Classification

By blood supply:
- Random pattern (subdermal plexus only).
- Axial pattern (named axial artery — superficial or perforator-based).
By movement:
- Advancement: forward sliding (V-Y, A-T).
- Rotation: arc around pivot (Mustardé cheek, dorsal nasal).
- Transposition: lifted over intact skin (rhomboid Limberg, bilobed).
- Interpolated: pedicle bridges intact skin, divided at second stage (paramedian forehead, melolabial).
- Island: pedicled flap with skin paddle isolated on vascular pedicle (supraclavicular artery island, V-Y island).
By tissue composition: skin only, fasciocutaneous, musculocutaneous, osteocutaneous, chimeric.

Common regional / pedicled flaps in skin oncology

Paramedian forehead flap: axial flap on supratrochlear artery; nasal reconstruction (especially tip / ala / dorsum).
Melolabial (nasolabial) flap: random / perforator-based; nasal sidewall, ala, upper lip, intra-oral.
Pectoralis major myocutaneous: head & neck, intra-oral, neck.
Deltopectoral (Bakamjian): cervical / lower face / submandibular.
Supraclavicular artery island: head & neck, post-laryngectomy.
Trapezius / lower trapezius: posterior neck, scalp, complex defects.
Latissimus dorsi (pedicled): chest wall, breast.
Pedicled abdominal-based: pedicled TRAM (superiorly based) — historically for breast.
Keystone flap: trunk / lower limb / scalp; perforator-based curvilinear.
Propeller flap: islanded perforator with 180° rotation.
V-Y advancement: cheek, lip, nasolabial, trunk.
Karapandzic flap: lower-lip reconstruction.
Estlander / Abbe: vermilion / lip.
Mustardé cheek rotation: lower eyelid / cheek reconstruction.
Tenzel semicircular flap: eyelid margin.
Cervicofacial: facial / cheek reconstruction.
Submental island: submental artery; facial / intra-oral.
Sural artery flap: lower leg.

Defect assessment: size, depth, aesthetic subunit, functional requirements.
Skin laxity / mobility around defect; pinch test.
Vascular pedicle anatomy and reliability (Doppler / CT angiogram for perforator-based).
Donor site morbidity; aesthetic / functional impact.
Single- vs two-stage approach (interpolated flaps need division at 2-3 weeks).
Surveillance considerations: oncology follow-up; future re-excision; possible large flap concealing recurrence — counsel on imaging surveillance.
Patient factors: comorbidity, smoking, anticoagulation, occupation.

Pre-operative photographs and dermal markings.
Plan incisions along aesthetic subunit / RSTL.
Wide undermining in the appropriate plane (subdermal, sub-galeal, sub-fascial, sub-muscular).
Atraumatic flap handling (skin hooks over toothed forceps).
Tension on the subcutaneous / deep layers, not the skin edge.
Closure of donor defect ± Burow's triangles; sometimes STSG / FTSG donor closure.
Drainage if larger flaps or fluid accumulation expected.
Splinting / immobilisation across joints.
Interpolated flap pedicle division at second stage 2-3 weeks (after capillary inosculation).

Match aesthetic subunits: cheek-from-cheek, lip-from-lip, nose-from-nose.
Preserve free margins: brow, eyelid, alar rim, lip vermilion.
Plan for two-stage / refinement procedures up-front; communicate to patient.
Smokers / diabetics / radiated tissue: pedicled flap survival reduced; lower threshold for delayed flap, free-flap alternative or simpler graft.
Document oncological clearance with permanent paraffin before complex flap reconstruction (Mohs is concurrent).
Photographic record at each stage for audit and CPD.
Surveillance: large flaps obscure original site — ensure long-term follow-up plan with imaging where appropriate.