(D) Repair at 6 months. In other words, the reconstruction was predetermined and this in turn dictated the excision to be undertaken. In this manner, the first angle of the flap, or the takeoff angle, is 120° and the tip angle equals 60°. This is due to orienting the linear axis of the flap directly above … This can be either an advantage or a detriment, depending on the application. What is transposition flap surgery? With classic design, as with a rotation flap, pivotal restraint will only allow the flap to reach its destination under some tension. In clinical practice, this tension is often visible as a clearly demarcated area of hypoperfusion of the flap extending across the flap (Fig. The skin in this finger was indurated and tight secondary to the recent trauma and wound breakdown, leaving no slack for the use of a rotation flap, which allows direct closure of the donor site. Transpositional flap surgery is a reconstructive surgery which uses transposition flaps. Elevation of the flap by closure of the donor defect does not eliminate the limitation of the rotating movement. Institution: The Queen Elizabeth Hospital, Birmingham, UK. 4.5). While the design of a classic rhombic flap is complex, the dynamics of rhomboid flap motion are even more challenging to master. As noted, although imperfect in vivo, the classic Limberg flap does reduce tension on a primary closure by redirecting tension vectors to a secondary motion. These flaps are useful for fingertip defects where more dorsal skin is lost. A transposition flap is a flap rotated to cover an intervening area of normal skin to be placed in its recipient site. 4.9). Other examples of transposition flaps include: Bilobed Flap; Z-plasty For example, when repairing inferior-malar defects, bilobed flaps have a tendency to cause either ipsilateral alar elevation because of secondary tension vectors, ipsilateral alar … Learn the Transposition flap in the hand surgical technique with step by step instructions on OrthOracle. In areas of great convexity such as the repair of a defect along the jaw line, the shift in direction of a transposition flap can ameliorate the transition over a sharp protuberance. There are four possible answers of which one is correct (or on occasion more correct) than the others. Site by Redwire, Each operation and the questions associated become a named course in the CPD section. The donor site for a transposition acts much as a back cut, and the flap transposes by rotational motion on a pedicle at its base. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). The wound broke down three weeks following the operation, exposing the metal work, and leading to a significant infection risk. The first step in the Dufourmentel flap is to extend two lines from the rhombic defect. 4.8). Although the back-cut tip transposes over surrounding skin, the dynamic motion of the flap is rotation. A circular wound, for example, may be used with a 60° rhombic flap. This may be achieved by decreasing the apical flap tip angle, and the most common modification is the 30° angle flap.9 In this instance, the base of the flap is only about one-half the size of the recipient defect (Fig. Figure 4.10 A 30° angle transposition flap is only about one-half as wide as the defect. The flap is then created by drawing a line from the free end of the extended short diameter, parallel to one of the existing sides of the defect. Figure 4.5 Although rhombic flaps are geometrically correct, pivotal restraint (P) often keeps the two flap tips from reaching their destinations. Pivot flaps implies a side to side movement of the flap. The Dufourmentel flap is a complex repair to understand. Even more so than with rotation, transposition flaps accomplish tension redirection and redistribution.1 Adjacent laxity is tapped into to mobilize and transfer tissue from an area of laxity to an area of “need.” Transposition flaps are able to redirect tension vectors completely perpendicular to the needed primary motion of the repair, and as such can literally push tissue into a wound in order to avoid tension on a crucial structure or free margin. Modifications of transposition design and execution are able to overcome some of the potential drawbacks of the classic rhombic flap. (B) Operative wound and planned bilateral transposition flaps. The same principles apply to transposition, and some of the same oversizing modifications discussed in Chapter 3 are applied herein. In cases where a single rhombic flap may not recruit adequate laxity, two flaps may be designed to draw from different tension vectors.10–14 Two opposing full size flaps may not be needed, and in such cases the angle of each flap may be narrowed from 60° to 30° as deemed appropriate.15 Each flap is needed to close only one-half of the defect. (B) The upper triangular portion of the Limberg variation is a recipient for the tip created by the back cut, and the lower shaded portion of the wound is closed by rotational motion. Note curvature of the preoperative straight lines as the flap transposes and rotates, Figure 4.7 Transient ischemia of distal rhombic flap is noted secondary to forcible advancement of both tip points. This lateral movement differs it from a rotation flap. If the tissue is not moveable, the flap tip will be pulled forcefully into the angle that risks tip ischemia or necrosis. On successful completion you will receive a certificate accredited by both the Royal College of Surgeons of both England and Edinburgh as well as the British Orthopaedic Association. The complex resultant scar line is a detriment. 4.12) is a modified geometric rhomboid transposition flap that shares tension between the primary and secondary operative wounds. A local transposition flap was used to cover the defect with the secondary defect closed using a split skin graft taken from the same forearm. The tension forces on the donor defects are perpendicular and are drawn from different sources. There are additional quiz modules on the surgical steps, the implants and problem cases being added continually. Therefore, for any rhomboid defect, four flaps are available for use (Fig. This is the same mode of back-cut closure used in the dorsal nasal flap. The optimal rhombic flap will take advantage of regional laxity in closure of the donor defect and avoid anatomic distortion. (A) Classic rhombic flap design. A straightforward design modification is to make the leading edge of the flap longer than would be geometrically predicted.