make this a good choice for smaller defects where adequate recipient vessels are some length from the wound.

• Gracillis.*- Another workhorse.  A branch to gracillis off the medial femoral circumflex artery is very consistent.  It is a small muscle that has a very inconspicuous donor site.  The vessels can be small but are usually of excellent quality.

• Extensor brevis – This is a small muscle that is a good match for small defects, but the donor skin heals slowly.  A branch to extensor brevis off the dorsalis pedis artery supplies the inflow. 

Bone Flaps

• Great Toe – It is the best choice for thumb reconstruction.  The great toe is based on the first dorsal metatarsal artery. 

• Second Toe -  A good choice for finger reconstruction.  It is also based on the first dorsal metatarsal artery. 

• Rib – One of the first osseous flaps described, it is a difficult dissection.  The rib is based on the intercostal neurovascular pedicle.  A long pedicle is a plus for this flap.

• Fibula – Most often used in mandible reconstruction, this bone can be tailed or contoured for many long bone reconstructions.  It is based on the peroneal vessels.  This bone can be shaped in numerous ways.

• Radial forearm – As with the radial forearm flap it is based on the radial vessels as described above.  It can also be taken with a piece of radius bone.  Fracture of the radius in the post-operative period is a frequent complication.

• Iliac crest – An excellent flap when a large bone is required, but technically demanding.  It is based on the deep circumflex iliac system. 

• Scapula – Often taken with serratus or latissimus, it is based on the circumflex scapular vessels.  An excellent choice when a smaller piece of bone and long pedicle is needed.

• Calvarium – Skull bone based on the superficial temporal artery and vein.  It is rarely used because the superficial temporal vein is small and difficult to work with.

• Lateral arm- Taken with the lateral arm flap, it is based on the posterior collateral radial artery.  A good quality small piece of bone.

• Second metatarsal – Just as with the second toe, it is based on the first dorsal metatarsal artery.

Venous Flaps

Venous flaps can be designed from different donor areas but are most common from the:

• Forearm

• Wrist

• Dorsum of the Foot

Venous flaps are excellent choices for small defects requiring thin coverage, especially in the hand and fingers.

Other Less Common Flaps

•  Fascial flaps are less common, the most popular is the temperoparietal fascial flap based on the superficial temporal vessels.  

• Jejunum can be transplanted for esophageal reconstruction as can large bowel and ileum.

• Omentum was one of the first microvascular transplants ever performed.  It can be used to cover large defects, but the main disadvantage of the omentum is the requirement for a laparotomy.