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Local and Regional Flaps In

Head and Neck Cancer



INDIAN DENTAL ACADEMY

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PECTORALIS MAJOR MYOCUTANEOUS FLAP
TEMPORALIS FLAP
STERNOCLIEDOMASTOID FLAP
MASSETER FLAP
DELTOPECTORAL FLAP
TRAPEZIUS FLAP
LATISSIMUS DORSI FLAP
CONCLUSION
REFFERENCES

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PECTORALIS MAJOR MYOCUTANEOUS FLAP
Ariyan 1970
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Anatomy
Origin
Vessels
Function

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large fan-shaped muscle that covers much of the
anterior thoracic wall. To a variable extent, it overlies
the pectoralis minor, subclavius, serratus anterior,
and intercostal muscles.
origins -three portions.
1 cephalad -medial third of the clavicle.
2 central,-sternocostal-sternum &cartilages of
the first six ribs
3 aponeurosis of the external oblique, is
variable in size.
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vessels

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PECTORALIS MAJOR MYOCUTANEOUS FLAP
Superior and lateral
thoracic arteries -
additional pedicles
Overlying skin
additionally supplied by
intercostal perforators
3 subunits each with its
own vascular & motor
supply
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functions
adduct and medially rotate the arm
It becomes active in internal rotation of the arm only
when working against resistance.
upper muscle fibers help to flex the arm to the
horizontal level; the lower fibers assist in arm
extension.
Contraction helps to extend the arm to the individual's
side, but it plays no role in hyperextension beyond that
point.
loss of the dynamic activity of the pectoralis major
appears to be well tolerated
Much of the adductor activity is compensated for by
the powerful, latissimus dorsi muscle, which makes up
the posterior axillary fold.
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
Types
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
ADVANTAGES
One stage
Generous portion of skin & soft tissue(400cm2)
Consistent blood supply highly reliable
Adequate arc of rotation for facial defects
Donor site can be closed primarily
Two skin islands on the same muscle paddle
Protects the carotid artery
Technically, the flap is ease to elevate

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PECTORALIS MAJOR MYOCUTANEOUS FLAP
DISADVANTAGES
Arc of rotation limited for oromaxillary defects
It can be too bulky
There is distortion of symmetry at the donor
site
Shoulder function is impaired
Distal skin of the flap is not reliable

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Methods to Improve the Arc of
Rotation
Ariyan's -incorporated a long segment of skin that
extended from the clavicle to the caudal extent of
the muscle.
Distal skin paddle placed over the caudal extent of
the muscle
Maghee- skin paddle extended over rectus
abdominus
Lee and Lore -removal of a segment of the clavicle
to gain up to 3 cm of length.
Wilson et al. -tunneling the muscle pedicle deep to
the clavicle in a subperiosteal plane .

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Methods to Deal with Excessive Bulk
Sharzer et al. - harvesting a vertically
oriented "parasternal skin paddle that
extended across the sternum to the opposite
internal mammary perforators.
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Murakami et al. -eliminating the skin paddle
entirely.
two-stage procedure
a split-thickness skin graft was placed
over the muscle 3 to 4 weeks later harvest
the muscle-skin graft unit.
Maintain nerve supply or not


Methods to Deal with Excessive Bulk
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Methods to Achieve Two Epithelial Surfaces for
Reconstruction of Compound Defects
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Gemini flaps
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POTENTIAL PITFALLS
Incidence of total flap necrosis was reported
to be 1.0%, 1.5%, 3%, and 7%.
Partial flap necrosis- 14%-30%
Pedicle compression
In male patients may lead to problems with
excessive hair growth in the oral cavity or
pharynx

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TEMPORALIS MUSCLE FLAP
Golovine 1898 - orbital
exenteration
Gilles - reanimation of
paralyzed face
Fan - shaped muscle
arising from temporal fossa
& the superior temporal line
The muscle is bipennate,
with an additional superficial
origin from the temporalis
fascia


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TEMPORALIS MUSCLE FLAP
Main blood supply - anterior &
posterior deep temporal artery
Anterior deep temporal artery &
Posterior deep temporal enter the
muscle approximately 1cm
anterior & 1.7cm posterior to
coronoid process respectively
This vascular anatomy allows
splitting of muscle into anterior &
posterior flap


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TEMPORALIS MUSCLE FLAP
Mobilized flap consists of
fascia, muscle, & pericranium
Two distinct fascial layers, the
superficial & deep temporal
fascia
Superficial temporal fascia is a
thin, highly vascular layer of
moderately dense Connective
tissue
The absence of vascularity
between this two layers
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TEMPORALIS MUSCLE FLAP
Hemicoronal flap provides excellent access
Incision ends above the superior temporal line
Dissections proceeds down to the deep temporal fascia until the
entire muscle is exposed
Dissection in this plane protects the temporal branch of facial nerve
Reflection of the muscle of the temporal bone should be performed
in a strict subperiosteal plane
Rotation can be improved by dividing ZA & base of the coronoid
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TEMPORALIS MUSCLE FLAP
If the muscle is split in coronal plane posterior
portion of muscle is transposed anteriorly
Donor site - secondarily reconstructed by
alloplastic implants
Alopecia avoided by careful placement of
coronal incision parallel to hair shaft
Bradley & Brock hank - flap does not require
skin grafting & rapid mucolization occur


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It is relatively short (3 to 5 cm) and thin (2 to
3mm) and has a contraction capability of 1 to
1.5 cm
flap has a rotational radius of 8 cm
it is possible to cover defects of the mastoid,
cheek, pharynx, and palate.
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TEMPORALIS MUSCLE FLAP
ADVANTAGES
Ease of elevation
Reliable blood supply
Proximity
Camouflage of incision
with in hair line
Muscle support graft &
alloplast well
DISADVANTAGES
Sensory disturbances
Potential facial nerve
injury
Temporal hallowing

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STERNOCLEDOMASTOID
MYOCUTANEOUS FLAP
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
Long strap muscle
Muscular origin Tendinous
origin
Insertion
Branch of spinal accessory
nerve
Dominant blood supply
branches of occipital artery
& its draining vein
Middle third of the muscle
Inferior third of the muscle
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
REPORTED INDICATIONS
Provision of epithelial lining for mucosal
reconstruction
Closure of orocutaneous fistulas
Release of scar contracture in submandibular &
angle region
Provision of additional vascularized tissue around a
bone graft when the tissue bed has been heavily
irradiated
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
Superior blood supply
6 x 8 cm paddle of skin
Skin paddle should be kept
overlying the muscle above
the level of clavicle
Skin paddle is tacked down
to the muscle fascia
Muscle dissected &
elevated by incising the
fascia
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
Inferior blood supply
Branches of superior
thyroid artery are noted
to enter the anterior
aspect of muscle at the
level of carotid
bifurcation
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MASSETER FLAP
Lexer and Eden in 1911
Short, flat, thick quadrangular
muscle
Superior belly - downwards &
backwards
Deep belly - vertically & slightly
forwards
Massetric nerve & artery
Hemimandiblectemy. suturing
the masseter to the hyoid bone
to assist in laryngeal elevation
during swallowing.
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Does not restore emotional mimetic
movements
Muscle eliminated in extensive ablative
surgery
Limited in size & volume
Does not have skin paddle
Restricted arc of rotation

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DELTOPECTORAL FLAP
First axial pattern skin flap
The base of flap is parasternal includes the first three
or four perforating branches of internal mammary
artery, second perforator is largest
Artery as rich anastomosis, accompanied by Vein
It extend laterally over the upper chest at the level of
clavicle on to the deltoid muscle & shoulder
Width 8 - 12 cm, Length 18 - 22 cm
reverse of deltopectoral flap - Thoracoacromial flap
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DELTOPECTORAL FLAP
ADVANTAGES
High biologic
dependability
Readily accessible
Arc of rotation 45 - 135
May be used in male,
female & children
Hairless skin

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DELTOPECTORAL FLAP
DISADVANTAGES
Donor site require skin grafting
Moderate amount of scarring & deformity is
unacceptable in women
Physiologic disadvantage in malnourished patient or
post operative irradiation
Flap should not be used if previous scarring on
donor area
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DELTOPECTORAL FLAP
Superior incision is placed just below the clavicle
inferior one run parallel to it
Flap raised from lateral extent medially
Incision is carried down through the pectoral fascia
Plane of dissection is sub fascial
Dissection proceeds up to 2 cm of lateral border of
sternum
Back cut on medial aspect - improve the flap rotation
90% success rate

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PLATYSMA FLAP
Extremely thin band like & variable muscle
forming superficial boundary of neck
Arises from clavicle superiorly continues with
the attachment to the mandible
Submental branch of the facial artery
Flap size
Muscle - 10 x 10 cm to 10 x 20 cm
skin paddle - 3 x 6 cm to 6 x 20 cm

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PLATYSMA FLAP
ADVANTAGES
Proximity & Regionality
Thin & delicate
Reliable when vascu- -
lar criteria adhered
Arc of rotation - 180
No donor site disability

DISADVANTAGES
Lack of bulk
Hair bearing in male
Reliability 85%
Complication like skin
loss & fistula

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TRAPEZIUS FLAP
Mutter 1842
Originally described as
superior based cutaneous
flap
Flat & triangular and cover
the superoposterior aspect of
the neck & shoulder
Dominant pedicle, the
transverse cervical artery
Functions to rotate the
scapula & to elevate, rotate &
adduct upper arm
10 x 20 cm in size


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TRAPEZIUS FLAP
Lateral positioning of patient
to elevate flap
Ideally suited for radical
parotidectomy
Limited to small defects in
oral cavity

Generous amount of soft
tissue & large portion of
skin island
90 95 % of success

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TRAPEZIUS FLAP
ADVANTAGES
Flap is versatile
Regionality of flap
Strong vascular security
Supplies considerable bulk
Arc of rotation 90 180 degree
One stage procedure
Minimum deficit at donor area
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TRAPEZIUS FLAP
DISADVANTAGES
Venous system difficult to preserve
Vascular supply in general difficult to preserve
Can present with excessive bulk
Cannot be easily tubed
Moderate shoulder drop postoperatively
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LATISSIMUS DORSI MYOCUTANEOUS FLAP
Distant flap, provides largest possible skin paddle,
involves the most complex donor site dissection,
and arc of rotation extremely versatile
Donor site skin paddle measures 40 by 25 cm & still
allows primary closure
The latissimus dorsi is very broad muscle of the
back with a fascial origin from T7 to T12, from the
lumbar & sacral vertebrae, from posterior crest of
the ilium & also minor origination from the last four
ribs
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LATISSIMUS DORSI MYOCUTANEOUS FLAP
Insertion on the intertubercular groove of the
humerus
Extend, adduct, & medially rotate the arm
Major pedicle is thoracodorsal artery, a
terminal branch of the subscapular artery
Perforators enter the muscle medially along
the spine secondary supply

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LATISSIMUS DORSI MYOCUTANEOUS FLAP
ADVANTAGES
Size largest flap in
the body
Flap location
Arc of rotation - 180
Large, reliable
unicentric
neurovascular pedicle
Donor area
90% success rate

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LATISSIMUS DORSI MYOCUTANEOUS FLAP
DISADVANTAGES
Repositioning of the patient
Skin paddle is thick & has strong attachment
to the underlying muscle
Considerable bulk postoperative sagging &
pendulosity
Donor area may need skin graft
It is in competition with other very suitable
flaps
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conclusion
Success in reconstruction of the craniofacial
region by local and regional flaps requires
knowledge ,careful preop planning, skilled
tecqniques, and meticulous care after
operation
The goal is to return the patient as closely as
possible to the preop aesthetic and functional
level
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Thank you
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REFERENCES
Oral and Maxillofacial surgery clinics of North America November
1993
Flaps in Head and Neck Surgery 1989 John Conley and Carl Patow
Oral cancer Jatin P shah
GRABBS Encyclopedia of flaps Volume 1
Maxillofacial Surgery Vol. 1 Peter Ward Booth
Atlas of Regional and Free Flaps for head and neck reconstruction
Mark L. Urken
Plastic surgery McCarthy.vol-1
Fonseca OMFS Vol-7
Mastery in plastic and reconstructive surgery-Mimis Cohen
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REFERENCES
Oral and Maxillofacial surgery clinics of North
America NOVEMBER 1993
Flaps in Head and Neck Surgery 1989 John
Conley and Carl Patow
Oral cancer Jatin P shah
GRABBS Encyclopedia of flaps
Maxillofacial Surgery Vol. 1 Peter Ward Booth
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Defect PMMC VERTICAL
TREPIZIUS
PLATYSAMA DELTO
PECTROL
ORAL
MUCOSA
mnd intact
Centrl mnd
defects
Lateral mnd
- male
- female



1
st



1
st

2
nd







2
nd
1st



1
st


EXT FACIAL
DEFECT
Mand intact
Mand defect


3
rd
2nd


2
nd

1
st



1
st
2nd
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