– –

of advancement (that is, V-Y) and rotation flaps or

transposition
"Retalho" is the segment of the skin and subcutaneous tissue with

own vascular supply, which will be moved from a

area (donor) to another (recipient), with the
purpose of filling a surgical wound. There is
a communication from the retail to the donor area by
the middle of a pedicle, what will guarantee its
survival.

When a surgical wound is created by the removal of

a skin tumor, the first step is to try to close it
with the approximation and primary closing of the edges.
If the defect created by the surgical wound is too much
big, you can't get the edges closer and there
the need to make a flap or skin graft. The
reconstruction can be performed during the itself
surgery or left for a later time, if the
the patient's clinical conditions are not favorable.

It is allowed, on average, up to seven days for the realization.

from a patch. Meanwhile, the receiving bed should be
prepared, reviving the edges of the wound and
decreasing the granulation tissue.

The flaps can be made up of skin, skin and

fascia, skin and muscle or skin, muscle and bone.
Considering that the circulation for the tissue to be
mobilized is essential for the survival of
retail, the development of retail techniques
it presents a dependence on the definition of anatomy
vascular of the skin and the underlying soft tissue.

A scrap of random pattern based on this plexus

subdermal was designed to allow the elevation of
a rectangular piece, made of skin and From a historical point of view, attempts to use a
subcutaneous tissue with an extension: reason for random pattern patch based on circulation
width in a ratio of 2-1.5:1. Subsequently, subdermal distant from the site of the injury resulted
Milton questioned the concept of relationships of eventually in the introduction of the tubular patch
width/length. 30 Although limited in its pediculated. Through a series of late uses of
scope, or the random pattern patch can be drawing of the initial bipediculate patch, the arch of
elevated and rounded to provide viable skin and the rotation of the skin graft has been increasing.
subcutaneous tissue to cover a wound or injury Alternatively, the retail was linked to a branch
adjacent. Common patches based on the plexus carrier, which was then necessary
subdermal include the bipedicled flap, flaps transfer the retail transportation branch with
random pattern, from a region of the body extremities. The muscle was soon identified as
(donor site) to another region (recipient site). a fabric source that could be separated from its
normal origin or insertion and transposed as one
This use of randomized patch with multiples graft based on its main vascular supply
processes of autonomy or with the branch
(dominant).
the conveyor allowed the reconstruction of defects
complex and distant, especially in the region of
head and neck, and for covering injuries
composed, when the local tissue is not In 1981, Mathes and Nahai described a system of
available or severely damaged. Despite this, the classification for muscles based on the following
randomized retelling did not provide a new source of anatomical relationships between muscle and its pedicles
circulation when transferred to a distant place. vascular
In this way, the successes of these patches lately
1. The origin site of the pedicle penetrating the
depend on the environment of the wound site for the
muscle.
nutrition.
2. The number and size of the pedicle.
So far, there is no method 3. The location of the pedicle in reference to its origin
pharmacological that has surpassed the muscle and insertion.
reproducibility and the extent to which the procedure 4. The angiographic patterns of the vessels
surgical autonomization protects against necrosis intramuscular.
from scrap. There are two theories that describe the
potential mechanism by which the phenomenon of Type 1: Type I muscles are supplied by a
autonomization prevents dermal necrosis. unique vascular pedicle

The first is that the process of autonomy

acclimates the tissue to ischemia (tolerance), allowing
that the tissue survives with reduced blood flow
than what would normally be required. This theory
suggests that the decreased vascular flow causes
adaptive metabolic changes at a level
cell inside the tissue. The second theory is that
late surgical procedure improves the
vascularization by the increase in flow through the
pre-existing vessels, reorganizing the flow pattern
blood for the more ischemic areas. Type 2: Type II muscles are supplied by
a smaller vascular pedicle and a dominant one.
The surgical procedure of autonomization of
patchwork is carried out in two ways: autonomy The dominant vascular pedicle in general
standard, with an incision on the periphery of the territory will support the circulation of these muscles, after

cutaneous or partial elevation of the flap; and the elevation of the flap when the pedicles
strategic autonomization, with the division of Minors are sectioned. This is the standard.
selected pedicles for the graft, to improve most common circulation observed in the
perfusion through the pedicle or pedicles human musculature.
remnants.

The longer axial patches, not subjected to

surgical procedure of autonomization, made
immediate reconstruction of defects in
head and neck, groin and upper extremity,
encouraging the search for new patches based on
consistent vascular pedicles in the trunk and
 broad dominant close to the insertion of the
muscle with various segmental pedicles
near the origin. The vascularization
internal can be supplied by the pedicles
dominant or segmental and, in this way, the
muscle can be raised like a flap
in each vascular system.

Type 3: Type III muscles have two

broad vascular pedicles, originating from
distinct vascular. These pedicles present A fascial graft consists of the fascia separated from its
a separate source of circulation or are normal origin or insertion, transposed to another
located on opposite sides of the muscle. A local. The absence of overlying skin and fat
section of a pedicle during the elevation of the
represents a fragile patch. A patch
retail rarely results in the loss of fascio-cutaneous, originally called flap
muscle within its vascular distribution. axial, includes the skin, subcutaneous tissue, and fascia
The muscle will generally survive with a underlying, which can be evidenced in a way
of their dominant vascular pedicles. This distinct from the fascia that covers the musculature
vascular pattern allows the muscle to underlying. The vascular supply originates in the
divide, allowing the use of only part retail base, starting from the drillers
from the musculature as a muscle patch or musculocutaneous or directly from the branches
musculocutaneous septocutaneous of the main (or major) arteries.

In 1975, Schafer detected three vascular systems

main ones of the deep fascia:

1. The perforating arteries of the underlying musculature

they released several radiating branches that pierce the
Type 4: Type IV muscles are supplied by the fascia before proceeding to the subdermal plexus.
2. Subcutaneous arteries running through the area of
segmental vascular pedicles,
penetrating along the muscular belly. fat, frequently anastomosing with the
superficial plexus of the deep fascia and between both.
Each pedicle provides circulation for a
muscle segment. The section of more than 3. Subfascial arteries arising from the septum
two or three of the pedicles during elevation intermuscular traversing in the connective tissue
a piece of tissue can result in necrosis of the (areolar) loose below the deep fascia, and
distal portion of the muscle. adjacent to the superficial and deep plexus.

Type 5: Type V muscles are supplied by

a single dominant pedicle and pedicles
segmental vascular secondaries. These
muscles have a vascular pedicle
 The perforating patches were designated according to
with their locations (e.g., anterolateral flap of the
thigh), arterial supply (e.g., perforating flap
from the inferior deep epigastric artery) or the muscle
of origin (e.g., skin flap from the arteries
perforating branches of the gastrocnemius muscle.

The donor sites of perforating flaps

Acceptable things share four common characteristics:
(1) adequate and predictable blood supply; (2)
at least one wide perforating vessel (diameter ≥0.5
(3) sufficient extension of the pedicle for the
necessary anastomosis, unless the flap is
used as a pedicled flap; (4) capacity
to close the donor site first. The flaps
the drill bits normally used include the
piece of puncture from the inferior epigastric artery
deep, the patch of perforating branch of the gluteal artery
superior, perforating branch of the artery
toracodorsal, anterolateral thigh flap, flap of
perforating of the tensor fasciae latae muscle and graft
of the perforating branch of the medial sural artery.
These pedicles consist of an artery (usually
a branch of the artery to the specific anatomical region
of the fascia and regional musculature) and veins
paired comitants that drain the interior of the
main regional veins. The cutaneous pedicles and The abdominal viscera are not classified.
direct subcutaneous septa are quite concentrated easily; however, for the purposes of
There is no local. There is greater variability in the location.
flap transposition or tissue transplantation
two musculocutaneous perforators. These pedicles microvascular, the colon, the jejunum, and the omentum if
provides a vascular base for flaps conveniently fits within the system of
specific fascias or fascial cutaneous. muscle classification.

For microvascular transplantation, the segment of

intestine (jejunum or colon) is elevated in an arcade
The perforating patches have evolved from vascular with a single dominant vessel, a pattern
musculocutaneous and fascial cutaneous flaps without taking
of type I circulation. In exceptional circumstances,
muscle or fascia. It has been shown that neither the
where a longer segment of the intestine is
passively loaded muscle nor the plexus extends beyond the vascular territory of an arcade,
deep fascial vascular are necessary for the two arches should be included to ensure the
survival of the flap. The advantages of flaps viability of this longer segment of the intestine.
drillers include the reduced morbidity of the area In this case, the circulation pattern will be type III (two
donor, the versatility in the patch design, the dominant arches or pedicles). It is possible
muscle preservation (smaller functional deficit) and a reconstruct the esophagus from the base of the tongue for the
better postoperative recovery of the patient. The stomach with a long segment of jejunum, where
disadvantages of perforating patches include the a pedicle is revascularized in the upper thorax or
meticulous dissection, necessary to isolate the vessels the neck and the second pedicle is kept intact.
perforating (resulting in an increase in the period of
Other uses of the colon or jejunum as
surgery), the variability of the position and size of flaps were for vaginal reconstruction.
perforating vessels and the ease with which the vessels
can be damaged.
 tissue is often damaged due to its
proximity of the surgical or traumatic defect,
preventing the possibility of using it. The failure of
tissue expansion is generally attributable to
inadequate skin stability is associated with the tissue
mole during the expansion process.

Skin and adjacent soft tissue to the defect are preferred.

for the closure of the defect, considering the A muscle can be divided into a portion in
similarity in skin color, texture, and contour. The continuity with the dominant vascular pedicle,
local patch project for frequent advancement like a patch of transposition. The
it will allow the use of adjacent fabric, especially if muscle division techniques to preserve the tissue and
there is excess skin in the donor area. A flap the function. The remaining muscle with its origin and
of advance or rotation often requires insertion is maintained to preserve the function.
a cut or skin graft at the donor site. The Alternatively, the complete musculature can be
size of the defect or the surrounding area of the lesion divided and used to cover two shape defects
often avoids the use of adjacent fabric, which with simultaneous. Often, only a part of
frequency is not available for the closure of muscle near the vascular pedicle
wounds or for the reconstruction of composite defects. dominant is high for transplantation
microvascular. The skin territory can also be
In these circumstances, the expansion of tissues can modified and divided into two cutaneous islands
allow the use of the selected adjacent fabric for the separated or elevated with just one segment of
reconstruction. The expansion of tissues is a method muscle flap. Meanwhile, the cutaneous territory
effective for increasing the skin territory of flaps must include vascular connections through the vessels
facial muscles and muscles located superficially. musculocutaneous perforators, from the flap
Although this method is used more commonly segment
to increase the territory of the skin flap, the
the principle of tissue expansion can be applied
also to all soft tissues, including fascia and
peripheral nerve. The bone is vascularized through tissue sources
connective tissue that constitutes the endosteal surfaces and
Technically, the tissue expander is inserted under the periostea. The complex blood supply of
to provide a mechanism that enables bone is based on the nutrient vessels penetrating the
the increase in skin dimensions and offer a bone directly and through vascular connections
sufficient dermal circumference to project a between muscles and bone, specifically where the
transposition or advance cut. If it is muscle presents a broad bony source or a
planned a fasciocutaneous flap, the expander is insertion. The muscles with all five patterns of
placed below the deep fascia. If planned circulation presents vascular connections between the
a musculocutaneous flap, the expander is placed muscle fibers and the periosteum. However, the
below the deep surface of the muscle. The expander incorporation of vascularized bone with the flap of
should not be placed directly below the transposition is generally not viable, considering
dominant vascular pedicle at its entry point that the entry point of the vascular pedicle
in the retail territory to avoid injury to the pedicle dominance in the muscle determines the pivot point
during the expansion process. of graft. Bone insertions are usually
located beyond the point of rotation. An example of
The safe expansion of tissues depends on a
a rotational bone graft is the radial bone graft
surgical judgment regarding its
vascularized based on the supraretinal branches
utility for a specific problem. The benefits
intercompartimental 1,2 or 4,5 of the radial artery, for
of the surrounding tissues at the site for the surgery
the reconstruction of the carpal bone.
reconstructive are well recognized; however, this
 reconstructive surgery. Both the flaps of
fasciocutaneous transposition with musculocutaneous
they can be indicated to incorporate the sensory nerve
at the base of retail. If the cutaneous nerve does not penetrate the
base of the retail near the vascular pedicle,
it is also possible to divide the sensory nerve during the
elevation of the flap and then coapt the nerve to a
adequate sensory nerve at the receptor site. The
muscle scraps with intact motor nerves or
with reanastomosis of the motor nerve to the nerves
sensory or motor adequate at the receptor site
seem to retain a protective sensitivity,
possibly through nerve fibers of
proprioception.
The release of the origin or insertion of the flap
The maintenance of protective sensitivity is essential
muscle transposition will result in loss of function
for hands, feet, and other weight-bearing areas.
muscular. Meanwhile, many of the muscle flaps
Another common area where patches are used
they can be designed for both coverage and
sensory is the oral cavity, improving
for the transfer of functional muscles. For the
potentially the postoperative oral function. Harris
to be preserved, the motor nerve must be
et al. report that the reconstruction of areas of
preserved together with the vascular supply
weight support should provide contour
dominant; the muscle must be reinserted to a new one
suitable for normal footwear, thickness leather
bone or tendon through a joint; and the
durable, protective sensitivity and solid anchoring
muscle should exert a direct force on its new
for deep structures in order to withstand the forces of
insertion point.
shear. 92 Studies have demonstrated the benefits
Muscles suitable for use as flaps from from protective sensitivity for reconstruction of
transposition or transplantation of composite tissues ankle and heel, both with patches
microvasculars, providing both coverage rotational and by tissue transfer
as a function, they include the latissimus muscles, gluteus microvascular.
maximum (to segment), graceful, gastrocnemius and serratus. A
restoration of the length/width ratio of the
original muscle and the repair of the motor nerve for a
Two muscle scraps often
adequate motor nerve receptor at the target site
share a common regional source for their
are essential for the restoration of the function of
dominant veins or arteries. Both flaps
muscle at its new insertion site.
can be raised simultaneously and also
The flap of the latissimus dorsi muscle has been transposed as a regional patch or
used to: provide movement transplanted by microvascular surgery based on
neodiaphragmatic for hernia repair common regional vein or artery. This technique allows
recurrent congenital diaphragmatic; restore the a retail project with the capacity to cover
function of the knees after resection of the mechanism of broad defects or the use of two or more patches
quadriceps in the lower extremity; restore the for specialized coverage. The artery and the vein
shoulder and elbow movement at the extremity subscapularis are a common regional source for the
superior; and restore oral and nasal function after the dominant pedicles of the musculocutaneous flap or
of the latissimus dorsi muscle (or broadest muscle of the back),
tumor ablation of the head and neck.
flap of the serratus anterior muscle and flap
scapular fascial flap; all three flaps
they can be transposed or transplanted in this unique
Specific sensory nerves are identified in artery and vein.
cutaneous territory of many available flaps for