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Axial pattern flaps

image of Axial pattern flaps
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Abstract

Reconstruction of large skin defects following trauma or radical excision of neoplastic masses can be problematical, particularly when wounds occur on the extremities where there is not enough skin for primary closure. Options for management include: axial pattern flaps; local subdermal plexus flaps; skin grafts; and second intention healing. There may, however, be insufficient skin adjacent to the wound to allow second intention healing or the use of local subdermal plexus flaps. Second intention healing may also result in formation of fragile epithelium or wound contracture. Axial pattern flaps are used for the one-stage reconstruction of wounds. Flaps are usually raised from the trunk, neck or proximal limbs, where there is sufficient loose skin to allow closure of the donor site with minimal morbidity. They provide durable full-thickness skin with a predictable vascular supply, resulting in normal to near-normal hair growth and minimal visible scar tissue, although hair growth is in the opposite direction and may be of different length and texture to the hair in the local area. Functional results after successful axial pattern flap use are good, although some owners are dissatisfied with cosmetic results. The chapter considers Blood supply and axial pattern flaps; and Complications and flap failure. : Superficial cervical axial pattern flap for a face wound in a cat; Thoracodorsal axial pattern flap for an elbow wound in a dog. : Axial pattern flap; Thoracodorsal axial pattern flap; Superficial cervical (omocervical) axial pattern flap; Caudal superficial epigastric axial pattern flap; Lateral thoracic axial pattern flap; Deep circumflex iliac (ventral branch) axial pattern flap; Deep circumflex iliac (dorsal branch) axial pattern flap; Cranial superficial epigastric axial pattern flap; Superficial brachial axial pattern flap; Genicular axial pattern flap; Reverse saphenous conduit axial pattern flap; Superficial temporal axial pattern flap; Caudal auricular axial pattern flap; and Lateral caudal axial pattern flap

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/content/chapter/10.22233/9781905319558.chap7

Figures

Image of 7.1
7.1 The thoracodorsal (1), superficial cervical (2), caudal superficial epigastric (3) and deep circumflex iliac (4) direct cutaneous arteries are the largest direct cutaneous arteries supplying the skin of the dog. These axial pattern flaps are therefore the most robust and have the most predictable survival. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.2
7.2 Flaps can be created in a peninsular (rectangular) or L shape. Left peninsular thoracodorsal flap extending to the dorsal midline. Left peninsular thoracodorsal flap that has crossed the dorsal midline to include the secondary angiosome of the right thoracodorsal vessels. Left thoracodorsal flap that has crossed the dorsal midline and is continued at right angles to give an L-shaped flap. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.3
7.3 Thoracodorsal flap raised as a peninsular flap. The pedicle is incised to create an island flap (arrows). (Courtesy of John M Williams)
Image of 7.4
7.4 A defect of the caudal elbow can be closed using a thoracodorsal, lateral thoracic or superficial brachial flap. The thoracodorsal flap is preferred, if intact, as it has more predictable survival. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.5
7.5 Creation of an axial pattern flap where one border of the flap is adjacent to the defect and the flap is rotated through 90 degrees. The width of the flap (x) equals the width of the defect (x’). The distance from the pivot point to the furthest point of the defect (y’) is equal to the length of the flap from the pivot point to the flap tip (y). The distal tip of the flap is transposed into the defect. Flap rotated and sutured into the defect. Arrows show the direction of closure at the donor site. A ‘dog ear’ is often created in the base of the flap furthest from the pivot point, but this is not excised in case there is inadvertent damage to the direct cutaneous vessels. Donor site closed. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.6
7.6 Creation of an axial pattern flap where the flap is not adjacent to the defect and the flap is rotated through 90 degrees. The dimensions of the flap are planned as in Figure 7.5 , but the distance from the pivot point to the furthest point of the defect (y’) includes the defect plus the tissue between the flap and the defect. Bridging incision between the base of the flap and the defect. Flap rotated and sutured into the defect. Donor site closed. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.7
7.7 Creation of an axial pattern flap where the flap is not adjacent to the defect and the flap is rotated through 180 degrees. The dimensions of the flap are planned as in Figure 7.6 . Bridging incision between the base of the flap and the defect. Flap rotated and sutured into the defect. Donor site closed. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.8
7.8 Creation of an island axial pattern flap where the flap pedicle shares a common border with the defect (creating an island flap) and the flap is rotated through 180 degrees. The flap is tethered to the underlying tissue by the direct cutaneous vessels alone. The flap is rotated and sutured into the defect. The defect at the donor site is closed. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.13
7.13 Partial wound breakdown at the edge of a caudal superficial epigastric flap rotated into a stifle wound. There is also discharge within the wound and on the skin (arrowed). (© Alison L Moores)
Image of 7.14
7.14 Partial (distal) flap necrosis of a thoracodorsal flap used to close a defect of the elbow. The necrotic tissue has been debrided and the wound has been left to heal by second intention. (© Alison L Moores)
Image of 7.15
7.15 Large skin defect, including the left mammary chain and skin of the left thoracic/abdominal wall, secondary to sloughing of a large subcutaneous abscess of unknown origin. A thoracodorsal flap has been raised and rotated 90 degrees caudally into the defect. The distal end of the flap is over the dorsal midline at the contralateral scapulohumeral joint and therefore includes the secondary angiosome. The defect is adjacent to and shares a common border with the caudal aspect of the flap. Penrose drains have been placed in dependent positions under the flap and the donor site. A small amount of postoperative haemorrhage noted from the drains is within normal limits. Appearance 2 days postoperatively. There is marked bruising of the distal half of the flap, with a clear line of demarcation between normal and bruised skin. This represents the area of vascular communication between the primary and secondary angiosomes on the dorsal midline. There is serosanguineous discharge from the drains. Appearance 4 days postoperatively. The distal half of the flap is necrotic, there is dehiscence of the flap in the caudal aspect of the wound and purulent discharge from the drains. The distal portion of the flap was removed along the line of demarcation with normal skin. (© Alison L Moores)
Image of The wound on presentation.
The wound on presentation. The wound on presentation.
Image of Wound after debridement and lavage.
Wound after debridement and lavage. Wound after debridement and lavage.
Image of Flap in place and wounds closed.
Flap in place and wounds closed. Flap in place and wounds closed.
Image of Active suction drain in place.
Active suction drain in place. Active suction drain in place.
Image of The cat 4 weeks after the flap procedure.
The cat 4 weeks after the flap procedure. The cat 4 weeks after the flap procedure.
Image of The wound on presentation.
The wound on presentation. The wound on presentation.
Image of Thoracodorsal axial pattern flap, showing direct cutaneous vessels (forceps).
Thoracodorsal axial pattern flap, showing direct cutaneous vessels (forceps). Thoracodorsal axial pattern flap, showing direct cutaneous vessels (forceps).
Image of Active suction drain in place.
Active suction drain in place. Active suction drain in place.
Image of Penrose drain in place.
Penrose drain in place. Penrose drain in place.
Image of Discharge and dehiscence 6 days after surgery.
Discharge and dehiscence 6 days after surgery. Discharge and dehiscence 6 days after surgery.
Image of Caudal superficial epigastric axial pattern flap incised along an outline drawn on the skin. The flap is peninsular and includes mammary glands 3–5. The pedicle of the flap is not adjacent to the defect. In male dogs the incision includes the dorsal base of the preputial sheath to avoid damaging the vessels. (© Alison L Moores)
Caudal superficial epigastric axial pattern flap incised along an outline drawn on the skin. The flap is peninsular and includes mammary glands 3–5. The pedicle of the flap is not adjacent to the defect. In male dogs the incision includes the dorsal base of the preputial sheath to avoid damaging the vessels. (© Alison L Moores) Caudal superficial epigastric axial pattern flap incised along an outline drawn on the skin. The flap is peninsular and includes mammary glands 3–5. The pedicle of the flap is not adjacent to the defect. In male dogs the incision includes the dorsal base of the preputial sheath to avoid damaging the vessels. (© Alison L Moores)
Image of Flap elevated deep to supramammaricus muscle and mammary glands. Branches of the subdermal plexus located at the edge of the flap are ligated or electrocoagulated (shown in forceps). Note the use of stay sutures for flap manipulation. (© Alison L Moores)
Flap elevated deep to supramammaricus muscle and mammary glands. Branches of the subdermal plexus located at the edge of the flap are ligated or electrocoagulated (shown in forceps). Note the use of stay sutures for flap manipulation. (© Alison L Moores) Flap elevated deep to supramammaricus muscle and mammary glands. Branches of the subdermal plexus located at the edge of the flap are ligated or electrocoagulated (shown in forceps). Note the use of stay sutures for flap manipulation. (© Alison L Moores)
Image of Flap elevated to the pedicle. The direct cutaneous vessels cannot be visualized. A bridging incision is made between the defect and the flap pedicle. (© Alison L Moores)
Flap elevated to the pedicle. The direct cutaneous vessels cannot be visualized. A bridging incision is made between the defect and the flap pedicle. (© Alison L Moores) Flap elevated to the pedicle. The direct cutaneous vessels cannot be visualized. A bridging incision is made between the defect and the flap pedicle. (© Alison L Moores)
Image of A bridging incision has been made between the pedicle of the flap and the defect, and the flap has been rotated through 180 degrees into the defect. (© Alison L Moores)
A bridging incision has been made between the pedicle of the flap and the defect, and the flap has been rotated through 180 degrees into the defect. (© Alison L Moores) A bridging incision has been made between the pedicle of the flap and the defect, and the flap has been rotated through 180 degrees into the defect. (© Alison L Moores)
Image of A caudal superficial epigastric flap has been tubed to bridge the skin between the base of the flap and the defect on the lateral aspect of the thigh. (© Richard Coe)
A caudal superficial epigastric flap has been tubed to bridge the skin between the base of the flap and the defect on the lateral aspect of the thigh. (© Richard Coe) A caudal superficial epigastric flap has been tubed to bridge the skin between the base of the flap and the defect on the lateral aspect of the thigh. (© Richard Coe)
Image of
Image of Planning a thoracodorsal axial pattern flap.
Planning a thoracodorsal axial pattern flap. Planning a thoracodorsal axial pattern flap.
Image of Planning a superficial cervical flap to close a wound in an axilla.
Planning a superficial cervical flap to close a wound in an axilla. Planning a superficial cervical flap to close a wound in an axilla.
Image of Dorsal view of bite wounds over the ischial tuberosities in a cat. (Courtesy of John M Williams)
Dorsal view of bite wounds over the ischial tuberosities in a cat. (Courtesy of John M Williams) Dorsal view of bite wounds over the ischial tuberosities in a cat. (Courtesy of John M Williams)
Image of Planning a left-sided caudal superficial epigastric axial pattern flap in a cat to close the left side of the wound. A bridging incision is planned between the pedicle of the flap and the wound. The flap will be rotated through 180 degrees and sutured into the ischial wound dorsally.
Planning a left-sided caudal superficial epigastric axial pattern flap in a cat to close the left side of the wound. A bridging incision is planned between the pedicle of the flap and the wound. The flap will be rotated through 180 degrees and sutured into the ischial wound dorsally. Planning a left-sided caudal superficial epigastric axial pattern flap in a cat to close the left side of the wound. A bridging incision is planned between the pedicle of the flap and the wound. The flap will be rotated through 180 degrees and sutured into the ischial wound dorsally.
Image of Planning a left-sided caudal superficial epigastric axial pattern flap in a cat to close the left side of the wound. A bridging incision is planned between the pedicle of the flap and the wound. The flap will be rotated through 180 degrees and sutured into the ischial wound dorsally.
Planning a left-sided caudal superficial epigastric axial pattern flap in a cat to close the left side of the wound. A bridging incision is planned between the pedicle of the flap and the wound. The flap will be rotated through 180 degrees and sutured into the ischial wound dorsally. Planning a left-sided caudal superficial epigastric axial pattern flap in a cat to close the left side of the wound. A bridging incision is planned between the pedicle of the flap and the wound. The flap will be rotated through 180 degrees and sutured into the ischial wound dorsally.
Image of The flap is seen in the inguinal area ventrally and passes dorsally to close the ischial wound. (Courtesy of John M Williams)
The flap is seen in the inguinal area ventrally and passes dorsally to close the ischial wound. (Courtesy of John M Williams) The flap is seen in the inguinal area ventrally and passes dorsally to close the ischial wound. (Courtesy of John M Williams)
Image of The distal end of the flap has been used to close the ischial wound dorsally. The right wound was closed using a right deep circumflex iliac (dorsal branch) flap. (Courtesy of John M Williams)
The distal end of the flap has been used to close the ischial wound dorsally. The right wound was closed using a right deep circumflex iliac (dorsal branch) flap. (Courtesy of John M Williams) The distal end of the flap has been used to close the ischial wound dorsally. The right wound was closed using a right deep circumflex iliac (dorsal branch) flap. (Courtesy of John M Williams)
Image of Planning a lateral thoracic axial pattern flap. The origin of the thoracodorsal and lateral thoracic vessels are close to each other. The flap will be rotated into an elbow wound.
Planning a lateral thoracic axial pattern flap. The origin of the thoracodorsal and lateral thoracic vessels are close to each other. The flap will be rotated into an elbow wound. Planning a lateral thoracic axial pattern flap. The origin of the thoracodorsal and lateral thoracic vessels are close to each other. The flap will be rotated into an elbow wound.
Image of Planning a right-sided deep circumflex iliac (ventral branch) axial pattern flap to close a sacral wound. The flap is planned as an island.
Planning a right-sided deep circumflex iliac (ventral branch) axial pattern flap to close a sacral wound. The flap is planned as an island. Planning a right-sided deep circumflex iliac (ventral branch) axial pattern flap to close a sacral wound. The flap is planned as an island.
Image of Planning a right-sided deep circumflex iliac (dorsal branch) axial pattern flap to close a right ischial wound.
Planning a right-sided deep circumflex iliac (dorsal branch) axial pattern flap to close a right ischial wound. Planning a right-sided deep circumflex iliac (dorsal branch) axial pattern flap to close a right ischial wound.
Image of A deep circumflex iliac (dorsal branch) axial pattern flap has been used to close an ischial wound in this cat. (© John M Williams)
A deep circumflex iliac (dorsal branch) axial pattern flap has been used to close an ischial wound in this cat. (© John M Williams) A deep circumflex iliac (dorsal branch) axial pattern flap has been used to close an ischial wound in this cat. (© John M Williams)
Image of Planning a right-sided cranial superficial epigastric axial pattern flap to close a sternal wound. The flap is planned as an island incorporating nipples 3 and 4.
Planning a right-sided cranial superficial epigastric axial pattern flap to close a sternal wound. The flap is planned as an island incorporating nipples 3 and 4. Planning a right-sided cranial superficial epigastric axial pattern flap to close a sternal wound. The flap is planned as an island incorporating nipples 3 and 4.
Image of Untitled
Image of Planning a left-sided superficial brachial axial pattern flap to close an antebrachial wound.
Planning a left-sided superficial brachial axial pattern flap to close an antebrachial wound. Planning a left-sided superficial brachial axial pattern flap to close an antebrachial wound.
Image of Untitled
Image of Planning a left-sided genicular axial pattern flap to close a lateral crural wound in a dog after radical resection of a tumour.
Planning a left-sided genicular axial pattern flap to close a lateral crural wound in a dog after radical resection of a tumour. Planning a left-sided genicular axial pattern flap to close a lateral crural wound in a dog after radical resection of a tumour.
Image of The flap has been raised to the level of the greater trochanter. The vessels are very susceptible to damage and should be handled with care. (Courtesy of Jane Ladlow)
The flap has been raised to the level of the greater trochanter. The vessels are very susceptible to damage and should be handled with care. (Courtesy of Jane Ladlow) The flap has been raised to the level of the greater trochanter. The vessels are very susceptible to damage and should be handled with care. (Courtesy of Jane Ladlow)
Image of The flap is rotated 90 degrees distally into the wound. (Courtesy of Jane Ladlow)
The flap is rotated 90 degrees distally into the wound. (Courtesy of Jane Ladlow) The flap is rotated 90 degrees distally into the wound. (Courtesy of Jane Ladlow)
Image of The donor site is closed. (Courtesy of Jane Ladlow)
The donor site is closed. (Courtesy of Jane Ladlow) The donor site is closed. (Courtesy of Jane Ladlow)
Image of Untitled
Image of Chronic wound over the calcaneus secondary to rupture of the gastrocnemius tendon in a dog. (Courtesy of John M Williams)
Chronic wound over the calcaneus secondary to rupture of the gastrocnemius tendon in a dog. (Courtesy of John M Williams) Chronic wound over the calcaneus secondary to rupture of the gastrocnemius tendon in a dog. (Courtesy of John M Williams)
Image of The outline of the flap is drawn on to the skin prior to surgery. The caranial and caudal lines are pulled together to ensure there is sufficient skin to close the donor site as there is little spare skin over the medial aspect of the crus. Flaps of smaller width must be raised in some cases. (Courtesy of John M Williams)
The outline of the flap is drawn on to the skin prior to surgery. The caranial and caudal lines are pulled together to ensure there is sufficient skin to close the donor site as there is little spare skin over the medial aspect of the crus. Flaps of smaller width must be raised in some cases. (Courtesy of John M Williams) The outline of the flap is drawn on to the skin prior to surgery. The caranial and caudal lines are pulled together to ensure there is sufficient skin to close the donor site as there is little spare skin over the medial aspect of the crus. Flaps of smaller width must be raised in some cases. (Courtesy of John M Williams)
Image of Planning a reverse saphenous conduit axial pattern flap to cover a defect on the lower leg.
Planning a reverse saphenous conduit axial pattern flap to cover a defect on the lower leg. Planning a reverse saphenous conduit axial pattern flap to cover a defect on the lower leg.
Image of Caudomedial view of the flap, which has been rotated 180° distally into the wound over the calcaneus. The donor site on the medial aspect of the crus has not yet been closed. (Courtesy of John M Williams)
Caudomedial view of the flap, which has been rotated 180° distally into the wound over the calcaneus. The donor site on the medial aspect of the crus has not yet been closed. (Courtesy of John M Williams) Caudomedial view of the flap, which has been rotated 180° distally into the wound over the calcaneus. The donor site on the medial aspect of the crus has not yet been closed. (Courtesy of John M Williams)
Image of Postoperative appearance of the distal end of the flap over the calcaneus, viewed from the caudolateral aspect. (Courtesy of John M Williams)
Postoperative appearance of the distal end of the flap over the calcaneus, viewed from the caudolateral aspect. (Courtesy of John M Williams) Postoperative appearance of the distal end of the flap over the calcaneus, viewed from the caudolateral aspect. (Courtesy of John M Williams)
Image of Appearance 2 weeks postoperatively. There is some oedema and bruising of the flap but this is within normal limits. (Courtesy of John M Williams)
Appearance 2 weeks postoperatively. There is some oedema and bruising of the flap but this is within normal limits. (Courtesy of John M Williams) Appearance 2 weeks postoperatively. There is some oedema and bruising of the flap but this is within normal limits. (Courtesy of John M Williams)
Image of Untitled
Image of Planning a superficial temporal axial pattern flap to cover a defect on the face of a cat.
Planning a superficial temporal axial pattern flap to cover a defect on the face of a cat. Planning a superficial temporal axial pattern flap to cover a defect on the face of a cat.
Image of Enucleation wound in a cat. The flap has been raised adjacent to the wound. (Courtesy of Jane F Ladlow)
Enucleation wound in a cat. The flap has been raised adjacent to the wound. (Courtesy of Jane F Ladlow) Enucleation wound in a cat. The flap has been raised adjacent to the wound. (Courtesy of Jane F Ladlow)
Image of The length of the flap that is raised is sufficient to reach the distant end of the defect, but shorter than the maximum length that can be raised without significant distal necrosis. The flap is rotated through 90 degrees into the defect. (Courtesy of Jane F Ladlow)
The length of the flap that is raised is sufficient to reach the distant end of the defect, but shorter than the maximum length that can be raised without significant distal necrosis. The flap is rotated through 90 degrees into the defect. (Courtesy of Jane F Ladlow) The length of the flap that is raised is sufficient to reach the distant end of the defect, but shorter than the maximum length that can be raised without significant distal necrosis. The flap is rotated through 90 degrees into the defect. (Courtesy of Jane F Ladlow)
Image of Donor site closed. (Courtesy of Jane F Ladlow)
Donor site closed. (Courtesy of Jane F Ladlow) Donor site closed. (Courtesy of Jane F Ladlow)
Image of About 3 months after surgery, the flap has healed without complication and hair growth gives a good cosmetic appearance. (Courtesy of Claudia Hartley)
About 3 months after surgery, the flap has healed without complication and hair growth gives a good cosmetic appearance. (Courtesy of Claudia Hartley) About 3 months after surgery, the flap has healed without complication and hair growth gives a good cosmetic appearance. (Courtesy of Claudia Hartley)
Image of Untitled
Image of Use of a caudal auricular flap to close a wound over the right orbit in a dog after radical resection of a mass. The flap has been raised to the level of the scapular spine, therefore including the secondary angiosome of the superficial cervical vessels, and rotated 180 degrees rostrally into the defect. (Courtesy of Jane F Ladlow)
Use of a caudal auricular flap to close a wound over the right orbit in a dog after radical resection of a mass. The flap has been raised to the level of the scapular spine, therefore including the secondary angiosome of the superficial cervical vessels, and rotated 180 degrees rostrally into the defect. (Courtesy of Jane F Ladlow) Use of a caudal auricular flap to close a wound over the right orbit in a dog after radical resection of a mass. The flap has been raised to the level of the scapular spine, therefore including the secondary angiosome of the superficial cervical vessels, and rotated 180 degrees rostrally into the defect. (Courtesy of Jane F Ladlow)
Image of Appearance of the flap 10 days postoperatively. (Courtesy of Jane F Ladlow)
Appearance of the flap 10 days postoperatively. (Courtesy of Jane F Ladlow) Appearance of the flap 10 days postoperatively. (Courtesy of Jane F Ladlow)
Image of Planning a lateral caudal axial pattern flap to close a sacral wound. A dorsal incision is made over the tail, the coccygeal bones are removed and the distal two-thirds of the tail is amputated.
Planning a lateral caudal axial pattern flap to close a sacral wound. A dorsal incision is made over the tail, the coccygeal bones are removed and the distal two-thirds of the tail is amputated. Planning a lateral caudal axial pattern flap to close a sacral wound. A dorsal incision is made over the tail, the coccygeal bones are removed and the distal two-thirds of the tail is amputated.
Image of The flap is rotated dorsally into the wound and sutured. There is no donor site to close as the tail has been removed.
The flap is rotated dorsally into the wound and sutured. There is no donor site to close as the tail has been removed. The flap is rotated dorsally into the wound and sutured. There is no donor site to close as the tail has been removed.

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