Pedicle Flaps

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- Discussion:
    - pedicle flaps can incorporate a variety of tissues, ranging from skin
            and subQ fat to essentially a complete finger;
    - used to provide coverage in areas where tendon (denuded of epitenon),
            bone (denuded of periosteum), or joints are exposed;
    - areas that must support tendon grafting or transfers are best covered
            w/ pedicle flap;
    - periosteal surfaces can be skin grafted, but flap coverage provides
            more durable surface that is less prone to traumatic breakdown;
    - pedicle flaps can be used to provide sensation or specialized tissues
    - blood supply to pedicle flaps is thru intact base, stalk, or pedicle;
    - donor site is closed primarily or is skin grafted;
    - local flaps are obtained within the area of the defect and mobilized
            to fill the defect;
    - regional flaps are further removed from the defect but raised on the
            same extremity;
    - most regional and all distant pedicle flaps coverage requires at least
            two stages;
            - in the first stage the flap is inset at the recipient site;
            - more complete the inset at primary stage, more extensive vascular
                  ingrowth into the flap;
            - vascular supply of either local or distant pedicle flap can be
                  enhanced by the staged division of a portion of its vascular
                  supply (delay maneuver), thereby encouraging a more efficienct
                  circulation;
                  - this permits its use of a greater length to width ratio than
                          would otherwise be possible;
    - after flap has established sufficient vascular connections w/
          recipient site, the second stage, pedicle transection and inset
          completion, is performed;

- Axial Pedicle Flaps:
    - classified as either peninsular or island
    - peninsular flaps maintain tissue continuity across the length of
          to the donor area;
    - island flaps consist of an island of skin, muscle, fascia, or
          subQ tissue maintained on a debulked or skeletonized pedicle;
    - flaps are often designed of greater dimension than initially estimated
          to avoid tension, since undue tension will initially impair venous
          return;
          - tension associated with a single suture can produce a white line
              across a flap, resulting in distal necrosis;
          - thick flaps are less pliable and compensations for their
              inelasticity must be made;
          - pallor reflects inadequate arterial supply, while cyanosis
              indicates venous congestion;
          - mottling, cyanosis, and and edema herald impending necrosis, and
              violet discoloration signals established tissue necrosis;
          - hematoma or seroma between the flap and recipient bed will impair
              healing and predispose to infection and flap necrosis;
              - hematoma can also reduce vascular flow thru direct pressure;

- Innervated Pedicle Flaps:
    - innervated flaps are used primarily to provide coverage of the working
          (opposable) surfaces of the hand;
    - this includes the ulnovolar surfaces of the thumb pad and the radio-
          volar surfaces of the finger pads;
    - these flaps can be developed from local or regional tissues;