Local flaps
- 1. Local Flaps used in Head & Neck Reconstruction Local flaps Dr V.RAMKUMAR CONSULTANT DENTAL&FACIOMAXILLARY SURGEON REG NO:4118-TAMILNADU-INDIA(ASIA)
- 2. Principles techniques of wound closure (reconstructive ladder)
- 3. What is …… Flap: In its basic form is a tongue of tissue consisting of the entire thickness of skin and variable amount of subcutaneous tissue, which is transferred from one site to another. (McGregor)
- 4. Local / Regional flaps – Goals (Kinnerw & Jeter) 1. Adequate color match 2. Adequate thickness – avoid protrusions or deficiencies 3. Preservation of clinically perceivable sensory innervation 4. Sufficient laxity – avoid retraction or deranged function 5. Resultant suture lines of either primary or secondary defects are restricted to anatomic units and fall within natural skin lines.
- 5. Delay of Flap: surgical outlining - before actual transfer -improve circulation. (1- 2 weeks) 2 basic schools 1. Delay improves nutrient blood flow 2. Delay increases the tolerance of the cells to ischemia, allowing them to survive at a lower flow rate.
- 6. Planning in Reverse : used when a local flaps jumps over skin and in distant flaps. ( a piece of fabric to represent it the flap is taken in reverse through various stages of the mock transfer to ensure that the real flap is large enough and long enough to reach its destination without kinking or undue tension at any stage of transfer)
- 7. Classification of flaps 1. Based on movement Local flaps: Advancement (single / bipedicle, V-Y) Pivotal : Rotation Transposition Interpolation Distant flaps Direct Tube Microvascular (free)
- 8. Local Flap: skin flap taken from an area close to the wound. E.g. a wound on the lip may be repaired by a flap from the adjacent cheek. Regional Flap: skin flap is not from the adjacent area, but is from the same region of the body. E.g. a wound on the tip of nose might be repaired with a flap from the forehead.
- 9. Distant Flap: - When a flap is from a different part of the body. - Any flap taken from below the lower border of the mandible is considered a distant flap. A local flap repair is usually done in one operation, whereas regional and distant flaps need two or more operations.
- 10. Free Flap: This is a distant flap, but the whole procedure is done in one stage by repairing the donor and recipient blood vessels by microsurgery.
- 11. 2. Based on blood supply: Axial Random Daniel (1973) blood supply to skin: Musculocutaneous arteries random arteries myocutaneous Septocutaneous arteries fasciocutaneous arterial Septocutaneous arteries
- 12. Musculocutaneous system: Vascular system penetrating the underlying muscles and then continues to supply the skin. Random cutaneous: it is composed of skin and subcutaneous fat with multiple musculocutaneous arteries at the base. Myocutaneous flap: it is composed of skin, subcutaneous fat and muscle with its blood supply coming from muscular arteries plus numerous terminal musculocutaneous arteries.
- 13. Septocutaneous system: vascular system reaching the skin through septa between muscles. (groin & DP flaps)
- 14. 3. Based on composition Skin (cutaneous) Visceral ( colon, omentum) Muscle Mucosal Composite Fasciocutaneous Myocutaneous Osseocutaneous Tendocutaneous Sensory/innervated flaps Osseo-myo-cutaneous
- 15. Based on vascular pedicle types In muscles Mathes and Nahai (1979) Type I: one vascular pedicle Type II: dominant pedicle (s) + minor pedicles Type III: two dominant pedicles Type IV: Segmental vascular pedicles Type V: dominant pedicle + secondary segmental pedicles
- 16. Areas of skin availability exploited most commonly for facial local flap transfer Palpation & PINCH Test
- 17. Advancement flaps flap moves in a straight path without any lateral movement into the primary defect. (Burrows Triangle’s) sites – forehead, brow, cheek. Single advancement flap: movement is entirely in one direction.
- 18. Bilateral advancement flap: When large tissue is required. Same technique & principle. used: forehead, mustache area and posterior neck.
- 19. A to T flap: variant of bilateral advancement flap Useful for defects at the periphery of the face around the nasal ala and upper lip dog–ear almost always forms Disadvantages: number of scars- created with the three limbs and Burow’s triangle and with the three point closure
- 20. V-y advancement flap: (Herbert flap) A V shaped flap is moved into a defect with primary closure of the donor area leaving a final Y shaped suture line. It is pedicled from the underlying subcutaneous tissue rather than the surrounding skin. Ideal for Lesion in the cheek and alar base
- 21. Burow’s triangular flap Variation of advancement flap cover those areas on the face where there are anatomical structures on one side of the defect that should not be pulled or stretched. repair of upper lip or over the lateral eyebrow, Point C moves to point B & point D moves to point F
- 22. Panthographic expansion: variation of the advancement instead of the flap being advanced as a rectangle, the limbs of the flap are designed at 120º with back cuts at the bottom so that it looks like an inverted tumbler. The flap is then advanced so that the donor site closes primarily. This technique is particularly useful on the cheek and neck.
- 23. Pivot flaps: Derives its name from the pivot point at the base of the flap as well as its arc of rotation . When flap moves laterally into the primary defect - transposition flap when it is rotated into the defect - rotation flap isosceles triangle- triangulation of the defect
- 24. Pivot point Is the axis around which the transfer takes place. Flap is designed so that the distance from the pivot point to each part of the flap before transfer is atleast equal to the distance to be expected after transfer pivot point is on the side of the flap away from the direction of movement of the flap.
- 25. Rotation flaps: it is semicircular flap that rotates about a pivot point to fill the defect. Place the arc closest to the defect higher than the defect itself, to reach the most distal point of the defect Should be 5-8 times the width of the defect
- 26. Simple rotation flap Ideally suited on a convex surface cheek Submandibular area
- 28. Transposition flaps Classic form - a rectangle or near square which is raised and moved laterally into a triangular defect In a correctly designed flap, the distance from the pivot point to A equals the distance to B and the transfer is carried without tension sites of choice retroauricular area submandibular area perioral area for upper and lower lip reconstructions. scalp A B
- 29. not to rotate more than 90º More acute –less dog ear
- 31. Methods for correction of “dog ear”
- 32. Limberg’s flap: combination of flap rotation and transposition BD=DE=EF EF at angle of 60º & Parallel to one side Disadvantages: Excess tension Anatomic landmark displacement because the tissue used to resurface the rhomboid defect is borrowed from single area. Rotation pucker at Point C Best in temple region between the eyebrows and anterior hair line
- 33. Limberg’s flap
- 34. Dufourmental flap: variation of a rhomboid flap Need not convert into 60º rhomboid Such flaps are designed for closure of square & rectangular defects. Adv: less closure tension Disadv: rotation puckering at point C
- 35. Double ‘Z’ rhomboid flap: by Cuono Advantage over Limberg flap: Excessive tension is reduced by using two flaps anatomic landmark displacement in minimized because tissue used to resurface the rhomboid defect is borrowed from two areas. Rotation pucker seen with Limberg flap is avoided and the resultant scar forms an elongated ‘Z’ plasty.
- 36. Bilobed flap: First by Esser in 1918 popularized by Zimany reconstruct nasal and facial defects and even full thickness cheek defects. Tension free closure of original and secondary defects. 90º is the optimal angle between the first and second flap Maximum distortion occurs around the flap bases and the second donor lobe closure sites Disadvantages: Rotation pucker
- 37. ‘ S’ plasty: Schrudder First by Szymanowski modification of transposition flap Difference between transposition and S- plasty Proximity of the flap base to the defect. It is positioned tangential to the wound margin leaving a ‘V’ shaped flap between them. Intermediate flap created between the flap and the defect.
- 38. 60 degree between the flap and the defect will avoid ‘dog ear’ 1/5th to 1/6th higher ½ or ¾ the defect width
- 39. Interpolation flaps: An interpolation flap is from a nearby, but not immediately adjacent donor Site and transposed either above or below the intervening skin to the Recipient defect Types: Cutaneous: requires two stage procedure but more reliable Subcutaneous Island Ex: Median forehead flap Nasolabial flap
- 40. LOCAL FLAPS Buccal fat flap / Syssarcosis : Masticatory space average volume of the fat is 9.6ml (8.4 to 11.9) cover defects of up to 4cm blood supply from branches of facial, transverse facial and internal maxillary arteries. epithelization within 2-3 wks
- 41. Uses: Oro-antral & oro-nasal communications reconstruction of ablative defects of the maxilla and cheek, hard and soft palate, retro-molar and pterygo-mandibular regions, as An interpositional graft in OSMF Advantages: Easy Donor site complications rare Disadvantages: Facial asymmetry is a possible complication
- 42. Buccal Pad Fat
- 43. Buccal pad of fat
- 44. Tongue flaps First by Gersuny Eiselberg popularized in 1901 Blood supply: lingual artery advantages: reliance on an excellent blood supply low morbidity Can be used in irradiated patients Used to cover defects in cheek, floor of the mouth, soft palate and hard palate, alveolus, oroantral fistulas and vermillion and lip reconstruction
- 45. Classification of tongue flaps: Flaps from dorsum of tongue Posteriorly based dorsal tongue flap Anteriorly based dorsal tongue flap Transverse based dorsal tongue flap Flaps from lingual tip Perimeter flap Unipedicle and bipedicle Dorsoventrally disposed flaps Flaps from ventral surface of tongue
- 46. Posteriorly based dorsal tongue flap Uses: To repair a defect of moderate size in the retromolar trigone, tonsillar fossa of the ipsilateral side To cover a posterior mucosal defect in cheek minimum thickness of the flap should be 8mm
- 48. Anteriorly based dorsal tongue flap Uses: to repair defects in the anterior cheek, lip, anterior floor of the mouth, anterolateral floor of the mouth and palate
- 49. Transverse based dorsal tongue flap to repair anterior floor of the mouth and lower lip
- 50. Perimeter flap unipedicled or bipedicled for repair of vermillion border of either lip Upper and lower lip reconstruction
- 51. Dorsoventrally disposed flaps Flaps reflected ventrally on a anterior base: Used for lining in lower lip reconstruction Flaps reflected dorsally on a posterior base. Used for lining in upper lip reconstruction Flaps from ventral surface of tongue cover defect on anterior floor of the mouth
- 52. Nasolabial flap: Sushruta in 600 BC popularized by Esser and Ganzer reconstruction of facial skin defects of the upper lip, nose and cheek following extirpation of skin cancers. superiorly based nasolabial flap- closure of the oro antral fistulae. The bilateral inferiorly based nasolabial flap has utility in the reconstruction of the anterior defects of the floor of the mouth. Defect in the anterior face, nose and upper lip, floor of the mouth OAF
- 53. Adv: It provides thin, local tissue for coverage of small defects. It may be also be deepitheliazed at the base for one stage procedure. Disadv: Limited donor tissue Facial scarring Second surgical procedure might me needed Difficult to use in the floor of the mouth if the patient is not edentulous Transfer of beard in male patients
- 54. Inferiorly based Superiorly based For reconstruction in the anterior floor of the mouth
- 56. Forehead flap: McGregor. Blood supply superficial temporal artery and posterior auricular artery. Hemiforehead flap or total forehead flap
- 57. Long enough to reach any part of the ipsilateral face
- 58. Butterfly shape is used to repair of defects of the posterior tongue to allow Mobility, the other wing closing the defect in the cheek. The distal extension provides cover and seal. The narrow flap repairs central and alveolar defects The repair following total glossectomy should be in the form of a shield
- 59. Advantages: Near to the oral cavity Hairless Tissue is firm and holds sutures well Excellent blood supply Thin and suitable for intraoral lining Disadvantages: Noticeable donor defect Need to divide the pedicle and close the oral fistula at a second operation Bleeding Flap necrosis can occur
- 60. Glabellar Flap - Axial pattern flap - Based on supra-trochlear artery uses: -nasal reconstruction -cheek defects disadvantages: -donor site morbidity -limited amount of tissue
- 61. Temporalis flap: Golovine in 1898 Type III Temporoparietal fascia - superficial temporal artery Temporalis muscle - anterior and posterior deep temporal br. Max. art
- 62. Uses: Useful for obliterating skull base, maxillofacial and orbital defects. It is also used in cranialisation procedure Reanimation of the face Used to close CSF leaks & dural tears secondary to trauma & cancer surgeries. Used for midface augmentation for hypoplasia secondary to trauma & congenital anomalies.
- 63. Advantages: Close to the oral cavity Good arc of rotation Reliable and well tolerated Thin flap Problems from the loss of muscle function are minimal Disadvantages: Cosmetic deformity in donor site Traction paresis of Facial nerve
- 64. Temporalis flap
- 65. Narayanan bilobed flap Uses: Useful for obliterating skull base, maxillofacial and orbital defects. It is also used in cranialisation procedure Reanimation of the face Advantages: Close to the oral cavity Good arc of rotation Reliable and well tolerated Thin flap Disadvantages: Cosmetic deformity in donor site Facial nerve paresis
- 66. Cervicofacial flap: •Ideal for Aged patient •Defects of 4x4 to 6x7 cm. •based laterally •It involves lower cheek and upper neck •useful, well tolerated flap for closing cheek defects with or without an associated neck dissection. •maxillary artery, vein and their branches-blood supply
- 67. Intra –oral flaps Palatal flaps (Ashley) Buccal advancement flaps -Rehrman’s -Moczair buccal sliding trapezoidal flap. (is slid to use the papilla of the adjacent tooth to rotate into the defect)
- 69. Bipedicled flap
- 72. Thank U