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Contents
INTRODUCTION HISTORY RECONSTRUCTIVE LADDER PLANNING CONSIDERATIONS SKIN FLAP PHYSIOLOGY CLASSIFICATION LOCAL FLAPS REGIONAL FLAPS DISTANT FLAPS FREE FLAPS MONITORING OF FLAP MEASURES TO INCREASE THE VIABILITY OF FLAPS FATE OF FLAP COMPLICATIONS SALVAGING REFERENCES
Introduction
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.
1440 : Dutch word "flappe" : something that hung broad and loose, fastened only by one side
HISTORY
Tansini first described the latissimus dorsi flap in 1896 Before 1963, oral and pharyngeal defects were closed primarily and reconstructed with random pattern skin flaps or tubed-pedicled flaps of skin from the trunk. In 1973, Daniel and Taylor reported the first free flap, In 1976, Panje and Harashina simultaneously described the use of free flaps to reconstruct defects of the oral cavity. In the late 1980s and early 1990s, the use of osteocutaneous free flaps to reconstruct mandibular defects was advanced.
Reconstruction Ladder
Planning considerations
The anatomy & physiology of skin, including color, texture, appearance & amount. Local muscle anatomy : vascular, nerve supply & lymphatic drainage The aesthetics of the area Possible sites for incision placement Areas of local tissue availability i.r.t the area to be reconstructed
The sensory nerves are distributed in a segmental fashion Sympathetic nerves in the area of cutaneous arterioles Precapillary sphincter- nutritive blood flow, local stimuli Preshunt sphincter- thermoregulation, sympathetic stimulation
CLASSIFICATION
Based on blood supply Axial
Random
CLASSIFICATION
By method of movement from the donor site 1) Advancement flaps 2) Transposition flaps 3) Rotation flaps 4) Interposition flaps By distance from donor site
Local Flaps Regional flaps
Local Flap
Advancement flaps Linear or rectangular configuration Sub classification Single pedicle Bipedicle V-Y flaps Single-pedicle advancement flap A rectangle of skin is moved forwardly elasticity of skin The advancement creates a length discrepancy which creates standing cone deformities
Local Flap
Bipedicle advancement flaps Advanced into the adjacent defect in a vector that is perpendicular to the flap axis Used to close a defect in an area of high visibility by moving the defect into an area of low visibility The V-Y advancement flap Pushed rather than stretched into the defect The donor flap, which usually is triangular, is advanced, and the resulting donor defect is closed in a straight line This approach results in a suture line with a Y configuration
Local Flap
Pivotal flaps Moved about a pivotal point from the donor site to the defect Rotation Transposition Interpolation flaps Interpolation flaps The flap is moved about the pedicle and the pedicle rests over the intervening tissue. The most common interpolation flap is the forehead flap.
Local Flap
Rotation flaps The leading edge of the flap also is a border of the defect Based inferiorly to promote lymphatic drainage The border perpendicular to the axis of rotation usually is curvilinear and designed to contact at the junction of 2 facial subunits for optimal scar camouflage The length of the flap should be larger than the defect by a 4:1 ratio.
Local Flap
Transposition flaps The flap is moved about the pedicle and transposed over the intervening tissue into the defect Versatile and offer a choice of flaps of similar color and texture from various donor sites -defects in the head and neck
Z-plasty
2 transposition flaps with identical angles to the direction of the defect and transposing them in opposite directions
Local Flap
Rhombic flaps Limberg specially designed transposition flap used to correct a rhombus-shaped surgical defect The classic rhombus defect has sides of equal length, with 2 opposing 60 angles and 2 opposing 120 angles. This configuration creates a short diagonal of the same length as that of the sides of the rhombus.
The Dufourmentel flap is a variation of the classic Limberg rhombic flap with any 2 opposite angles rather than the 60 and 120 angles.
Local Flap
Bilobed flaps 2 transposition flaps that share a common pedicle 1st -to reconstruct the defect 2nd -to repair the donor site for the flap The angle between each flap is 90, with a total transposition of 180 Standing cone deformities, Pincushioning Zitelli's modification 45 & 90 The key to the success of the bilobed flap is the distribution of tension over both limbs of the flap.
Local Flap
Abbe cross-lip flap 1/2-2/3 lip defects. Flap width should approximate half width of excised tissue. The recommended limit of flap width is 2 cm. The flap blood supply is based upon the labial artery The advantage is maintenance of sensory and motor competent lip segment. The disadvantage is second stage requirement and relative microstomia. Potential complications include vascular compromise, vermilion notching, lip asymmetry, and scarring extension beyond the sublabial crease
Local Flap
Estlander flap 1/2-2/3 lip defects. The Estlander flap involves rotating the upper lip tissue around the lateral edge of the mouth to correct defects involving the oral commissure. It is based upon the labial artery. The flap maintains motor and sensory competence of lip. The pedicle is divided at 2-3 weeks It requires commissure plasty at 3 months.
Local Flap
Karapandizic flap A complete lip is formed by rotating the upper lip and perioral tissue by bilateral advancement flaps. The disadvantage of this technique is frequent loss of sensory and motor innervation Potential complications include microstomia, difficulty of introducing full dentures, inversion of the vermilion and flattened mentolabial junction, and dysesthesia/anesthesia of the lip
REGIONAL FLAPS
TONGUE FLAP
Eiselberg 1901
Advantages
Adjacent tissue Excellent blood supply
Low morbidity
Reinnervated from adjacent host tissue Provide 90 to 100 cm2 of mucosal surface for rotation Half of tongue can be used without compromising the functions. Can be used in irradiated patients
REGIONAL FLAPS
TONGUE FLAP
Vasculature : Suprahyoid artery Dorsal lingual artery Sublingual artery Deep lingual artery Types : I : Random flap design a) Dorsal tongue flap - Posteriorly based to treat defects of soft palate, retromolar region. - Anteriorly based hard palate anterior buccal mucosa, anterior FOM, lips
REGIONAL FLAPS
TONGUE FLAP
Used to reline large defects of buccal mucosa extending form the commissure to the anterior mandibular ramus.
REGIONAL FLAPS
TONGUE FLAP
II. Axial flap design Sliding posterior tongue flap Coverage of lateral tongue defect measuring 4-6 cm. Created by releasing the tongue from the hyoid bone and maintaining the dorsolingual branch of the lingual artery
REGIONAL FLAPS
Blood supply 3 sources : Anterior deep temporal artery 21 % of the muscle Middle temporal artery 38% of the muscle Posterior deep temporal artery 41% of the muscle
REGIONAL FLAPS
Uses Obliteration of oral defects Gap arthroplasty of TMJ Cranial base reconstruction Obliteration of orbital defects after enucleation Facial reanimation Midface suspension or orbital repair with the coronoid process, attached to temporalis after maxillectomy
REGIONAL FLAPS
TEMPORALIS FLAP
Disadvantages
Sensory disturbance Potential facial N injury Temporal hollowing
Advantages
Ease of elevation Reliable blood supply Proximity to maxillofacial skeleton Camouflage of incision within hair line
REGIONAL FLAPS
Monks, Golovine and Brown 1898 repair eyelid and orbital defects, and perform auricular reconstruction TPGF is pedicled on the superficial temporal vessels and is a component of the SMAS TPGF can be made as wide as 14 cm on a 18 cm superficial temporal vascular pedicle. Superficial temporal V is posterior & superior to A Uniform location of vascular pedicle micro vascular transfer
REGIONAL FLAPS
Uses Obliteration of oral defects Cranial base reconstruction Obliteration of orbital defects after enucleation Malar augmentation, maxillary & mandibular reconstruction with vascularised osseous cranial bone As a skin island flap- hair bearing upper lip/ brow reconstuction
REGIONAL FLAPS
Advantages
Relatively constant & reliable blood supply Ultrathin ~ 2-4 mm Surface area ~ 120 cm.sq Lack of hair Well camouflaged donor site
REGIONAL FLAPS
Masseter Flap
In 1987 Tiwari as a cross-over flap in the tonsillar repair and retromolar trigone Origin: Superficial anterior 2/3 lower border of zygomatic arch Deep inner surface of zygomatic Insertion: Superficial lower portion of mandibular ramus Deep lateral surface of the coronoid process Innervations: Masseteric nerve (CN V3) Blood supply: Masseteric artery (internal maxillary artery)
REGIONAL FLAPS
Masseter Flap
Uses
Reconstruction of ablative procedures of parotid gland, mandible, palate and nasopharyma
Advantages
Usefull, readily available local tissue for site specific defects of oral cavity
Disadvantages
Limited tissue volume Potential for devolopment of trismus Training for emotional mimetic movement Limited arc of rotation
REGIONAL FLAPS
1887 1st used by Gersony through and through cheek defect. 1951 Edgerton lateral cervical island flap 1959 Desprez and Klehn modified apron flap Arterial supply
Anterior superior
Sub mental A
Posterior superior
Occipital and posterior auricular arteries
Anterior midportion
Superior thyroid artery
Inferiorly
Transverse or superficial cervical arteries
Skin
Fasciocutaneous perforators
REGIONAL FLAPS
Venous drainage
Postrior- EJV AJV, sub mental V, anterior communicating V
Innervation
Cervical branches of 7th CN
Contraindications
Previous radiotherapy to neck Dominant blood supply violated due to previous surgery Muscle previously transected
Flap designs
Posteriorly based Superiorly based Inferiorly based
REGIONAL FLAPS
REGIONAL FLAPS
Superiorly Plastysma Myocutaneous Flap Dominant A submental branch of facial A near inferior border of mandible Submental V Arc of rotation is suitable for reconstruction of
Ant. & lateral FOM Buccal mucosa Retromolar trigone Skin of lower cheek & parotid region Facial animation- Cervical branch of 7th CN
REGIONAL FLAPS
Advantages
Good color match Easy access to donor site Minimal donor site morbidity Easy primary closure of donor site Appropriate flap thickness for oral & facial defects
REGIONAL FLAPS
Nasolabial Flap
Sushrutha samhitha, 700 BC Diffenbach , 1830- nasal alae reconstruction Nasolabial crease 1cm superior- lateral alar rim 1cm lateral- corner of mouth Medially- orbicularis oris muscle Superior & lateral cheek Buccal & zygomatic branches of facial N
REGIONAL FLAPS
Facial A Uses Reconstructing perioral defects Upper or lower lips Comissure Buccal mucosa Full thickness defects immediately following trauma Reconstruction of upper lip scarring secondary to trauma
REGIONAL FLAPS
Infra-orbital & transverse facial A Used to reconstruct Maxillary lip Buccal mucosa Nasal defect Columella Moderately sized maxillary defect
DISTANT FLAPS
Origin
Medial 11/2 2/3 of clavicle Lateral portion of entire sternum Adjacent cartilages of first 6 ribs Bony portion of 4th ,5th ,6th ribs
Insertion
Intertubercular groove of humerus
Action
Abducts , Flexes & Medially Rotates Arm
DISTANT FLAPS
Clavicular
Arises from clavicle Deltoid branch of thoracoacromial A Lateral pectoral N
Sternocostal segment
Most muscle mass Pectoral branch of thoracoacromial A & parasternal perforators of internal mammary A Lateral pectoral N
External segment
Medial pectoral N Lateral thoracic A / Pectoral branch of thoracoacromial A/ combination
DISTANT FLAPS
Advantages
Familiar, accessible Large skin territory Rich vascular supply Large arc of rotation Used with other flaps
DISTANT FLAPS
Complications- PMMC
Donor site Uncontrolled bleeding Hematoma Wound dehiscence Infection & seroma Rarely Rib osteomyletis Seeding of tumor Metastasis
DISTANT FLAPS
Origin Clavicular head Sternal head Insertion Mastoid process of temporal bone Innervation Spinal accessory N Proprioception cervical spinal N Blood supply Occipital A / direct from ECA Superior thyroid A Transverse cervical A
DISTANT FLAPS
Sternocleidomastoid flap
Flap types Composite skin muscle flap Myocutaneous skin island flap Composite muscle bone flap Use Reconstruction- oral cavity, cheek lip Particularly as superiorly based muscle flap small defects of pharynx & oral cavity Split along its length & rotated anteriorly to cover vessels of compromised neck
DISTANT FLAPS
Sternocleidomastoid Flap
Disadvantages
Upper scm composite skin flap is poorly viable Vascularity of lower muscle flap is unreliable Upper & lower ends are of oncologic significance
Advantages
Accessible Good colour match Proximity to defect site Lack of requirement of another incision when used in conjunction with neck dissection Good thickness tissue coverage
DISTANT FLAPS
Perforator flap Based on lateralcircumflex thoracic A- descending branch Pedicle descends down b/w rectus femoralis & vastus lateralis muscles Venous drainage- 2 vena comitans of LCFA Sensate flap lateral cutaneous N of thigh
DISTANT FLAPS
Thinner flaps
Orophyngeal / Hypopharyngeal reconstruction
DISTANT FLAPS
Advantages
Low donor site morbidity Primary closure Two team approach Long vascular pedicle ~15cm Large vessels ~ 2-4 cm Large skin paddle ~ 10 x 20 cm Pliable, hairless skin
DISTANT FLAPS
Is an axial pattern flap Composed of fascia, subcutaneous tissue and skin; muscle is not transferred with this flap Boundaries Clavicle superiorly Acromium laterally A line running through the anterior axillary fold to above the nipple inferiorly Based medially on the upper chest in the upper 3 or 4 perforating branches of internal mammary A from medial end of intercostal spaces
DISTANT FLAPS
Deltopectoral Falp
Extends to any site in neck & occasionally up to zygoma Flexibility of the flap
Retracts from side to side Anomolous pivot point
Uses
To cover whole anterior neck without any subsequent revision To reconstruct a defect by passing as a bridge over normal tissues where conventionally the pedicle may be tubed Repair of pharyngeal fistula but lacks muscle bulk Reconstruct defects lower face & upper neck
DISTANT FLAPS
Deltopectoral Falp
Disadvantages
Failure rate is 9 to 18%. If flap is used to cover the carotid vessels, blow out of the carotid artery is a hazard if the flap fails.
Advantages
Usually not delayed Unilateral or bilateral Deltoid portion usually not hair bearing Excellent blood supply, with dependent venous drainage Donor site hidden, thus cosmetically acceptable Outside radiation field
DISTANT FLAPS
Tanzini,1896- 1st myocutaneous flap in medical literature Quillen,1978- head & neck reconstruction Origin Sacrum & lumbar vertebrae Posterior iliac crest Lower 6 thoracic vertebrae Slips from lower 3 ribs Insertion Intertubercular groove of humerus
DISTANT FLAPS
Thoracodorsal vessels from subscapular A Venacommitans draining into axillary V 10 x 8 cm- easily harvested with primary closure Musculocutaneous flap ~ 40 x 20 cm skin grafting As a free tissue- dividing circumflex scapular A , pedicle 10cm long, 3 mm diameter
DISTANT FLAPS
Advantages
Large amount of tissue can be transferred Pedicled or free tissue transfer Cosmetic advantage, esp. females Versatile ; tubed/ multiple/ osseous components When pedicled can reach upper face & scalp
Free Flap
Criteria for selection The length & diameter of vascular pedicle available The type, thickness & color match of the skin required Whether associated tendon, fascia or nerves are needed Whether a large composite free flap is required The morbidity caused by harvesting the flap should be considered
Disadvantages
Partial skin graft loss Tendon exposure Delayed healing of STSG donor site # radius at harvest Sensory loss in distribution of superficial radial N Restricted forearm function
Tubular shaped with Thick cortical bone Nutrient A from peroneal A enters the medial surface of bone just above its midpoint Pedicle up to 8cm Venacommitans Fasciocutaneous- skin paddle centered over intermuscular septum & including deep fascia
Complications
Partial loss of donor site STSG Ankle stiffness Donor site pain Ankle instability Peroneal N motor & sensory loss Decreased knee extension Decreased flexion strength
Contraindication
Peripheral vascular disease
Disadvantages
Ltd cutaneous paddle Soft tissue bulk often requiring a second free flap
Scapular Flaps
In 1978, Saijo was 1st to describe the scapular fasciocutaneous flap anatomy based on the circumflex scapular artery (CSA). This donor site was popularized for head and neck reconstruction by Swartz et al in 1986 Based on the subscapular artery and vein, branches of the third part of the axillary artery and vein.
Scapular Flaps
Indications: Oromandibular defects, scalp defects, Palatal / midface defects Flaps based on the subscapular arterial system Scapular/parascapular fasciocutaneous flap Scapular/parascapular osteocutaneous flap Latissimus dorsi muscle flap Latissimus dorsi musculocutaneous flap Serratus anterior muscle flap Serratus anterior musculocutaneous flap Dorsal thoracic fascia flap
Monitoring of Flaps
Signs of abnormal perfusion Arterial compromise Skin Pale, slow capillary refill; cool. Muscle Pale; no brisk bleeding; skin graft not adherent; no doppler signal. Fascia No palpable pulse; skin graft not adherent; no doppler signal. Venous compromise Skin patchy; bluish fast capillary refill; cool. Muscle Dark; dark red bleeding; skin graft not adherent. Fascia Dark; greyish, doppler signal may remain normal for a longer period
Outflow
Chemical methods
Delay in Flaps
Incise and undermine
10 to 21 day delay most common No benefit at 3 wks to 3 mos Improved blood supply
AV shunt closure Conditioning to ischemia Alignment of vessel
Delay Four facts are accepted about the delay phenomenon Surgical trauma to flap Large percentage of the neurovascular supply to the flap must be eliminated. Delay results in increased flap survival at the time of tissue transfer. Beneficial effects can last upto 6 weeks. Three theories Delay improves blood flow Depletion of vasoconstricting substances Formation of collateral and reorientation of vascular channels Stimulation of inflammatory response Release of vasodilating substance Conditions tissue to ischemia Closure of arteriovenous shunts
Fate of flap
In surviving flaps, the blood flow gradually increases if the flap is in a favorable recipient site, A fibrin layer forms with in the first 2 days. Neovascularization of the flap begins 3 to 7 days after flap transposition. Revascularization adequate for division of the flap pedicle by 7th day The return of blood flow to a flap that is ischemic due to excessive release of norepinephrine occurs in approximately 12 48 hours.
Post operative
Extrinsic
Pedicle kinking Infection Vascular thrombosis
Intraoperative
Technical errors. Design errors Poor choice of recipent vessels
Intrinsic
Distal ischemia
Releasing the sutures to relieve any tension which may be compromising the circulation Venous congestion can be relieved by elevating the flap or changing it from a dependent position Hynes (1951) designed a mechanical intermittent venous occluder device, which could be applied to the distal end of the flap Leeches Cooling Hyperbaric oxygen Dextran
References
Head & Neck Surgery- Stell & Maran Grabbs Encyclopedia of Head and Neck Reconstruction:1998 Plastic Surgery, McCarthy, Vol 5 , Tumours of Head & Neck Cancer of Face and the Mouth, Pathology and management for surgeon - Mcgregor. Basic principles of oral and maxillofacial surgery, Peterson Facial Plastic and Reconstructive surgery, Ira A Papel. 1992 Local Flaps in Facial Reconstruction, Shan Ray Baker & Neil A Swanson Maxillofacial Surgery Vol 2; P W Booth, Stephen A Schendel OCNA- 1994, August 2001 OMFSCNA- NOV 2003 AOMFSC- SEPT 2006, MARCH 2007