SEMINAR

ON

FLAPS IN MAXILLOFACIAL
RECONSTRUCTION

Presented by
Dr. Jaspreet Kaur Bhasin
Department of Oral and Maxillofacial Surgery,
National Dental College, Derabassi.
PUNJAB.
Contents :

1. Introduction
2. Free skin grafts
3. Skin flaps-
Flaps definition, history and classification
4. Designing of the flap
5. Planning considerations
6. Commonly used local and regional flaps in the reconstruction of
maxillofacial defects
7. References
Introduction –
The defects both of the skin and the mucous membrane which follow excision of
malignant tumours, closure by direct suture is used when the defect is small enough and is
otherwise suitable.
When the defect is too large or for other reasons is unsuitable for direct suture, the
potential methods of reconstruction are by the use of a free skin graft, a skin flap, a composite
flap, or a free flap. The skin and/or mucosal defects created sometimes include in addition a
segment of mandible too.

Free Skin Grafts

Free skin graft they consist of the entire thickness of the epidermis and a variable amount
of dermis. They are designated according to their dermal component as whole skin grafts,
containing the entire thickness of the dermis, and split-skin grafts, containing a proportion only.
Split-skin grafts are further subdivided into thin, medium, and thick.

The whole skin graft is cut with a scalpel while the split-skin graft, of is cut with a special
instrument – the Humby Knife or the Dermatome.

The whole skin graft, once cut, leaves behind no epidermal structure in the donor area
from which resurfacing can take place; the split-skin graft leaves adnexal remnants,
pilosebaceous follicle or sweat gland apparatus, from which the donor site can resurface. Donor
area of a split-skin graft requires no care other than that usually accorded any raw surface; the
donor area of a whole skin graft has to be closed, in most instances by direct suture. This limits
the size of the whole skin graft by direct suture. So , extensive defects are split-skin grafted.

While so detached ,such a graft can remain viable for a limited period and depends on the
ambient temperature. The various processes which result in its reattachment and
revascularisation are collectively called take.

The process of take :

The graft initial adheres to its new bed by fibrin and its immediate nutritional requirements
appear to be met by diffusion from the plasma which exudes from the bed providing a so-called
plasmatic circulation,reinforced by the outgrowth of capillary buds from the recipient area. The
presence of circulating blood in a graft can be demonstrated approximately 48 hours post-
application. Gradually , the initial adhesion provided by the fibrin cloth converts into a more
effective definitive attachment of fibrous tissue and provides within 4 days an anchorage which
allows the grafted area to be handled safely if reasonable care is taken.
 The speed and effectiveness with which blood supply and fibrous adhesion are provided
are determined by the qualities of the bed, the characteristics of the graft itself, and the
conditions under which the graft is applied to the bed.

The Graft bed

The bed must have a rich enough blood supply to vascularise the graft as rapidly as
possible and be capable also of providing the necessary fibrin anchorage.

Vascularisation.-This is achieved by outgrowth of capillary buds and the more rapid the
process ,the more suitable the particular surface is for grafting. Capillary outgrowth is also the
key factor in the production of granulation tissue. The surgeon can assess the suitability of a
surface by considering the speed with which it would be expected to granulate, left ungrafted.

The soft tissue of the face, muscle, fascia and fat, are so vascular that they all accept
grafts extremely readily. Cartilage covered with perichondrium, whether of nose or ear, takes
a graft without difficulty as does also bone covered with perisoteum.

Bare cartilage cannot be relied upon to take a graft. If the area is small, the blood supply
of the surrounding tissues may be sufficeintly profuse to allow the graft to bridge the avascular
area and cover it successfully (nasal defect reconstruction).

Bare bone, its behaviours varies in different sites. The bare cortical bone of the outer
table of the skull vault and the bare bone of the mandible both lack sufficient vascularity to take
a graft successfully. The hard palate, the neighbouring bone of the maxilla, the walls of the orbit,
the circumorbital bony buttresses are all capable of taking grafts in descending order of case.

The graft
Variations in graft thickness relate to the thickness of the dermal component and this
influences their vascularity ,dermis in general ,being less vascular in its deeper part.

The number of cut capillary ends exposed when a thick split-skin graft is cut is smaller
than with a thin graft and the full thickness graft has even fewer. Thin grafts are generally easier
to get to take than thick grafts.

Conditions for take.

1. Rapid vascularisation is all important. The graft has therefore to be in the closest possible
contact with the bed. The most frequent cause of separation is hematoma acting as a
block to link-up of the out-growing capillaries.
2. At the same time the graft has to lie immobile on the bed until it is firmly attached.
3. It should be free of pathogens.

Preparation of a surface of grafting.- Complete haemostasis is desirable before any

surface is grafted and the various steps of the excisional procedure. The raw surface may be
irrigated with saline to wash off any cloth, but wiping with gauze or the careless use of the
suction nozzle is to be discouraged as it is likely to start fresh bleeding. Keep the volume of
tissue ligated or burned as small as possible.

Clinical methods of grafting. -The methods depend on whether the graft is being
applied on the skin surface or inside the mouth and/or sino-nasal cavity, but in both sites two
distinct techniques are used. In the first, pressure is applied to the graft; in the second, the graft is
left exposed without pressure.

THE SKIN SURFACE

Pressure methods
The pressure is exerted by a bolus applied directly to the graft further pressure is usually
also applied by added dressings. The pressure is merely a means of providing immobility of the
graft and holding it in contact with the bed.

The graft is sutured to the margins of the defect, edge to edge in a full thickness graft, and
with the graft overlapping the defect in a split-graft. The sutures fixing the graft to the margins
are left long and tied over a bolus dressing. Further dressing are provided by crepe bandage
and/or Elastoplast.

Various bolus materials are used – flavine wool, cotton wool moistened with saline or
liquid paraffin, cotton waste and polyurethane foam.

Pressure methods are preferable when the graft is small in area and are invariable when it
is full thickness in type. They are advisable even if the graft is split-skin when the defect is in an
area which is inherently mobile.

When grafting is carried out primarily, pressure methods, apart from helping to create
immobility for the graft and its bed, helps also to achieve haemostasis by maintaining the two in
contact.

Exposed grafting
The graft is laid on the defect, without dressing of any kind, merely protected from being
rubbed off, and allowed to attach by fibrin adhesion alone. Any air trapped under it is pressed out
and the skin is allowed to overlap the defect margins.
 If exposed grafting is being used primarily, control of all bleeding points must be
rigorous since pressure is not available to help haemostasis. This is far from easy and for this
reason delayed exposed grafting is more usual. Application of the graft to the defect is postponed
for several days, the skin in the interval being stored in the refrigerator. The time lag between
excision and grafting allows bleeding to stop completely and the waiting period is used to free
the wound of all residual blood clot. As soon as the site is clean ,the graft can be applied; 2-5
days is an average but the time is not critical.

The most important single point of technique is to make sure that the surface of the defect
is not allowed to dry out. It can be avoided by making sure that an occlusive dressing is applied
to the defect as soon as it has been made.. A 5mm thick layer of tulle gras sheeting is used. Its
occlusive properties prevent the surface from drying out and it can be removed with a minimum
of discomfort 24 – 28 hours later.

Storage of skin
The graft is wrapped in gauze moistened with saline, placed in a sterile, sealed container
and stored in a refrigerator until required. A storage temperature of 4 oC is likely to give the
longest survival.

Antibiotics in intra-oral grafting

Squamous carcinoma in the oral cavity has been found to harbour anaerobic bacteria.
They are sensitive to the nitroimidazole antimicrobials, such as Metronidazole or Tinidazole.

Skin Flaps

Flap Definition, History, and Classification

A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site)
while maintaining its own blood supply. A skin flap in its basic form is a tongue of tissue
consisting of the entire thickness of the skin plus a variable amount of the underlying
subcutaneous tissue. It is transferred in order to reconstruct a primary defect and is inset into this
defect. The transfer usually leaves a secondary defect which is either closed by direct suture or
covered with a free skin graft.

Flaps come in many different shapes and forms. They range from simple advancements of skin
to composites of many different types of tissue. These composites need not consist only of soft
tissue. They may include skin, muscle, bone, fat, or fascia.
How does a flap differ from a graft? A flap is transferred with its blood supply intact, and a graft
is a transfer of tissue without its own blood supply. Therefore, survival of the graft depends
entirely on the blood supply from the recipient site.

History of flap surgery

The term flap originated in the 16th century from the Dutch word flappe, meaning something
that hung broad and loose, fastened only by one side. The history of flap surgery dates as far
back as 600 BC, when Sushruta Samita described nasal reconstruction using a cheek flap. The
origins of forehead rhinoplasty may be traced back to approximately 1440 AD in India. Some
reports suggest flap surgeries were being performed before the birth of Christ.

The surgical procedures described during the early years involved the use of pivotal flaps, which
transport skin to an adjacent area while rotating the skin about its pedicle (blood supply). The
French were the first to describe advancement flaps, which transfer skin from an adjacent area
without rotation. Distant pedicle flaps, which transfer tissue to a remote site, also were reported
in Italian literature during the Renaissance period.

Subsequent surgical flap evolution occurred in phases. During the First and Second World Wars,
pedicled flaps were used extensively. The next period occurred in the 1950s and 1960s, when
surgeons reported using axial pattern flaps (flaps with named blood supplies). In the 1970s, a
distinction was made between axial and random flaps (unnamed blood supply) and muscle and
musculocutaneous (muscle and skin) flaps. This was a breakthrough in the understanding of flap
surgery that eventually led to the birth of free tissue transfer.

In the 1980s, the number of different tissue types used increased significantly with the
development of fasiocutaneous(fascia and skin) flaps (which are less bulky than muscle flaps),
osseous (bone) flaps, and osseocutaneous (bone and skin) flaps.

The most recent advancement in flap surgery came in the 1990s with the introduction of
perforator flaps. These flaps are supplied by small vessels (previously thought too small to
sustain a flap) that typically arise from a named blood supply and penetrate muscle, muscle
septae, or both to supply the overlying tissue. An example of this is the deep inferior epigastric
perforator (DIEP) flap, which has now become the criterion standard in breast reconstruction.

Classification of flaps

1. Blood supply
I. Random (no named blood vessel)
II. Axial (named blood vessel) - further classified by Mathes and Nahai as:
 One vascular pedicle (eg, tensor fascia lata)
 Dominant pedicle(s) and minor pedicle(s) (eg, gracilis)
  Two dominant pedicles (eg, gluteus maximus)
 Segmental vascular pedicles (eg, sartorius)
 One dominant pedicle and secondary segmental pedicles (eg, latissimus dorsi)

1. Axial pattern flap

Flap is constructed around a pre-existing anatomically recognized arteriovenous system.
This system running along its length makes it possible to construct a flap at least as long as the
territory of its axial artery with minimal regard for considerations of breadth.

2. Random Pattern flap

Flap has no pre-existing bias in its vascular pattern and this lack places stringent limits on
its dimensions particularly on the ratio between its length and breadth. The degree of stringency
depends to a considerable extent on the richness of its subdermal vascular pattern.

Below the level of the zygomatic arch ,there is a very rich subdermal plexus in the fatty
layer between the skin and the muscles of facial expression, fed from deeper vessels which
emerge from between the facial muscles and In the nasolabial area ,from the facial artery . The
branches that pass upwards towards the inner canthal region, lateral to the angle of mouth and
the alar base, are conccentrated mainly at the level of these land marks.

Facial flaps are raised deep to the subdermal plexus and they largely rely on its richness.
They can be regarded as random.

Above the zygomatic arch vascular anatomy is different. In the scalp proper ,the vessels
run horizontally in the dense connective tissue layer between skin and galea with no significant
deep vascular connections; in the forehead the situation is similar with frontalis muscle replacing
the galea and a looser background of connective tissue.

The arteries and veins are in a line encircling the head at the level of the supraorbital
ridges, the zygomatic arches, the mastoid area on each side and the highest nuchal line on the
occipital bone.

The vessels which cross this line are the superficial temporal artery and vein just in front
of the ear, each dividing into anterior and posterior branches, the posterior auricular and occipital
vessels behind the ear, the supraorbital and supratrochlear vessels on the medial side of each
supra-orbital ridge.

The success of such flaps relates to two factors – the virtual absence of deep vascular
connections and the calibre of the vessels themselves in the plexuses.
2. Tissue content

 Cutaneous

 Composite

Faciocutaneous

Myocutaneous

osseocutaneous

o Flaps may be composed of just one type of tissue or several different types of
tissue. Flaps composed of one type of tissue include skin (cutaneous), fascia, muscle, bone,
and visceral (eg, colon, small intestine, omentum) flaps.

o Composite flaps include fasciocutaneous (eg, radial forearm flap), myocutaneous

(eg, transverse rectus abdominis muscle [TRAM] flap), osseocutaneous (eg, fibula flap),
tendocutaneous (eg, dorsalis pedis flap), and sensory/innervated flaps (eg, dorsalis pedis flap
with deep peroneal nerve).

3. Location of donor site-local flaps

-regional flaps

-distant flaps

Local flaps imply use of tissue adjacent to the defect, whereas regional flaps refer to those
flaps recruited from different areas of the same part of the body. Distant flaps are harvested
from different parts of the body.

4. Configuration Flaps are often referred to by their geometric configuration. Examples of

these flaps include bilobed, rhombic, and Z-plasty

5. Method of Transfer The most common method of classifying flaps is based on the
method of transfer.
 Advancement flaps-single pedicle advancement flap

- V-Y,flap

-Bipedicle flap
  Pivotal flaps- rotation flap

-transposition flap(bilobed and rhomboid flap)

-interpolation flap (Z-plasty)

Advancement flaps are mobilized along a linear axis toward the defect .

Rotation flaps pivot around a point at the base of the flap . Although most flaps are moved by a
combination of rotation and advancement into the defect, the major mechanism of tissue transfer
is used to classify a given flap.

Transposition flap refers to one that is mobilized toward an adjacent defect over an incomplete
bridge of skin. Examples of transposition flaps include rhombic flaps and bilobed flaps .

Interposition flaps differ from transposition flaps in that the incomplete bridge of adjacent skin
is also elevated and mobilized. An example of an interposition flap is a Z-plasty. Interpolated
flaps are those flaps that are mobilized either over or beneath a complete bridge of intact skin via
a pedicle. These flaps often require a secondary surgery for pedicle division.

Microvascular free tissue transfer from a different part of the body relies on reanastomosis of the
vascular pedicle.

Designing the Flap

 A stepwise approach can be helpful in selecting and designing a flap.

 The characteristics of the defect and adjacent tissue must be analyzed. These include
color, elasticity, and texture of the missing tissue.
 The defect size, depth, and location are evaluated as well as the availability and
characteristics of adjacent or regional tissue.
 Determine the mobility of adjacent structures and identify those anatomic landmarks
that must not be distorted.
 The orientation of the RSTLs and esthetic units should by analyzed closely.
 Potential flap designs should be drawn on the skin surface being careful to avoid those
designs that obliterate or distort anatomic landmarks.
 The final location of the resultant scar should be anticipated by previsualizing suture
lines and choosing flaps that place the lines in normal creases.
 The secondary defect that is created as the tissue is transferred into the primary defect
must be able to be closed easily. When designing a flap, it is important to avoid
secondary deformities that distort important facial landmarks or affect function.
 Avoid obliterating critical anatomic lines that are essential for normal function and
appearance.
  Proper surgical technique involves gentle handling of the tissue by grasping the skin
margins with skin hooks or fine-toothed tissue forceps.

 Avoid traumatizing the vascular supply by twisting or kinking the base of the flap.

 Deep pexing sutures minimize tension on the flap and eliminate dead space.

 Excessive tension on the flap may decrease blood flow and cause flap necrosis.

 Meticulous hemostasis should be achieved prior to final suturing so that a hematoma

does not develop beneath the flap.
 It is important to adequately mobilize and extend the flap, which should be of adequate
size to remain in place without tension to minimize the chance of dehiscence, scarring,
or ectropion.

Planning considerations
In cancer of the head and neck., the precise characteristics of the resection are rarely
known with absolute certainty and time to prepare a flap is seldom available. So both local and
distant, flaps have become established for routine use in head and neck malignancy without prior
preparation and transferred in a single stage.
Detailed planning often used usually involves making use of the pivot point of the flap or
of the method of planning in reverse. The flap must be designed so that the distance from the
pivot point to each part of the flap before transfer is at least equal to the distance to be expected
after transfer. This ensures that no part of the flap is under unacceptable tension. The method is
used most often in planning transposed or rotation flaps.
Planning in reverse is used when the flap is jumping over intact tissue and is not a
straightforward transposed flap.

LOCAL FLAPS
If a tumour occurs in a site where skin is lax and available, flaps are less often needed since
suture of the defect sufficies. If the tumour occurs where skin is not available. It is then that the
need for a flap arises.
It is because area of availability exist in the face that the secondary defect which result
from the transfer of such local flaps can be closed by direct suture and do not require to be
grafted.
Surgeon needs to be aware which area of availability he is exploiting so that he can assess
whether or not the area is present in the particular patient and how abundant the skin is. There is
much greater availability of skin in most elderly patients. It is the presence of wrinkles which
indicates tissue availability.
 The area of availability which are exploited most frequently are the
mandibulomasseteric , the nasolabial fold, the glabellar area, the temple area beyond the lateral
canthus. To a lesser degree, the forehead, particularly towards the mid-line has a limited
availability.

Forehead has only its convenience and effectiveness as a source of hairless skin to cover
defect of the middle third of the face – nose, cheek, lower eyelid, is so great that it is regularly
used in this capacity.

The movement of tissue as a local flap can be by advancement, rotation, or transposition.

The initial step with the rotation flap and the transposed flap in its basic form is the
conversion of the primary defect into the shape of an isoscale triangle. The triangle is outlined
beyond the clearance limit of the tumour. The flap is constructed on the skin adjoining one of the
equal sides of the traingle. It is rotated or moved laterally into the defect. To close the defect by
the movement of one side of the triangle across to the other.
When the flap is a transposed one, involving tissue movement laterally, there is a
triangular secondary defect left which corresponds to the triangle of the primary defect.
The advancement principle makes use of a single pedicled rectangular flap, raised and
advanced to cover a rectangular primary defect which adjoins its distal end. Advancement
creates a triangular dog-ear of redundant tissue at the base of the flap on each side and excision
of these completes the procedure.
Even in the face there is always a continuing tendency for the tissue to revert to their
original site as a result of differential tissue pull. The method has an extremely limited role.

The rotations flap

Since the flap is being rotated to its destination ,its idealised form is as the large arc of a
circle of which the triangular primary defect is a small arc, flap and defect together making a half
circle.
With the flap rotated there is a difference in the lengths of the two sides of the defect
being sutured together and closure is achieved with a degree of differential tension. The larger
the flap in relation to the defect the less the difference in length and the less the differential
tension.
The absence of a secondary defect in the rotation flap, or its reduction to a small area
compared with the primary defect, is possible only because of the presence of skin laxity. The
pivot point of the flap, is approximately at the centre of the curve of the flap. Evidence of this is
the dog ear which develops at the apex of the triangular defect when the flap is transferred and
the fact that the bulk of the laxity taken up during transfer is at the other extremity of the flap.
Rotation flaps require a reasonably flat surface and are consequently raised on the cheek
and submandibular area, the forehead and temple, and the scalp. The scalp fortunately also
tolerates closure under tension better than almost any other skin area. When the rotation flap is
actually being transferred differential suturing is used. There is a tightness on the flap side of the
suture line and a redundancy on its outer side, representing the discrepancy in a lengths of the
two sides. One of the two steps can be taken:
1. A back-cut can be made along the diameter line of the circle of the flap until the tension
has been sufficiently reduced. The secondary defect can be convered with a split skin
graft.
2. A dog ear may be excised from the redundant tissue outside the flap, usually from the end
furthest away from the primary defect to equate the two sides of the suture line.
When a back cut is considered it must be remembered that it is reducing the vascular cross
section of the flap.

The transposed flap:

In its ‘classic’ form this flap is a rectangle, usually near square, which is raised and
moved laterally into the primary defect, previously triangulated in preparation for it, leaves a
secondary triangular defect which is at least equal in area to the primary defect. The cosmetic
disability, acts as a significant bar to the widespread used in the head and neck. Its role confined
to the hair bearing scalp in the head and neck generally the transposed flap is modified. Flaps are
routinely raised which are very much longer than their breadth, on occasion as much as 4:1. At
the defects which the flaps are designed to fill are usually comparatively small. Most of the
secondary defects can be closed by direct suture. A further variation is to jump over intact tissue
in moving to its destination.
Forehead flaps are most often used to cover defects below the level of the eyes
and this makes it possible to inset only the distal segment of the flap at the initial transfer. In
most flaps outside the neck and head a free bridge segment is tubed but not in forehead flaps, or
indeed, in facial flaps generally. The general rigidity of any flap which includes galea would
make tubing undesirable, because of the compressing effect it would have on the blood vessels of
the flap. Forehead flap is capable of coping with the presence of a raw surface over much of its
length, if the raw surface seems undully extensive a split skin graft is applied to the raw surface
as an exposed graft.
When a split skin graft has been required, graft only the area of the ultimate secondary
defect. The graft in its early appearance tends often to form a depression on the forehead
particularly if the frontalis muscle has been included in the flap. This can be partly countered by
bevelling the margin of the flap or alternatively, the grafting be postponed for 10 days or so to
allow a build up of granulations.
During the three weeks before it is divided the bridge segment spontaneously tubes itself
to some extent by wound contraction on its deep surface and by marginal epithelialization .
If the bridge segment is being returned to the forehead all marginal epithelialization
should be excised. The fibrous tissue predominantly along the axis of the flap causing it to tube
should be excised. In suturing it back, the wound edge tend to invert unless removal of the scar
and excision of spread epithelium are both scrupulous and even this does not entirely eliminate
the tendency. Vertical mattress sutures are sometimes required to counter the inversion.
 When the secondary defect has been closed by direct suture, the bridge segment can
either be discarded or returned to its original site.
The distal segment is often raised between muscle and skin, a difficult plane to achieve
consistently since it is not a natural one but must be created surgically. In passing from the distal
segment to the bridge segment it is usual to deepen the plane immediately to the standard
surgical one just superficial to the pericranium to make sure that the maximum of axial
vasculature is included this is liable to destroy the nerve supply to the forehead muscle medial to
it but this has to be accepted. The extent of the palsy is greatest with the lateral pedicle, less with
the inferior pedicle and often nil with the mid line pedicle.
Variations in hair distribution the presence of baldness extend the possible variations in
flap. Another variation is the flap which runs vertically from the zygomatic arch instead of
curving across the forehead, using as its axial vessel the posterior branch of the superficial
temporal artery instead of the more usual anterior branch.

Commonly used Local and regional flaps in the reconstruction of

maxillofacial defects :

LOCAL/RANDOM PATTERM FLAPS:

Buccal fat:

The first reported utilization of the buccal fat pad as a pedicled flap was by Egyedi on the
successful closure of oral antral and/or oral nasal communications following resection. Use of
the fat pad as a free graft has been reported by Neder. The buccal fat pad lies within the
masticatory spaces, and is termed a syssarcosis, as it enhances the motion of the muscles. It is in
intimate contact with the facial nerve, parotid duct and the muscles of mastication, the average
volume of the buccal fat pad was 9.6 ml (8.3-11.9 ml). It receives arterial blood supply from
branches of the facial, transverse facial and internal maxillary arteries.
Technique:
It is assessed via a mucosal incision in the maxillary vestibule in the second molar region , or
directly by dissection at the margin of a surgical resection in the posterior maxilla. The flap is
carefully mobilized by blunt dissection. It is delivered into the defect passively once adequate
mobility is obtained. The fat pad is typically encased within a thin fascial envelope which aids in
this dissection. The fat is sutured into position with absorbable sutures. The authors allow the fat
pad to heal secondarily and rapid mucosalization takes place within weeks.
 The donor site exhibits slight edema for the first few weeks. It is adequately vascularized
to allow its transfer to cover defects of the maxilla and cheeks. It can also be utilized to provide
increased soft tissue bulk over reconstruction bars. A defect of 4 cm can usually be covered
adequately. Partial necrosis has been reported in irradiated tissue and can also result from
inappropriate tension, if it is transferred too great a distance. Following ablative surgical
procedures, the most common utilization is the reconstruction of the posterior maxilla and soft
palate and has also been utilized in conjunction with free bone grafting.

Nasolabial:
It is used for the reconstruction of facial skin defects of the upper lip, nose and check
following extirpation of skin cancers. The superiorly based flap can be transferred to an intraoral
location for the closure of oral antral fistulae. The bilateral inferiorly based flap has utility in the
reconstruction of anterior defects of the floor of mouth.
Technique:
It requires the development of finger shaped flaps in the redundant tissue of the
nasolabial fold. In elderly, a flap of 5 cm width can be harvested. The flap is raised in the
subcutaneous fat plane and then tunneled through an incision in the buccal mucosa. The blood
supply is derived from branches of the facial artery. The donor site is closed primarily in a
layered fashion. The pedicle requires division at 2-3 weeks to allow inserting of the flap and
closure of the orocutaneous tunnel. The disadvantages are: limited donor tissue, facial scarring
and a second surgical procedure is extremely difficult to use in dentate patients.

Tongue:
They can be based anteriorly, dorsally, posteriorly or bipedicled dorsally. Anteriorly
based are useful for vermilion or floor of mouth repair. Dorsally based is most useful for closure
of residual cleft fistulae of the hard palate. A posteriorly based flap is helpful in the
reconstruction of defects of the tonsillar, retromolar or lateral floor of mouth defects. A
bipedicled dorsally based tongue flap has been described for replacement of the vermilion, best
results are obtained if the tongue tip is not violated. Second procedure for the division of the
pedicle is not usually required.
Technique:
A finger shaped flap is marked our on the lateral surface of tongue from the circumvallate
papillae to 1-2 cm behind the tongue tip, approximately one third of the tongue can be used. The
flap is raised with a combination of blunt and sharp dissection through the tongue muscle,
multiple small bleeders will be encountered. These vessels are coagulated. The donor site is
closed in two layers. It is best to avoid shortening the tongue by closing it on itself. The main
disadvantage is the limited arc of rotation and its small size. In secondary reconstruction, the
donor site has typically received significant radiation, further decreasing mobility. In cases of
patients with field changes the surgeon runs the risk of transferring tissue to the site of the
ablative operation that has potential for malignant degeneration.
The tongue flap remains, best means of restoring bulk with an adequate color match in
the region of the vermilion. The flap also remains useful as an emergency flap when prior
reconstructive efforts have failed.

Uvula:
The uvula shows great variation in size between individuals. In patients who have a long,
redundant uvula who have undergone a resection of the posterior hard palate or part of the soft
palate, the uvula provides an easily harvested source of muscle and mucosa.
Technique:
A suture is passed through the tip of the uvula and provides traction, while a mucosal
incision is made on the side nearest the defect. The muscularis uvulae is split by sharp dissection
and it is then unrolled from its base to the tip of the uvula. The result is a mobile tissue with
dimmensions of 2-3 cm in length and 1-1.5 cm in width. Usually used to cover other flaps, foe
example buccal fat pad and can be used to provide mucosa for the oral and nasal surfaces of the
hard palate as well.

AXIAL PATTERN/FLAPS

FASCIAL/FASCIOCUTANEOUS:

Submental

The submental artery arises from the facial artery 5-6.5 cm from the origin of the facial
artery on the external carotid. It is easily identified in a groove on the medial surface of the
submandibular gland. It passes anteriorly between the gland and the mylohyoid muscle giving
off multiple branches. Additional muscular branches to the mylohyoid, platysma and digastric
muscles are present. Cutaneous perforating arteries pierce the platysma muscle and form
extensive branches in the subdermal plane. The skin teritory ranges from a 4 x 7 cm to a
maximum of 15 x 7 cm. The submental vein runs with the artery, its average diameter is 2.3-3.2
mm.
Technique:
 The head is extended. The inferior border of the mandible is palpated and marked. The
dimensions of the available lax tissue are determined by pinching. The neck is incised through
platysma in the submandibular area. The upper skin platysma flap is retracted carefully, taking
care to protect the marginal mandibular branch of the facial nerve. The submandibular gland is
identified and gently retracted posteriorly. The submental artery and vein are found running in a
horizontal direction, in the tissue plane between the gland and they mylohyoid muscle. The
vessels are carefully dissected until the first cutaneous perforator is identified. It is necessary to
ligate branches to the gland and muscles to achieve adequate mobilization. The incision of the
flap is then completed. The fascia, platysma, fat and skin are carefully handled to avoid shearing
injury to the perforating vessels and the subdermal plexus. The vascular pedicle is then dissected
proximally as far as necessary. The flap is inset after creation of the necessary tunneling. The
donor site is closed primarily in layers. The proximity of the tissue, reliable vascular anatomy are
of rotation and the ease of elevation make this flap useful for intraoral defect reconstruction.
Disadvantages are limited to the incisional scare.

Temporoparietal flap:
The aponeurosis has an intermediate extension between the occipitalis and frontalis
muscles, and a lateral extension also known as the temporoparietal fascia. The temproparietal
fascia is continuous below the zygomatic arch as the superficial musculo aponeurotic system.
Posteriorly is continuous with the occipital fascia. The gliding property of the temproparietal
fascia has been utilized in extremity reconstruction to cover tendons as a free tissue transfer.
It provides with a thin, paliable, abundant and well vascularized tissue with a sufficient
are of rotation to reach the majority of areas of the face, oral cavity and oropharynx. The rich
vascular supply assures the survival of tissues grafted to its surface.
The earliest reported utilization dates back to 1898. This flap makes use of the dense
communications between the posterior branch of the superficial temporal artery and the
retroauricular artery. It receives its blood supply from the superficial temporal artery. The artery
enters near the zygomatic arch where it becomes more superficial, emerging from beneath the
parotid gland, a major division into anterior and posterior branches occurs about 2 cm above and
2 cm anterior to the superior attachment of the helix. It may be absent in patients with severe
forms of hemifacial microsomia. Venous drainage is from the superficial temporal vein. The vein
lies more superficial. It usually is identified on the superficial aspect of the temporoparietal
fascia. The course of the vein can vary significantly.

Technique:
 A generous shave and preparation is completed. The doppler probe is used to outline the
course of the superficial temporal artery. A vertical preauricular incision is made in the skin with
the bifurcation at the superior temporal line. The flaps are reflected in a subfollicular plane.
Careful identification and protection of the superficial temporal vein is required. Flap is then
outlined within the temporoparietal fascia with extension to the galea. Above the origin of the
temporalis muscle the flap is harvested in a subpericranial plane. At the superior temporal line
the dissection is carried out within the areolar plane between the temporoparietal fascia and the
superficial layer of the deep temporal fasica.
The vascular pedicle is then carefully skeletonized to allow free rotation without kinking
of the vessels, the zygomatic arch can be osteotomized and later replaced with miniplate fixation.
Blunt dissection is carried out to allow passage of the flap into the area of the surgical defect.
The flap is sutured into position with resorbable suture and is allowed to epithelialize, or it can
be skin grafted. The major donor site complication is alopecia. The temporal branch of the facial
nerve crosses the zygomatic arch within, or just superficial to, the temporoparietal fascia an
average of 2 cm (range 0.8-3.5 cm) anterior to the external auditory canal. Avoidance of injury is
accomplished by limiting the dissection of the temporoparietal fascia anteriorly to above the
anterior branch of the superficial temporal artery. The auriculotemporal nerve lies on the
temporoparietal fascia and is sacrificed in the dissection leaving an area of anaesthesia of the
scalp above the ear.
The major advantages are its robust blood supply, thinness, lack of hair, well
camouflaged donor site and ease of elevation. Disadvantages are limited rotation, lack of skin
paddle for flap monitoring, numbness of the donor site and potential for the development of
alopecia.

MUSCLE/MYOCUTANEOUS:

Platysma:
It is utilized as a means of providing local coverage of defects of the floor of mouth and
posterior pharynx. The plasma muscle is a thin, band like muscle forming the superficial
boundary of the beck and allows successful transfer of a segment of cervical skin to the oral
cavity, pharynx or face in an unpredictable manner.
It extends as an extremely thin and variable muscle from the clavicles superiorly where it
is continuous with the superficial musculo aponeurotic substance (SMAS) and has some
attachments to the mandible. The major blood supply to the platysma is the submental branches
of the facial artery. The motor nerve supply to the muscle is supplied by the facial nerve.
Technique:
 Most commonly utilized in conjunction with a neck dissection. The cervical incision of
choice is the McFee incision. The superior and inferior limbs are made in a deep subcutaneous
plane preserving the integrity of the thin platysma muscle. Paddle is taken from the inferior
extent of the neck flaps. Following the elevation the platysma muscle is divided inferiorly. The
dissection is continued on the deep surface taking care not to injury the vascular supply. The flap
is then passed beneath the central limb of the McFee incision in preparation for its insetting.
This flap should not be utilized in previously irradiated patients because the viability of
the flap and the skin are questionable, in such cases. The flap may be used for floor of mouth,
check neck and pharyngeal defects. The viability of the skin paddle is not reliable.

Masseter:
It has been utilized for many years in the reanimation of the paralyzed face. Its use in
intraoral reconstruction was popularized by Tiwari for reconstruction of oral defects following
the ablation of small tonsil and retromolar fossa cancers.
Technique:
At the completion of the neck dissection the inferior border of the mandible is exposed in
a subperiosteal plane. Masseter muscle is elevated from the lateral surface of the mandible. It is
dissected to the level of the coronoid notch. The masseteric artery passes through the notch and
should be carefully protected. The tumour is then resected in continuity with the neck dissection.
When the tumour margins have been confirmed clear by frozen section the masseter muscle is
transposed to the posterior edge of the mylohyoid muscle. It is sutured there with restorable
suture.

Temporalis:
The use of the temporalis muscle for began in 1898, with a report by Glovine on the use
of it for the obliteration of dead space following orbital exenteration.
The origin of the temporalis muscle is along the surface of the lateral skull at the
temporal line. The muscle inserts on the coronoid process of the mandible and is a powerful
elevator of the mandible. The temporalis muscle receives arterial blood from three arteries. The
anterior deep temporal and the posterior deep temporal arteries are branches from the internal
maxillary artery. The middle temporal artery arises from the superficial temporal artery just
below the zygomatic arch.
The importance of this work is the recognition of the bipennate nature of the flap and
gives scientific basis for the methods described for the splitting of the muscle in clinical use. The
arterial blood flow is distributed mainly in the medial and lateral portions of the muscle with
numerous minor interconnecting vessels. It is possible to maintain axial blood flow within a flap
split in the sagittal plane. The unelevated muscle remains viable within the temporal fossa
limiting the cosmetic deformity of the flap harvest.
The anterior deep temporal artery arises from the internal maxillary artery and enters the
temporalis muscle at its anterior inferior aspect. It runs superiorly to the cephalic extent of the
muscle paralleling the direction of its fibres. The posterior deep temporal artery, another branch
of the internal maxillary artery, enters the muscle at its inferior medial aspect. It travels
superiorly to the cephalic extent. However the course of the middle temporal artery is at an
oblique angle to the direction of the muscle fibers. It arises from the superficial temporal artery
and enters the posterior inferior aspect of the temporalis muscle. The vessel travels perpendicular
to the direction of the muscle fibers. The secondary arises run at right angles to the primaries to
interconnect. The result is a biplanar arterial distribution, the venous network closely follows the
arterial distribution.
Technique:
A hemicoronal incision with or without anterior and posterior releases is utilized. The
initial incision is made to the level of the deep temporal fascia. An exception, in which a
tempororparietal flap is additionally required. In that circumstance the temporoparietal flap is
first fully elevated exposing the deep temporal fascia. Dissection in the plane is generally
bloodless. The plane is safe until 1-2 cm above the zygomatic arch where the temporal ramus of
the facial nerve is encountered, the superficial layer of the deep temporal fascia is incised 1.5-2.0
cm superior to the zygomatic arch where it splits into two layers separated by a pad of fat. The
dissection is then continued subperiosteally along the zygomatic arch and the entire temporalis
muscle is exposed. The temporalis muscle is raised from the skull by dividing its fascial origin
above the temporal line. Care is taken to avoid injury to the vascular pedicle on the deep surface
of the muscle. Depending on the bulk and its required rotation it may be passed over or beneath
the zygomatic arch. It is often preferable to perform an osteotomy or resection of the arch to
avoid compression of the pedicle. It may be necessary at times to perform an intraoral
coronoidectomy to further mobilize the temporalis muscle. When doing so the masseteric artery
must be protected. Only the quantity of muscle necessary for reconstruction is harvested,
disturbing the remaining muscle as little as possible. A subperiosteal pathway is cleared for the
transposition of the muscle to the recipient site. The muscle is sutured into position with slow
reabsorbing sutures. The donor site is closed in layers over a suction drain.
The advantages of the temporalis muscle flap are its ease of elevation, reliable blood
supply, proximity to the maxillofacial structures and camouflage of the incision within the
hairline. Disadvantages include sensory disturbance, potential facial nerve injury and temporal
hollowing.
 The flap has founmd utilization in the reconstruction of the lateral face, orbit, maxilla,
cheeks and temporomandibular joint. The muscle flap is readily combined with grafts of bone,
cartilage and skin.

Trazepius:
Throughout its length the trapezius muscle has a segmental blood supply derived from
vessels which reach its deep surface after passing through the post-vertebral muscles. It also
has a supply provided by the transverse cervical artery. It crosses the lower part of the
posterior triangle directly from its point of origin, either from the third part of the subclavian
artery or the thyrocervical trunk, reaching the anterior border of trapezius close to the
accessory nerve.
The artery passes deep to trapezius and at the anterior border of levator scapulate it
divides into a deep and a superficial branch. The deep branch passes deep to levator scapula;
the superficial branch continues between trapezius and levator scapulae dividing into an
ascending branch and a descending branch.
The pattern of veins is much less constant. The standard picture os of a vein is nearer the
surface than the artery, but running approximately parallel to it, sometimes superficial and
sometimes deep to omohyoid, finally draining into the external jugular vein just above the
clavicle.
Three basic myocutaneous flaps have been described which make use of trapezius.
1. Upper trapezius flap
2. Lateral trapezius flap
3. Lower trapezius flap
1. Upper trapezius flap:
This flap is the myocutaneous version of the standard nape of neck skin flap in which the
strip of trapezius which directly underlies the skin element is raised along with the skin to form a
composite myocutaneous flap. The bulk which the muscle adds to the flap does however reduce
its flexibility. Flap is unable to turn except in a gentle curve and this has to be taken into account
in the geometry of planning.

The flap has also been used in the form of an island flap. Elimination of the skin element of
the pedicle reduces the safety of the flap to a slight but not prohibitive degree. At the same
time its flexibility is substantially increased.
 Transferred with a skin-muscle pedicle the flap finds it has main use in providing skin cover.
The pedicle tolerates the curve to bring the flap forward but the combination of skin and
muscle does not permit the torsion which is also required if mucous membrane is being
replaced. The flap in the form of an island can be rotated to allow the skin paddle to replace a
mucosal defect.
2. Lateral trapezius flap:
This flap is based on the transverse cervical arterio-venous system. Its anterior border
corresponds approximately to the anterior margin of trapezius and from there it extends
backwards and downwards in the general direction of the spine of the scapula. In order to be
certain of including the vessels in the flap both the muscle element and the skin should
extend above the point at which the transverse cervical vessels disappear deep to trapezius,
i.e. approximately 5 cm above the clavicle.
The pivot point of the transfer is the medial end of its feeding arterio-venous system. The
course of the artery is generally reliable; difficulty concerns the vein and whether it reaches
the external jugular vein or passes down behind the clavicle beyond the reach of safe
dissection.
The vessels reach the muscle approximately 5 cm above the clavicle the length of the pedicle
in the posterior triangle can be measured accurately and the pivot point pinpointed.
The island of skin with the underlying muscle is raised from levator scapulae and elevation
of the muscle segment of the pedicle is continued forward at a width similar to that of the
island to the anterior border to trapezius. There is becomes continuous with the purely
vascular element of the pedicle.
The flap can be used in conjunction either with a radical or a functional neck dissection. The
lower posterior triangle is virtually never the site of metastasis in the clinical situation
potentially suitable for the flap so that its use is unlikely to compromise resection.
A flap which combines the island form of the upper trapezius myocutaneous flap with the
vascular pedicle of the lateral trapezius myocutaneous flap the double blood supply which
such a design would provide could be expected to enhance significantly the safety of the
transfer. The double pedicle would however limit the ways in which the flap could be
transferred and its reach within the oral cavity.
3. Lower trapezius flap:
This flap makes use of the anatomical fact that the descending branches of the transverse
cervical arterio-venous system run over the deep surface of trapezius in the general direction
of its lowest point of origin, namely the 12th thoracic spinous process, branches entering the
muscle en route. Using this system it is possible to construct a skin paddle overlying the
lower trapezius and raise it on a muscle pedicle similar in breadth to the skin island and
passing upwards towards the point at which the vessels reach the muscle i.e. 5 cm above the
clavicle.
Trapezius might be left undisturbed above the level of the scapular spine when the muscle
pedicle is being designed so that a degree of accessory nerve function can be maintained.
One of the technical problems of the lower trapezius flap, not immediately obvious, concerns
the thickness of trapezius along its anterior border in the lower part of the neck. The
thickness makes it difficult to hinge the flap upwards without endangering its blood supply
and the bulk created by the curve is not easy to accommodate without compressing it if the
skin is directly closed over.
Sternocleidomastoid:
This muscle does not have a localised vascular hilum. It is supplied segmentally by
vessels which enter it at intervals along its length in the neck. The principal ones enter its
upper half and consist of two branches of the occipital artery, an upper entering the muscle
alongside the accessory nerve and a lower arising close to the origin of the parent vessel and
a branch of the superior thyroid artery.
A myocutaneous flap was described by Owens (1955) and is the myocutaneous
counterpart of the sternomastoid skin flap.
The inclusion of the muscle improves the poor viability record of that flap. It is not
recommended for routine use.
The island sternomastoid myocutaneous flap has very severe restrictions. A radical neck
dissection remvoes sternocleidomastoid and a functional neck dissection disrupts its blood
supply. When either of these procedures has been carried out an island sternocleidomastoid
myocutaneous flap cannot be used.
Sternomastoid has also been used as a pedicle to allow transfer of a segment of clavicle in
order to reconstruct mandible.
Pectoralis major:
The vascular basis of this flap is the pectoral branch of the acromio-thoracic axis and its
associated veins. The point 2-3 cm medial to the carocoid process, is the surface making of
the neurovascular hilum of the muscle. The vessels do not enter the muscle belly
immediately but run over its deep surface in a generally downward and medial direction and
branching as they go. The lateral thoracic vessels also contribute to the blood supply.
 Vessels also reach the muscle from perforating branches of the internal mammary system
as well as from branches of the intercostals and injection studies indicate that the several
systems communicate freely.
The pivot point is the neurovascular hilum of the muscle though, depending on the
geometry of the transfer, it is sometimes possible to avoid dividing the lateral thoracic
vessels.
The skin element of the flap can be designed with a composite skin – muscle pedicle
(Arivan, 1979), the skin element extending the entire length of the flap, or as an island flap
(Baek et al, 1979). When an island flap is used the skin paddle lies below and medial to the
nipple, about the level of the 6th rib.
The safe extension varying with the age, sex, adiposity and muscular development of the
patient. 3-4 cm beyond the muscle on to the abdominal skin probably represents an average
extreme and in this extension the aponeurosis overlying rectus abdominis should be raised
with the flap. In the female the breast, particularly it size, is a significant factor in
determining the safe extension. Extension may have to be medial more than lateral and
downwards. In the male patient the lateral extension can include the nipple-areolar complex.
The complex can be excised from the flap and grafted back on its original chest site.
If a composite skin-muscle pedicle is used the parallel lines of the skin element are
centred on the surface marking of the neurovascular hilum.
The skin incisions are deepened to the muscle which is sectioned in the same line as the
skin. If an island flap is used the paddle to be transferred is outlined on the skin which is then
incised down to muscle or aponeurosis. The simplest and most direct approach uses a skin
incision which passes directly downward and medially from the surface marking of the
vascular hilum to meet the skin paddle. This incision precludes absolutely any subsequent
use of a deltopectoral flap. If it is considered that it is desirable to have a deltopectoral flap
available in reserve the incision used to expose the muscle can follow the outline of a
deltopectoral flap, turning down to meet the skin paddle. The use of such an incision, allow a
combined pectoralis major myocutaneous flap and deltopectoral flap to be used
simultaneously, one for oral lining, the other for skin cover.
The width of the muscle pedicle is usually made similar to that of the paddle although
once the flap is raised and its arterio-venous network is visible the pedicle can sometimes be
narrowed. The muscle fibres are incised and the times be narrowed. The muscle fibres are
incised and the flap is elevated from the chest wall, the ribs, the intercostal muscles and
pectoralis minor.
Latissimus dorsi:
It originally designed for defects of the chest wall. Its use in head and neck reconstruction
(Quillen et al, 1978) represents an extension of the technique.
Latissimus dorsi form part of the posterior wall of the axilla as it converges on its
tendinous insertion into the upper humeral shaft. Near its insertion the subscapular artery
arises from the axillary artery and with its venae comitants passes downwards in the general
direction of the muscle. About 4 cm from its origin it gives off the circumflex scapular artery,
continuing on as the thoracodrsal artery to enter the muscle approximately 10 cm from its
humeral insertion. The branching vessels run generally parallel to the muscle fibres.
The skin paddle transferred has varied from almost horizontal to more oblique following
the line of the underlying muscle fibres. The oblique construction has the further advantage
that the procedure can be carried out without need to move the patient from the usual supine
position other than to abduct his arm.
The line of the anterior border of the muscle is marked out on the skin pre-operatively,
remembering that towards its origin the muscle is thin along this border, and the true line
may be as much as 3 cm in front of the estimated one.Towards the lower end of the line, the
skin island is outlined.
The outline of the skin island is incised down to muscle and elevation is commenced
anteriorly. When the anterior border of the muscle is reached the plane of elevation is
continued deep to it, sharp dissection being required to divide the attachment of muscle fibres
to the ribs, exposing the vessels which enter the muscle on its deep surface.
The skin incision is extended from the island upwards along the anterior border of the
muscle and continuing dissection allows the muscle increasingly to fall back as elevation
proceeds, displaying further the blood vessels on its deep surface. The artery and vein to
serratus anterior are divided and nearer the axillary vessels the circumflex scapular vessels
and any unnamed branches are also sectioned.
The clear visualisation of the vascular pedicle, makes it possible to tailor the width of the
proximal muscle pedicle, at the same time making sure that the vessels supplying the island,
usually the anterior branches of the thoracodorsal vessels, are not divided.
Dissection proximally is continued only as far as the geometry of the transfer dictates, but
if need be the entire muscle pedicle can be divided. With a pedicle limited to its vascular
component it is naturally essential to avoid all traction during and after transfer of the flap.
 When pedicle and flap are more bulky the direct route to the neck is under pectoralis
major and a window has to be cut in the muscle to allow passage.
If the donor defect cannot be closed directly it is probably wise to use as a delayed graft.
The main virtue of this flap lies in the large area of skin which can be transferred.

AN OVERVIEW OF THE PRINCIPLES OF RECONSTRUCTION

Principles of soft tissue reconstruction:
If non-vascularized transfer of skin is considered, full-thickness grafts should be
preferred, as split-thickness grafts often provide inadequate thickness for fully satisfying
esthetic results and tend to show discoloration by increased pigmentation.
In general, facial skin is best repaired by pedicled transfer of facial skin itself. The
anatomical basis of local flaps in the facial area is different. There is no continuous
superficial fascia overlying the muscles, which usually facilitates the dissection of pedicled
skin flaps and the facial nerve limits the depth of dissection to a level above the mimic
muscles. Axial flaps, which include the facial artery, are therefore impossible to dissect
without violation of the facial nerve function. For this reason, axial flaps are only used in the
forehead region, where the supratrochlear artery, the frontal artery or the superficial temporal
artery can be included. Entire facial skin is equipped with a rich dermal-subdermal vascular
plexus and is particularly intense in the area of the cheek and the nasolabial fold. The length
to width ratio is supposed to be no larger than 2:1 in most regions of the body surface, it can
be upto 3:1 in the maxillofacial area. Thus, in most cases, local random pattern flaps are used
for the closure of facial skin defects.
Skin repair in the head and neck region by local flaps comes to its limits, when large
intra-extraorally perforating defects have to be covered, voluminous flaps with a bulk of
viable soft tissue are required to provide both volume substitute and safe defect coverage.
Pedicled transfer of myocutaneous flaps or free vascularized myocutaneous and
fasciocutaneous grafts are the reconstructive means of first choice in these cases.
Closure of tumour related perforating skin defects below the occlusal plane can be
reliably and conveniently achieved by a pedicled tissue transfer. Suitable flaps for these
locations are the detropectoral flap, a pectoralis major island flap or a pedicled transfer of the
latissimus dorsi.
Posterior defects may be likewise suitable for closure by a trapezius flap. However for
defects above the occlusal plane and extensive defects, involving bone, muscle and
cutancous tissue. Free vascularized grafts are preferble such as a fascioucutancous or
myocutaneous flaps. If the defect is shollow and there is not too much volume to be replaced,
a vascularized flap form the forearm of the lateral thigh may be the method of choice. In
larger defects situations, additional transfer of muscle tissue of fat tissue may be required
using the latissimus dorsi, the rectus abdominis or the parascapular flap.
Reconstruction of subdermal tissue
Reconstruction of subdermal tissue may be necessary in postresectionaldefects, in cases
of posttraumatic atrophy or congental hypoplasia, where the skin surface has been preserved,
but underdevelopment or loss of subdermal soft tissue have resulted in a volume deficit and
loss of contour deviation. In general, fat and muscle can be used for the correction of theses
deformities. The major problem of any flap used of the augmentation of soft tissue contour
and volume in the head and neck region, however, is the long term maintainance of the
grafted tissue volume after term maintainance of the grafted tissue volume after transfer to
the recipient area. Non-vascularized transfer of fat tissue has been subject to resorption of up
to more than 50% of the grafted volume in the long term. Due to necrosis and subsequent
replacement by connective tissue. For this reason, vascularized transfer is considered to be a
precondition for successful grafting of fat tissue. One of the vasularized free flaps most
frequently used for the replacement of subcutaneous soft tissue is the deepithelialized
parascapular flap. This flap offers adequate volume and has a reliable vascular anatomy.
Another frequently used donor site for vasularized fat grafts is the groin area. In soft tissue
defects, which cover more than two third soft the facial height and require correc5tion by a
flat but subtle soft tissue augmentation, the specific arcade-like vascular architecture. Other
grafts of relevance for the correction of soft tissue deficits may be the latissimus dorsi muscle
flap and the rectus abdominis muscle flap. However, when in deepithelialized myocutaneous
flaps are used to fill in defects of the facial contour, denervation atrophy can cause and
unpredictable reduction correction of volume and contour with the option of secondary
surgical reduction.
Reconstruction of muscles
Reconstruction of muscles combines both the replacement oof muscle volume and the
reinstitution of muscle function. The two aims are difficulat to achieve at the same time, as
the transfer of muscles is associated with a division of the nerve supply on the one hand
causing shrinkage of graft volume due to denervation atrophy. On the other hand, it is clear
that even reinnervated muscle grafts are unlikely to replace the lost muscle function
completely. Not all of the muscles in the oral and maxillofacial region require reconstruction
movements of the facial muscles, the movements of the soft plate and the function of the
tongue muscles.
Facial reanimation after long standing paralysis of the facial nerve has made a great
progress with the transfer of neurovascular segments of the gracilis muscle or the pectoralis
minor muscle.
Reconstruction of intraoral mucosa
Superficial defects in the floor of mouth and the cheek may be repaired by avascular
transfer of split thickness skin grafts. With complete defects, pedicled arterialized skin flaps
from the forehead and form the deltopectoral region have long been used as standard means
of reconstruction of intraoral soft tissue. The use of these skin flaps, however, has
shortcomings in terms of are long-term graft performance. Skin contracture, subcutaneous
scarring with subsequent flap shrinkage, desquamationof the surface epithelium and hair
growth occurs. The use of small bowel grafts for repair of large mucosal defects had
considerable improved the functional results, if the defects were located unilaterally in the
floor of the mouth and the cheek. However, when large mucosal defects were associated with
extensive loss of soft tissue volume in subtotal or glossectomies. The replacement of tissue
volume rather than the closure of the surface defect appears to be of major functional
importance. This can be accomplished by the vascularized transfer of the rectus abdominis
and the latissismus dorsi muscle with an overlying skin area for closure of the mucosal
defect.
References :
1. Petersons principles of oral and maxillofacial surgery
2. Reconstructive surgery –fonseca vol 7
3. Langdon patel –maxillofacial surgery
4. Oral and maxillofacial surgery clinics of north America-soft tissue flaps-vol
7
5. Maxillofacial surgery –vol 1- by Peter Ward Booth
6. Closure of oroantral communications with Bichat’s Buccal Fat Pad - J Oral
Maxillofacial Surg 67:1460-1466,2009