# Flap procedures

The concept model for flap procedures is based on three attributes in a role group as outlined below:

### 363701004 |Direct substance (attribute)|

* 363701004 |Direct substance (attribute)| must have a value from the 256683004 |Flap (substance)| subhierarchy, and indicate the direct flap substance composition, and its blood supply.
* 363701004 |Direct substance (attribute)| must be used for flap procedures (and **not** 424361007 |Using substance (attribute)|).
* Flap substances exist for free flaps and pedicle flaps (<<261238005 |Free flap (substance)| and << 261235008 |Pedicle flap (substance)|) and reflect the fact that whether a flap is free or pedicle is also a function of its blood supply (i.e. completely unattached from its original blood supply, or still attached via a vascular pedicle).
* Also see [Flap (substance) editorial guidance](https://docs.snomed.org/snomed-ct-specifications/snomed-ct-editorial-guide/readme/authoring/domain-specific-modeling/substance/substance-naming-and-modeling-conventions/guidelines-for-specific-substance-types/flap-substances).

### 260686004 |Method (attribute)|

* For flap reconstruction procedure, 260686004 |Method (attribute)| must have a value from the 360032005 |Flap reconstruction - action (qualifier value)| subhierarchy and indicate the flap procedure technique, for example, advancement or rotation of flap.
* For free flap procedures, the method is 1193839003 |Distant flap reconstruction - action (qualifier value)|
* The proximity of the flap donor site to the flap recipient site (local flap/distant flap) must be modeled as part of the methodology of the procedure (and is no longer a characteristic of the flap substance).
  * For example,
    * 1193839003 |Distant flap reconstruction - action (qualifier value)| relates to the remote distance between the donor site and the recipient site.
* When the donor site is indicated in the FSN, for a flap reconstruction procedure for example, then an additional role group is added including the 260686004 |Method (attribute)| with a value of 1193917004 |Flap creation - action (qualifier value)|. The donor site may be stated by the use of 'from x body structure' in the FSN, or if the donor site is indicated by the flap substance (See Example 2 below).

### 405813007 |Procedure site - Direct (attribute)|

* If it is known where on the body the procedure to perform the flap reconstruction, or flap creation, or other flap procedure is performed, then 405813007 |Procedure site - Direct (attribute)| is used (do not use 405814001 |Procedure site - Indirect (attribute)|).
* Do not include 405813007 |Procedure site - Direct (attribute)| if no location on the body is specified.
* Do not include general value 442083009 |Anatomical or acquired body structure (body structure)| if no body site is stated.

#### Example 1: 304093002 |Reconstruction using local subcutaneous pedicle osteomyocutaneous flap (procedure)|

<figure><img src="https://4060284305-files.gitbook.io/~/files/v0/b/gitbook-x-prod.appspot.com/o/spaces%2FuoSxuN6wQMDYcvuq2wNX%2Fuploads%2FyDgDUzKABtUGx1NJSWIu%2Fimage.png?alt=media&#x26;token=cf879aaf-dfef-41a2-aa26-f4a6b762e98c" alt=""><figcaption><p>Stated diagrammatic view of 304093002 |Reconstruction using local subcutaneous pedicle osteomyocutaneous flap (procedure)|</p></figcaption></figure>

<figure><img src="https://4060284305-files.gitbook.io/~/files/v0/b/gitbook-x-prod.appspot.com/o/spaces%2FuoSxuN6wQMDYcvuq2wNX%2Fuploads%2F5keAY12Mh7YJAt9L14We%2Fimage.png?alt=media&#x26;token=cbd3ce87-bd69-44e3-8f34-b8288da87271" alt=""><figcaption><p>Inferred browser view of 304093002 |Reconstruction using local subcutaneous pedicle osteomyocutaneous flap (procedure)|</p></figcaption></figure>

#### Example 2: 14390001000004103 |Reconstruction of mouth using pectoralis major myocutaneous flap (procedure)|

<figure><img src="https://4060284305-files.gitbook.io/~/files/v0/b/gitbook-x-prod.appspot.com/o/spaces%2FuoSxuN6wQMDYcvuq2wNX%2Fuploads%2FmSUfnMt0LFJRRrlyrunF%2Fimage.png?alt=media&#x26;token=e30b2711-45b6-463d-83e0-385f270bb678" alt=""><figcaption><p>Stated diagrammatic view of 14390001000004103 |Reconstruction of mouth using pectoralis major myocutaneous flap (procedure)|</p></figcaption></figure>

<figure><img src="https://4060284305-files.gitbook.io/~/files/v0/b/gitbook-x-prod.appspot.com/o/spaces%2FuoSxuN6wQMDYcvuq2wNX%2Fuploads%2FSYRbTa1QMyzPsyuK4FN5%2Fimage.png?alt=media&#x26;token=e10aa2dd-a669-4e93-81a5-30fad900c2c9" alt=""><figcaption><p>Inferred browser view of 14390001000004103 |Reconstruction of mouth using pectoralis major myocutaneous flap (procedure)|</p></figcaption></figure>

## Flap procedure naming

#### Simple procedure terming <a href="#simple-procedure-terming" id="simple-procedure-terming"></a>

* FSN: Reconstruction using flap (procedure)
* PT: Reconstruction using flap
* SYN: Reconstruction with flap
* SYN: Flap reconstruction \[optional]
  * For example,
    * FSN: Reconstruction using free flap (procedure)
    * PT: Reconstruction using free flap
    * SYN: Reconstruction with free flap
    * SYN: Free flap reconstruction \[optional]

#### Flap reconstruction 2 <a href="#flap-reconstruction-2" id="flap-reconstruction-2"></a>

* FSN: Reconstruction of x body structure using y flap (procedure)
* PT: Reconstruction of x body structure using y flap
* SYN: Reconstruction of x body structure with y flap
* SYN: y flap reconstruction of x body structure \[optional]
  * For example,
    * FSN: Reconstruction of breast using pedicle transverse rectus abdominis myocutaneous flap (procedure)
    * PT: Reconstruction of breast using pedicle transverse rectus abdominis myocutaneous flap
    * SYN: Reconstruction of breast with pedicle transverse rectus abdominis myocutaneous flap
    * SYN: Breast reconstruction using pedicle transverse rectus abdominis myocutaneous flap \[optional]

{% hint style="info" %}
Existing flap procedure concepts may not align with this new terming. No new ‘flap graft’ procedures should be added going forward.
{% endhint %}

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