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GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY
SEMINAR ON
Flaps for reconstruction



Presented by-
Dr. Sambhav. K.Vora
III M.D.S
Contents
Flaps for maxillofacial reconstruction
1
I. Introduction
II. Classification
III. Local flaps
IV. Regional flaps
V. Distant flaps
VI. Composite flaps
VII. Free flaps
VIII. Reconstruction of specific regions
IX. Conclusion
X. References
Introduction
Surgical practice routinely involves excision of body parts for
treatment of pathologic lesions, producing defects of varying sizes.
Defects may also be caused by other factors such as trauma, burns etc.
Reconstruction of the lost body part is important in many respects. They
include provision for cover, restoration of function and aesthetic
rehabilitation.
Flaps for maxillofacial reconstruction

! flap is defined as a tissue that is either transferred or transplanted


"ith intact circulation. #hen vital structures are exposed in a complex
"ound or "hen reconstruction has significant functional or aesthetic
conse$uences, a flap is generall y re$uired.
Reconstructive ladder
! defect may be managed by a "i de variety of methods. The first
ob%ective in anal ysing a reconstructive problem is a correct diagnosis. The
extent and type of missing tissue are assessed in order to formulate a plan
for correction and reconstruction. In planni ng for management of defects
of s&in, mucous membrane and underl yi ng structures, it "oul d be prudent
to follo" "hat is &no"n as the 'reconstructive ladder(.
Small defects produced by burns or ulcerations may be allo"ed to
epithelise primaril y. !nother option is closure by direct suturing "hen the
defect is small enough and is other"i se suitable. #hen the defect is too
large, the potential methods of reconstruction are the use of a free s&in
graft, a local s&in flap, a distant s&in flap, a composite flap or a free flap.
)lanni ng involves consideration of the simplest alternative follo"ed
progressivel y by the more complex, advancing up the ladder to the most
complex. )rogression from primary closure to s&in grafts to local flaps to
distant flaps and finally to microvascular free tissue transfers provides a
set of options that can be applied to any reconstructive situation.
!llo" "ound to heal by secondary intention
Direct tissue closure
S&in graft
*ocal tissue transfers
Distant tissue transfers
Flaps for maxillofacial reconstruction
+
,ree tissue transfers.
-eneral considerations
! s&in flap in its basic form is a tongue of tissue consisting of the
entire thic&ness of the s&in plus a viable 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, "hi ch is either closed by direct suture or covered by a
s&in graft.
!n ideal flap should satisfy the follo"i ng goals
1. provisions of a suitable colour match to the surrounding s&in of the
recipient bed.
. assurance of a compatible thic&ness
+. retention, or provision of recovery, of clinicall y perceptible sensory
innervation
.. attainment of sufficient laxity and tissue ablation such that mobile
margins, as in an eyeli d or lip, are spared retraction and deranged
function
/. assurance that the resultant suture lines of either primary or
secondary defects are restricted to anatomic units and fall "i thin
natural s&in lines.
0. assurance that the reservoir from "hi ch the flap is mobilized is
sufficiently lax to allo" closure of the donor site resultant defect.
The flap may be raised from the tissues immediatel y ad%oini ng, or
very close to, the primary defect, in "hich case it is called a
local/regional la!1 alternatively it may involve the movement of tissue at
a distance from the primary defect and is then called a "i#$an$ la!.
#hen a local flap is transferred, movement ta&es place in the form
of advancement, rotation, transposition or interpolation. Some flaps, at the
time of transfer, are reattached to the body over their entire area, and the
proximal end of such a flap, "here it remains continuous "ith the ad%acent
s&in, is referred to as its %a#e.
#ith other flaps, the distal segment alone of the flap is inserted into
the defect, its central segment and base remaining unattached. The base
is then called the !e"icle and the central segment is referred to as the
%ri"ge #eg&en$. These t"o, pedicle and bridge segment, act as the
Flaps for maxillofacial reconstruction
.
carrier and provide the channel for the blood suppl y of the distal segment.
2nce the distal segment establishes at the ne" site, "hich usuall y ta&es
three "ee&s, the bridge segment is divided and either returned to its
original site or discarded depending on the local situation. Insetting of the
distal segment is then completed. In order to inset the distal segment, it is
necessary to undercut its margin for a short distance.
#hile the pedicle of a flap usuall y consists of s&in and
subcutaneous tissue, it is occasionall y reduced to its subcutaneous
component, the distal segment alone, as an i#lan" la!, retaining s&in as
"el l as subcutaneous tissue.
#hen a distant flap is transferred, it is raised prior to transfer either
single !e"icle" as a relativel y long narro" tongue of tissue, or %i!e"icle"
as a strap of tissue "ith a pedicle at each end. Transfer to its destination
is carried out in one of t"o "ays 3
a. If the flap is relativel y near its ultimate destination, it may be s"ung
on its pedicle, follo"i ng division of one pedicle if it "as bipedicled, and
"altzed to its destination.
b. If it is at a greater distance from its destination, the flap is attached
instead to a carrier, usually the "rist, on "hich it is conveyed to its
destination.
4ost local flaps have an axis around "hich they rotate or are
transposed in the process of being transferred, and this is called the 'pivot
point( of the flap. #hen it is at all possible, the bridge segment of any flap
is 'tubed( in order to eliminate unnecessary ra" surface and to reduce
sepsis.
If it is felt that the blood suppl y of a flap "ould not be ade$uate for
its survival if it "ere transferred straighta"ay, the circulation can be
rendered more efficient by surgically outlining the flap. Such outlini ng is
called 'delay( . The term is also used for the procedure of surgicall y
augmenting the blood suppl y of the flap.
!ccording to 4c-regor and 4organ 5167+8, t"o distinct types of
flaps can be distinguished according to their vascular characteristics and
behaviour, each "ith a distinct geometry imposed by its vascular anatomy.
Axial pattern flaps
This type of flaps is constructed around a pre9existing anatomicall y
recognized arteriovenous system. The vascular system running along its
Flaps for maxillofacial reconstruction
/
length ma&es it possible to construct a flap at least as long as the territory
of its axial artery "ith minimal regard for consideration of its breadth. This
factor also ma&es the flap more robust and better able to cope "ith any
adverse circumstances that may arise.
Random pattern flaps
! random pattern flap has no pre9existing bias in its vascular
pattern, and this lac& places stringent limits on its dimensions, particularly
in the ratio bet"een its length and breadth. The degree of stringency
placed on the dimensions of a random flap depends to a considerable
extent on the richness of its subdermal vascular pattern.
:lassification
There are a number of methods of classifying cutaneous flaps.
,laps may be classified by the arrangement of their blood supply 5random
vs. axial8, by configuration 5rhomboid, bilobed, elliptical etc.8, location
5local, regional and distant8 ands by the method of transferring the flap
5rotation, advancement, transposition etc.8
*ocal flaps
The local flap consists of tissue immediatel y ad%oini ng the defect to
be closed. It consists of s&in and subcutaneous tissue. The local tissue
may be dissected into a flap and mobilised to the defect by advancement,
rotation, transposition or interpolation.
Advancement flaps
The advancement principl e ma&es use of a linear configuration flap,
raised and advanced to cover a rectangular primary defect "hi ch ad%oins
its distal end. Tissue transfer is achieved by moving the flap and its
pedicle in a single vector. !dvancement flaps may be categorized as
single9pedicled, bipedicled or ;9<.
Single-pedicle flaps
Single9pedicle flaps are created by parallel incisions, "hich allo" a
sliding movement of the tissue in a single vector to"ards a defect. The
movement is in one direction, and the flap advances directly on the defect.
The flap is developed ad%acent to the defect and one border of the defect
Flaps for maxillofacial reconstruction
0
becomes a border of the flap. Repair "ith an advancement flap involves
both primary and secondary tissue movement. :omplete undermining of
the advancement flaps as "ell as of s&in and soft tissue around the
pedicle is important to enhance tissue movement. =ilateral advancement
flaps are fre$uentl y combined to close various defects, resulting in '>( or
'T( shaped repairs. It may also be used as an 'island( advancement flap.
It is virtually onl y in the face that the necessary s&in laxity exists to
allo" advancement flaps to be used successfully. It "or&s "el l in the
repair of the defects of foreheads, helical rims, upper and lo"er lips, and
medial chee&. 4ucosal advancement flaps are also used for vermilion
reconstruction.
The main dra"bac& of this type of flaps is that a standing cutaneous
deformity is created.
Bipedicle flaps
=ipedicle advancement flaps are used primarily for repair of large
defects of the scalp. The flap is designed ad%acent to the defect, and
advanced to the defect at right angles to the linear axis of the flap. This
leaves, apart from the dog9ear deformity, a secondary defect "hich must
be repaired "ith a split s&in graft. So, these flaps are seldom used no"9a9
days in the reconstruction of head and nec&.
V- ad!ancement flaps
In the case of ;9< advancement flaps, a ;9shaped flap is pushed
to"ard the defect. Thus the flap is moved into the recipient site "ithout
any "ound closure tension. The secondary triangular donor defect is then
repaired "ith "ound closure tension by advancing the t"o edges of the
remaining "ound to"ards each other. Thus the "ound closure suture line
assumes a '<( shape, "ith the common limb of the '<( representing the
suture line resulting from closure of the secondary defect.
;9< advancement is useful "hen a structure or a region re$uires
lengthening or release from a contracted state. It is particularl y effective in
lengthening the columella in the repair of cleft lip nasal deformities. It is
also helpful in releasing contracted scars that are distorting ad%acent
structures as the eyel id or vermilion.
Flaps for maxillofacial reconstruction
7
Pivotal flaps
There are three types of pivotal flaps 3 rotation, transposition and
interpolation flaps. !ll pivotal flaps are moved to"ards the defect by
rotating the base of the flap around a pivotal %oint. The greater the degree
of pivot, the shorter the effective length of the flap. This is because the
pivotal point is fixed in position, and the base of the flap is restricted in
pivoting around this point because of the development of redundant tissue
at the base &no"n as 'standing cutaneous deformity 5dog ear8. )ivotal
flaps must be designed to account for this reduction in effective length as
they move around their point of pivot.
Rotation flaps
Rotation flaps are pivotal flaps that have a curvilinear configuration.
Since the flap is being rotated to its destination, its ideal form is as the
large arc of a circle of "hich the triangular primary defect is a small arc,
"ith the flap and defect together ma&ing a half circle. They are designed
immediatel y ad%acent to the defect and are best used to close triangular
defects. They are usually random in their vascularity but depending on the
position of the base of the flap, they may be axial. =ecause the flap has a
broad base, it vascularity tends to be reliabl e. Rotation flaps are useful in
repairing medial chee& defects located near the naso9facial sulcus.
*arge rotational flaps are particularl y useful for reconstruction of
sizable posterior chee& and upper nec& defects. Incisions for the flaps are
placed in a pre9auricular crease, and can extend for some distance along
the anterior border of the trapezius muscle to facilitate rotation of upper
cervical s&in to"ard the area of the posterior chee&. ! z9plasty at the base
of the flap facilitates closure of the secondary defect. :hin reconstruction
often can be readil y accomplished "ith rotational flaps. Smaller rotational
flaps may also be used for repair of defects located in the glabel lar area.
Scalp defects may be reconstructed "i th one or more flaps.
"ransposition flaps
In contrast to rotation flaps, "hich have a curvilinear configuration,
the transposition flaps have a straight linear axis. It can be designed in
such a "ay that one border of the defect is also a border of the flap, or
alternativel y, "ith borders that are removed from the defect "i th only the
base of the flap contiguous "i th the defect. In its 'classic( form, this flap is
Flaps for maxillofacial reconstruction
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a rectangle, usually near s$uare, "hich is raised and moved laterally into
the primary defect, previously triangulated in preparation for it. Such a
transfer leaves a secondary triangular defect "hich is at least e$ual in
area to the primary defect.
Transposition is the most common method of moving local flaps into
s&in defects of the head and nec&. They can be elevated in a multitude of
sizes, shapes and orientation and usually are random cutaneous flaps, but
may occasionall y be compound. It is a reconstruction option for small and
medium9sized defects. Its main advantage is that the flap can be designed
some distance a"ay from the defect, and the surgeon can select areas of
s&in elasticity and redundancy. The chief dra"bac& is the secondary
cosmetic deformity, but this can be hidden in hear9bearing areas.
Interpolation flaps
The interpolation flap, though it is a pivotal flap "ith a linear
configuration, differs from transposition flaps in that its base is located at
some distance from the defect. Thus the pedicle must pass over or under
intervening tissue, and must subse$uently be detached in a second
procedure. This is the greatest disadvantage of this flap. 2n occasion, the
pedicle can be de9epithelised or reduced to subcutaneous tissue only and
brought under the intervening s&in, to allo" a single9stage repair.
! common interpolation flap is the mid9forehead flap, "hich includes
the median and paramedian flap. They are highl y effective in midface
reconstruction because of their excel lent vascularity and superb s&in
colour and texture match. !part from nasal defects, defects of the medial
canthal region, upper and lo"er eyeli ds, medial chee&, melolabial region
and upper lip may be repaired "ith mid9forehead flaps. They are thin and
viable flaps and can be easily contoured.
R#om$oid flaps
,irst described by *imberg 516008 and named after him 5*imberg
flap8, the distinctive feature of the rhomboid flap is the precision of its
design, "hich involved both the shape of the defect and the size and
shape of the flap used to fill it. The defect is made in the form of a
rhombus 5 8 in such a "ay that its shorter diagonal e$uals the four
sides in length.
The flap is outlined by extending the line of the shorter diagonal, for
a distance e$ual to its length. ,rom the extremity of this line, again e$ual
Flaps for maxillofacial reconstruction
6
in length to the shorter diagonal, is dra"n at an angle 0@A to it. In this "ay,
a flap ad%oini ng the defect is enclosed, "i th a size and shape similar to the
rhomboid of the defect. =oth the lines extended from the rhombus for flap
design can be directed in either directions so that the flap can be placed in
one or either side of the defect, "ith a further possibil ity of designing t"o
flaps on each side, ma&ing four potential flaps in all. In practice, the side
and direction of the flap are determined by the tissue available to be
included in the flap.
The flap is raised and s"ung into the defect. This leaves a
secondary defect, "hi ch is then closed by direct suture. The area "here
the rhomboid flap has its greatest value is the temple, bet"een the
eyebro"s and the anterior hairline, and the appropriate direction is along
the 'cro"(s foot( "rin&l e lines lateral to the outer canthus.
Bilo$ed flaps
In some situations, a defect "hi ch, in other respects is suitable for
local flap reconstruction, is some"hat distant from an area of availabil ity
or lies at such an inappropriate angle that a suitable flap cannot be
designed. Bimany in 16/+ described a 'bilobed( flap for such situations.
The overall outline of the defect plus the flap is a 'cloverleaf( 3 one
of the outer leaves being the defect, other t"o the bilobed flap, sharing the
same pedicle. In the transfer, the central lobe of the leaf is rotated into the
primary defect. This leaves a secondary defect "hi ch, in turn, is filled by
the remaining cloverleaf. The tertiary defect so left is in an area of tissue
availability, and so may be closed by direct sutures.
Hinged flaps
:utaneous hinge flaps 5trapdoor, turn9in, turn9out flaps8 may be
designed in a linear or curvilinear shape "ith the pedicle based on one
border of the defect. The flap is dissected in the subcutaneous plane and
turned over on to the defect li&e the page of a boo&. The epitheli al surface
of the flap is turned do"n"ard to provide internal lining of a facial defect
that re$uires both external and internal lining surfaces. The exposed
subcutaneous surface of the hinge flap is covered by a second flap.
The vascular suppl y of a hinge flap is derived from the soft9tissue
border of the defect. !nd conse$uently they have limited and often
restricted vascularity. The dissection should proceed in such a "ay that
the base is thic&er than the distal portion of the flap. >inge flaps are
Flaps for maxillofacial reconstruction
1@
commonl y used for repair of full9thic&ness nasal defects and to close
mature sinofacial and salivary fistulae.
Flaps for maxillofacial reconstruction
11
Regional flaps
The regional flaps are local cutaneous flaps "hich involves transfer
of tissue from areas ad%acent to the defect. The commonl y used regional
flaps in head and nec& include nasolabial flaps, forehead flaps, glabel lar
flap, tongue flaps etc.
%asola$ial flap
! nasolabi al flap consists of a finger of tissue lying astride the
nasolabi al s&in crease. It can be based above or belo" 5superiorly or
inferiorl y based81 and its main use is as a transposed flap to reconstruct
defects of the side of the nose and the upper lip, occasional ly the lo"er lip
and oral cavity.
The nasolabial site is one of the most consistentl y available areas
of lax s&in. The area of s&in "hich is used as the flap and its extension
up"ards and do"n"ards varies considerabl y depending on the site, size
and shape of the defect it is designed to cover. The flap is raised as a
finger of tissue "ith its "i dth made to correspond to that of the defect.
#ithin limits, the length of the flap is not significant in vascular terms. The
secondary defect is normall y closed by direct suture.
The distribution of hair on the face and "hether hair on the flap is
desirable or undesirable "i ll determine the ultimate the ultimate details of
placing the flap. Csed for defects of the nose, the superior pedicle is
almost invariable. The lip and intra9oral defects may be repaired by either
superiorl y or inferiorl y based flaps.
! nasolabi al island flap may be designed, "hich bridges intact s&in
to reach the side of the nose. This is used to reconstruct the lo"er half of
the side of the nose, occasionall y the alar base and the margin, and rarely
the ad%oining upper lip.
Peri'alar ro$a$ion'a"(ance&en$ la!
This techni$ue, described by #ebster 516//8, addresses the
problem of asymmetry of the upper lip caused by direct closure of elliptical
defects of alar bases. It involves excision of a crescent of the s&in and
subcutaneous tissue immediately lateral to the ala of the nose and
mobilisati on of the s&in of the ad%acent nasolabial area from the underl yi ng
chee& and lip musculature. The crescentic defect is then closed directly
Flaps for maxillofacial reconstruction
1
and the effect is to rotate and advance nasolabi al s&in into the lip defect to
be closed "i thout creating asymmetry.
Fore#ead flaps
The forehead flaps transfer the s&in area from the forehead, most
often to cover a defect of the middle third of the face. The tissue
transferred can vary from a relatively small area to virtuall y the entire
forehead. The pedicles generally ma&e axial use of the superficial
temporal, supraorbital and supratrochlear vessels, entering from the
margins of the forehead. The secondary defect of a forehead flap is closed
by direct suture "hen it is small enough1 "here it is too extensive, it is
split9s&in grafted.
,laps raised from forehead are based either laterall y on the
temporal region, or inferiorl y on the supraorbital region. The flap based
laterall y uses part or all of the breadth of s&in bet"een the ear and the
outer end of the eyebro". The flaps raised "ith an inferior pedicle vary
considerabl y in design, but there are t"o basic designs 3 a straight
relativel y narro" finger li&e flap passing up"ards from the glabell ar region,
and a 'sic&le( shaped flap "hich rises in up"ard direction but curves do"n
on the scalp to run verticall y do"n"ards on the opposite side of the
forehead.
The temporal island flap, parented by the laterally based forehead
flap, is occasionall y used in the resurfacing of the malar region and also in
reconstruction of the eyebro"s.
,orehead flaps generally provide excellent contour and texture
matches in the sites to "hich they are usuall y transferred.
&la$ellar flap
The glabel lar flap acts by transferring the s&in from the glabellar
region to cover defects of the side of the nose "here it ad%oins the medial
canthus and the chee& immediately belo" the canthus. It is constructed on
the hairless area bet"een the eyebro"s and the ad%acent forehead,
pivoting around the region of the superior orbital foramen on the opposite
side from the defect, and incorporating a significant portion of the
supraorbital and supratrochlear arteriovenous systems. The flap itself is
triangular in outline "ith the apex pointing up"ards on to the forehead.
#hen it is rotated into the defect, it leaves a triangular secondary defect in
the centre of the forehead, and this is closed by direct suture.
Flaps for maxillofacial reconstruction
1+
! glabel lar island flap may be used to reconstruct the canthal area
or the ad%oining side of the nose and the chee&. Its parent flap is the finger
variant of the supraorbital flap, rather than the classical glabell ar flap. The
subcutaneous pedicle pass from the island do"n"ards to"ards the
glabel lar region.
Me"ian gla%ellar la!
This rectangular flap 5Rintala and !s&o9Selvaara, 16068, long in
relation to its "i dth, is placed verticall y in the glabell ar region. #ith its
base approximately 1 cm above the medial end of the eyebro"s, its
rectangle extends do"n over the bridge of the nose. It uses the principle
of straight advancement to redeploy the glabel lar area of s&in availabi lity,
and can be used to cover s$uare shaped defects of the upper third of the
nasal s&in in the midline. This method can be used only if the gap
bet"een the eyebro"s is "ide enough to allo" a reasonably broad flap to
be constructed.
"ongue flaps
Diselberg used tongue flaps to repair oral defects in 16@1. >o"ever,
he gave credit to -ersuny at the end of the 16
t h
century for the first use of
a tongue flap to restore oral defects. Elopp and Schurter 516/08,
=a&am%ian 5160+8 and :onley 516?8 repopularised its use in the modern
era.
The tongue flaps offer the advantage of ad%acent and similar tissue
for repair of intra9oral defects. !n excell ent axial and collateral circulation
provides for flap viabil ity. The lingual artery is the main vessel suppl yi ng
the tongue. !nastomotic connections bet"een the terminal lingual artery,
the facial artery and the tonsillar branches of palatine artery are present.
The branches that directly supply the tongue are the suprahyoid artery, the
dorsalis lingual artery, the sublingual artery and the deep lingual artery.
There are vascular arcades, "hi ch often perforate the midline of the
tongue.
Dorsal based tongue flaps get most of their blood suppl y from an
intact lingual artery. The rich collateral circulation of the tongue prevents
tongue flap death as long as the base of the flap and its design allo" for
collateral circulation to develop.
! "ide variety of tongue flap designs are possible, the common
ones being anterior or posterior dorsal based lateral or midline flaps,
Flaps for maxillofacial reconstruction
1.
posterior based lateral flap 5;aughn, 16?+8, posterior based bilateral
lateral flaps, anterior based ventral flaps etc.
The common indications for tongue flaps include
1. reconstruction of intra9oral structures follo"i ng cancer excision,
. resurfacing of oral defects and
+. closure of palatal fistulae in cleft palate and ac$uired 2!,.
Flaps for maxillofacial reconstruction
1/
Distant flaps
Deltopectoral flap
The deltopectoral flap is an axial pattern flap, first described by
=a&am%ian in 160/. It is composed of fascia, subcutaneous tissue and
s&in, and can be used for soft tissue reconstruction of mandible and
maxil la.
The flap design is horizontal and rectangular "ith a rounded end
over the shoulder. =ased medially on the anterior chest "al l, the flap on
its upper border follo"s the clavicle and along the lo"er border, it runs %ust
above the male nipple and not lo"er than the anterior axil lary fold. In
females, the base of the flap should include the first five ribs. The base of
the medial portion of the flap must be cm from the lateral sternal border
to preserve the perforating vessels from the internal mammary artery,
"hi ch supply blood to the flap. The perforators enter the flap through the
first four intercostals spaces.
The fascia overl yi ng the deltoid and pectoralis ma%or muscles
should be elevated "ith the flap by sharp dissection. Several branches of
thoracoacromion artery "il l have to be ligated "hen elevating this flap.
!fter appropriate planning and mar&ing, the s&in, subcutaneous tissue and
the muscle fascia are sharpl y divided. The flap is elevated "ith s&in hoo&s,
and sharpl y dissected from the underl yi ng muscles. It is then passed on to
the defect and sutured in place.
The deltopectoral flap cannot be used for intra9oral reconstruction
"ithout creating an oral fistula. This is a controlled fistula and is
necessary to preserve the blood suppl y to the flap. !fter the flap is se"n
in place, it usuall y needs to be tubed.
The flap is divided + "ee&s later and the fistula closed. #aiting 0
"ee&s before dividing the pedicle ensures better survival of the flap. If the
flap as designed is not long enough to fill the defect, it may be delayed to
gain additional length.
The deltopectoral flap is useful for most reconstructive problems of
head and nec&, especial ly "hen a large amount of s&in is re$uired for
coverage. It has been used in the repair of defects in the cervical
oesophagus, hypopharynx, oropharynx, base of the tongue, mandible,
maxil la and s&in of chee&, chin and nec&. In situations "here both mucosal
Flaps for maxillofacial reconstruction
10
defects and s&in defects are to be corrected, the combination of an
appropriate myocutaneous flap for mucosal replacement, and the
deltopectoral flap for external s&in replacement "or&s "el l. This flap may
be used in most cases "ithout having to reposition the patient.
The main disadvantage of this flap is the need to form an oral fistula
and close it at a second operation. The donor defect is also a cosmetic
problem. !nother potential hazard is the rare occurrence of distal flap
necrosis.
Cervical skin flaps
,laps of varying size, shape, site and direction have been designed
"hi ch ma&e use if nec& s&in for reconstructive purposes. It is possible in
theory to raise a flap from virtuall y any site on the nec& and transpose it
up"ards to cover a defect of lo"er face or oral cavity. =eing random in
type, such flaps are restricted in their useful length.
Side of t#e nec'
The flaps ma&ing use of the side of the nec& are generall y
horizontall y designed, based anteriorly or posteriorl y. =ecause of their
limited application, they are rarel y used and have not been systematised
in design.
(ccipito-mastoid $ased flaps
,rom a base "hich extends form the midline and even beyond the
occiput and event o the angle of the mandible, these flaps pass in a
generall y do"n"ard direction curving slightl y laterall y. =ased on the
do"n"ard extension, they may be 'nape9of9the9nec&( flaps or
sternocleidomastoid flaps.
)Na!e'o'$*e'nec+, la!#
This random pattern s&in flap "as first described by 4utter 51?.8.
It ma&es use of the nec& s&in lying above the trapezius muscle. The flap
can be raised pedicled on the occiput and extended do"n"ard as re$uired
to the approximate level of the spine of the scapula. S"ung on the upper
pedicle, such a flap can be used as a transposed flap to reconstruct the
lo"er face and the submandibular region.
It is not generally considered safe to raise the ' nape9of9the9nec&(
flap and transfer it immediatel y because of the high incidence of necrosis.
Flaps for maxillofacial reconstruction
17
)rior delay is advisable and this ma&es it suitable for the already existing
defect rather than the fresh post9excisional one.
S$ernoclei"o&a#$oi" la!#
This is a single9pedicled random pattern flap 5=a&am%ian and
*ittle"ood, 160.8, based on the s&in overlying the upper insertion of the
sternomastoid and running do"n"ards along the line of the muscle.
)edicled above, it can be s"ung for"ard to be used both intra9orall y and
extra9orall y.
Csed as a s&in flap, it has a bad reputation for necrosis 5about
@F8. =ecause of its vascular vulnerability, it is sometimes delayed before
transfer. The incidence of necrosis can be greatly reduced by
incorporating the underl yi ng muscle as part of the transfer, thus ma&ing it
a myocutaneous flap.
Apron flap
Described by Bovic&ian in 16/?, this is a superiorl y based flap
"hi ch consists of s&in from the submental region and front of the nec&
bet"een the line of the carotids on either side. It is hinged along a line
parallel to and %ust belo" the lo"er border of the mandible and is designed
to be turned up"ards along the inner side of the mandible to replace the
mucosa of the anterior floor of the mouth and anterior part of lo"er
alveolus. )roblems resulting from the presence of beard s&in led to its use
as an island flap. This, combined "i th the compromise on vascularity
follo"i ng nec& dissection, has made this flap unpopular.
Flaps for maxillofacial reconstruction
1?
:omposite flaps
The composite flaps contain, apart from s&in and subcutaneous
tissue, underlying supportive tissue such as muscle, fascia or bone.
4yocutaneous flaps "ith their excellent blood supply have proved to be
very reliable in reconstruction follo"i ng ablative surgery. In some
instances, the underlying bone is pedicled on the muscle, thus ma&ing it
an osteomyocutaneous flap
Muscle / myocutaneous flaps
)ectoralis *a+or *,ocutaneous flap
The pectoralis ma%or myocutaneous flap is the most useful flap for
soft tissue reconstruction of bone and soft tissue defects of the mandible
and maxil la secondary to cancer surgery. This flap "as first described by
>euston and 4c:onchie, "ho used it to reconstruct a chest "al l defect in
160?. !ri yan 516768 demonstrated the vascular arrangement of the flap.
The pectoralis ma%or muscle is a fan9shaped muscle on the anterior
chest "all. It is bounded by the clavicle superiorl y and the sternum
mediall y. The lateral border forms the axil lary fold. The superior fibres run
parallel to the clavicle, and the inferior fibres run from the inferior border
of the deltoid to the /
t h
and 0
t h
ribs and lo"er sternum. The clavicul ar head
of the muscle originates from the upper three ribs and the clavicle and
inserts into the inter9tubercular groove of the humerus.
The pectoralis ma%or muscle has t"o separate blood supplies. The
thoracoacromial artery arises from the second portion of the axill ary
artery, and passes along the medial border of the pectoralis minor muscle
and penetrates the clavipectoral fascia. It has . branches at this level. The
pectoral branch is the largest, supplying the standard pectoralis ma%or
myocutaneous flap. The other blood suppl y to the muscle comes from the
perforating branches of the internal mammary artery , "hi ch penetrates the
muscle next to the sternum. The motor nerve to the upper half of the
muscle is the lateral pectoral nerve, and that to the lo"er half is the medial
pectoral nerve. Sensation is by the intercostals nerves.
The techni$ue for flap elevation depends on the location of the
defect. 4ost commonly defects of the head and nec& re$uire s&in for lining
the oral and maxill ary cavity and bul& for filling bone and soft tissue
Flaps for maxillofacial reconstruction
16
defects. :urrently t"o specific )44: flaps are commonl y used. These
are the )44: island flap and the )44: paddle flap.
,or raising an island flap, measurement is from clavicle to the
inferior margin of the s&in island, the measuring tape rotated to the defect
to arrive at the appropriate length of the flap. The s&in island may be
placed on any part of the muscle as needed. The s&in incision is carried
do"n to the fascia of the pectoralis ma%or muscle. Sutures are used to
secure the s&in island to the fascia. Then the entire muscle may be
elevated, or it may be divided lateral to the island, leaving the lateral
portion intact. The muscle is elevated primarily by blunt dissection off the
ribs, care being ta&en not to enter the chest cavity. 4edial to the island,
the muscle is divided cm lateral to the sternum to avoid in%uring the
internal mammary artery. The muscle is divided mediall y up to the clavicle.
*aterall y it is necessary to divide the humerus attachment. !fter the flap is
elevated, the s&in bet"een the upper portion of the chest and nec& is
elevated and the flap passed under the s&in to the defect. The nec&
incision is closed over the muscle, and the chest s&in is mobilised and
closed primarily in most of the cases.
In cases "here the island flap is not long enough to cover the
defect, a paddle flap may be useful. !nother variant is the bilobular or
'-emini( )44: flap, in "hi ch t"o separate s&in islands are raised "ith the
muscle for simultaneous replacement of oral mucosa and overlying s&in.
The pectoralis ma%or myocutaneous flap and its variants are the
flaps of choice for most defects in mandible and maxilla. It has also been
used for the reconstruction of pharngoeophageal area, the base of the
tongue, the anterior s&ull base, midface, total nose and orbital defects.
The )44: flaps are very reliable in their survival chances. ;ery
good functional and cosmetic results have been obtained using )44:
flaps along "i th dynamic fixation of the remaining mandible after partial
resections. The disadvantages of this flap are also mainly cosmetic, the
loss of muscle being very noticeable especiall y in thin patients. #ith 1?
other muscles assisting shoulder motion, functional problems are rare.
Fore#ead flap
The forehead flap in its most reliable configuration is a
myocutaneous flap, composed of the frontalis muscle extending from the
hairline to the eyebro"s "ith the overl yi ng s&in and subcutaneous tissue.
Flaps for maxillofacial reconstruction
@
It "as introduced by :arpue in 1?10. =lair 516.18, 4oore and =yars and
4c-regor 5160+, 160.8 have used this flap for lesions of the gingival
mucosa, buccal mucosa and lateral pharyngeal "al l. It may also be used
to reconstruct defects of hard and soft palate.
The flap may be designed "i th a dual or single blood suppl y. It
ma&es use of the superficial temporal artery and the posterior auricular
artery , branches of external carotid artery. It may be used as a hemi9
forehead flap or a total forehead flap dependi ng on the size and location of
the defect. The total forehead flap should include both the vessels.
The base of the total forehead flap extends from the lateral canthus
of the eye to a point cm posterior to the ear, to include the posterior
auricular artery. The distal extremity is a transverse line at the level of the
opposite lateral canthus. The base of the hemi9forehead flap extends from
the lateral canthus at the eyebro" to the root of the superior helix of the
ear and distally, it ends in the midline. The "idth of both types depends on
the distance bet"een the eyebro"s and hairline.
=oth the hemi9forehead and the forehead flaps are elevated at the
level of the pericranium. The donor defect is covered "i th a split s&in graft.
;arious methods have been used for placing the flap into the
oropharynx.
1. 4c-regor 5160+8 3 the flap is rotated 1?@A laterall y and entrance is
gained into the oral cavity through a separate transverse incision.
. >oopes and Ddgerton 516008 3 the flap is rotated 1?@A medially and
placed through a tunnel created at the base of the forehead pedicle
that lies bet"een the flap and the zygomatic arch.
+. Terz and *a"rence 516068 3 the temporal fascia is incised and the
flap folded medial to the zygoma to be transferred into the oral
cavity.
.. The flap is hinged do"n"ards and inserted into the oral cavity
through the posterior part of the submandibul ar component of the
nec& dissection incision.
The advantages of forehead flaps are its close proximity to the
orofacial regions, excellent blood supply and firmness of tissue. The main
disadvantages are noticeable the donor site defect, the need to divide the
pedicle to close the oral fistula art a second operation, and the fre$uent
complication of bleeding. ,lap necrosis, both ma%or and minor, is an
occasional problem.
Flaps for maxillofacial reconstruction
1
"emporalis flap
The temporalis flap "as introduced in 1?6? by -olovine. The flap is
useful
a. to obliterate s&ull base, maxil lofacial and orbital defects.
b. to close cerebrospinal fluid lea&s, to cover dural tears secondary
to trauma or cancer operations
c. to reconstruct patients re$uiring midface augmentation for
hypoplasi a secondary to trauma, operation or congenital
anomalies.
d. to reanimate the face after in%ury or resection of the facial nerve.
e. to reconstruct small intra9oral defects. The flap extends across
the midline of the soft palate for repair of velum defects.
The temporalis muscle is a broad, fan9shaped bipennate muscle
"ith t"o origins 3 deep one from the temporal fossa extending from the
superior temporal line to infratemporal crest, and the superficial one from
the deep temporal fascia. The insertion is onto the coronoid process and
anterior ramus of the mandible. The deep temporal fascia invests the outer
aspect of the mandible. The superficial temporal fascia lies on top of the
deep fascia.
The blood suppl y of the deep temporal fascia is by the middle
temporal vessel , a branch of superficial temporal artery. The temporalis
muscle has a dual blood suppl y from the anterior and posterior deep
temporal arteries . These vessels arise from the second portion of the
internal maxillary artery.
The available length of the arc of rotation is estimated pre9
operativel y by palpating the superior extent of the muscle "hil e the patient
clenches his teeth. The incision is started in a s&in crease anterior to the
ear, and is extended superiorl y to"ard the vertex, ending above the
superior temporal line. The incisi on is carried do"n to the deep temporal
fascia, and anterior and posterior flaps are developed above the deep
fascia, until the entire muscle is exposed. Then the fascia is incised
around the border of the muscle do"n to the calvarium. Dlevation of the
muscle is done in a subperiosteal plane.
The zygomatic arch may have to be divided to facilitate placement
of the flap into the mouth. !dditional mobility is gained by sectioning the
coronoid process. ! tunnel is created into the oral cavity by blunt
Flaps for maxillofacial reconstruction

dissection, and the flap is passed to the defect "ith the aid of traction
sutures. Split s&in grafts may be applied, but is not necessary.
The main advantage of the temporalis flap is its proximity to defects
high in the oral cavity or on the face. )roblem from loss of muscle function
are minimal. It can support s&in grafts, has a good arc of rotation, may be
turned in different directions and is thin, providing for less bul&y
reconstruction.
The main disadvantage is the cosmetic deformity, though minimal,
caused at the donor site. This may be corrected "ith autogenous or
alloplastic materials, or camouflaged by hairstyle.
)lat,sma flap
The platysma flap "as first used by -ersuny 51??78 for
reconstruction of a through9and9through chee& defect. In 16/1, Ddgerton
described a lateral cervical island flap based on the platysma muscle for
reconstruction of intra9oral defects. Des)rez and Eiehn 516/68 reported
the modified apron flap, "hich included the platysma muscle. In 167?,
,utrell and colleagues reported the use of the platysma muscle as a true
myocutaneous flap.
The platysma muscle lies deep to the subcutaneous tissue overl yi ng
the anterior and lateral aspect of the nec&. Superficial cervical fascia
separates it from sternocleidomastoid muscle, the great vessels of the
nec& and other underlying structures. The origin of the muscle is in the
subcutaneous tissue %ust caudal to the clavicle and the acromion. Its
insertion is %ust cephalad to the inferior border of the mandible. *aterally,
it extends over part of the posterior triangle and sternocleidomastoid
muscle. In the midline, it may merge at any point from the chin to the
thyroid cartilage. Its function is to depress the lo"er lip.
The blood suppl y of the muscle and overlying s&in "as described by
>ur"itz et al 516?+8 and Rabson et al 516?/8. The cervical s&in is supplied
by a random anastomosing net"or& located superficial to the platysma.
The principal vascular supply to the muscle is from branches of the facial
artery . =ut it also receives rich blood suppl y from other vessels such as
occipital, posterior auricular and superior thyroi d arteries.
The flap may be raised on either a superiorl y or inferiorl y based
pedicle. ,or use in the facial region, it must be raised as a superiorly
based flap. If t is to be used in con%unction "ith nec& dissection, it is
Flaps for maxillofacial reconstruction
+
elevated before the nec& dissection is done. ! s&in island is designed on
the inferior aspect of the muscle. ,ollo"i ng an incision outlined to the
platysma muscle, a supra9platysmal dissection is carried superiorl y to the
point of rotation. The incision through the inferior base of the s&in island is
carried deep to the platysma muscle and including the superficial cervical
fascia. It is preferable to preserve as many blood vessels in the vicinity as
possible.
The muscle is flipped 1?@A and brought through a tunnel into the
mouth or is rotated and ta&en through a subcutaneous tunnel for coverage
of extra9oral defects. The nec& is closed primaril y.
The primary use of this flap is in the reconstruction of intra9oral
defects of the palate, buccal mucosa, tongue, floor of the mouth and
pharynx1 and extra9oral defects in the chee& and lo"er lip region.
!dvantages of this flap include its close proximity, and a minimal donor
site defect "hi ch can be closed primaril y. This thin, pliable flap causes
negligible impairment of functions li&e deglutition, speech or prosthetic
appliance use. It can be used for mild facial augmentation and reamination
follo"i ng facial nerve in%ury.
The greatest disadvantage of the platysma flap is that it is not
reliable because of its unpredictable blood suppl y, "hich can cause flap
loss. !nother problem is the folding of the muscle "hi ch causes a bulge in
the nec&. !lso, it cannot be used in regions "here tissue bul& is re$uired.
Sternocleidomastoid flaps
The sternocleidomastoid flap "as introduced in 16@6 by Ginau for
facial reanimation. In 16.6, 2"ens described a compound nec& flap that
included the muscle. This flap can be used as a muscle, myocutaneous or
a myo9osseous flap.
The sternocleidomastoid muscle has t"o heads "hi ch at the origin
attach to the manubrium sterni and the medial third of the clavicle. The
insertion is to the mastoid process and lateral third of the superior nuchal
line of the occipital bone. It divided the nec& into anatomical anterior and
posterior triangles.
The blood suppl y to the muscle is through three arteries. Superiorly
a branch of the occipital artery enters the muscle belo" the mastoid tip.
The middle branch is from the superior thyroid artery . The inferior third is
Flaps for maxillofacial reconstruction
.
supplied by a branch from the thyrocervical trun& . The dominant vessel is
the occipital artery.
The incision is determined by the proposed use of the muscle. If a
muscle flap is to be used alone, a vertical incision over the midportion of
the muscle extending from its origin to insertion may be used. !s an
alternative, t"o horizontal incisions can be placed. The flap can then be
elevated by tunneling through these incisions. ! myocutaneous flap can be
developed by basing it either superiorl y or inferiorly "ith a s&in island or
s&in pedicle attached to the muscle. In cases of simultaneous nec&
dissection, the 4c,ee or hoc&ey stic& incisions can be modified to
accommodate its elevation.
,or superiorly based flaps, the flap is developed by elevating the
s&in and platysma from the underlying sternocleidomastoid muscle. The
sternal and clavicular head are transected and the muscle is elevated by
dissection bet"een its deep surface and the deep cervical fascia. The
lo"er branches of the vascular supply may be ligated "ithout affecting the
survival of the flap, according to !riyan 516768. =ut Sasa&i 516?@8 and
4arx H 4cDonal d 516?/8 recommend maintaining t"o of the supplying
branches, by dissecting the middle branch 5superior thyroid8 bac& to its
parent vessel.
The muscle is separated from the fascia, ta&ing care to preserve the
spinal accessory nerve. !rc of rotation may be restricted by the superior
thyroid artery or the spinal accessory nerve. The muscle is then
transposed and sutured in position, and the incision closed in layers over
suction drains.
#hen a s&in island is being ta&en, the incisions are carried do"n to
the muscle fascia, the s&in sutured to the underl yi ng fascia, and the
dissection proceeded as for the standard muscle flap. !fter the flap is
rotated into position, the muscle is sutured to the subcutaneous tissues,
and the s&in island to the mucosa or s&in as re$uired. =ecause of
variabil ity in the axial blood flo", fluorescein may be used intra9operativel y
to determine the amount of viable s&in. 1@@@ to @@@ mg of fluorescein is
in%ected intravenously and the flaps are observed.
Dxtra9orall y, the sternocleidomastoid flap can be used form the
chee& to the nec& area, and intra9orall y, from the palatal region to the
larynx. 2ther uses of the flap are to provide soft tissue augmentation after
parotidectomy, for facial reanimation in 7
t h
nerve in%uries, to obliterate the
Flaps for maxillofacial reconstruction
/
dead space around a bone graft and to provide a vascularised muscle bed
in patients "ith poor recipient tissues.
!dvantages of the flap are the close proximity to recipient site,
good colour match, ade$uate bul& and minimal donor site morbidity. The
disadvantages include flat nec& deformity, disruption of cutaneous nerve
suppl y of the nec& and unreliabil ity of vascular supply of the flap. )otential
limitations include the need to resect the muscle as part of nec& dissection
and obese people "ith short nec&s. :omplications include muscle atrophy
and flap necrosis.
"rape-ius flaps
,laps from the shoulder and bac& have a long history. 4utter
described the trapezius flap in 1?., "hi ch "as named after him.
Bovic&ian popularised these flaps in 16/7. Several designs of the
trapezius myocutaneous flaps have been used because of its triple blood
suppl y.
The trapezius is a flat and triangular muscle that covers the superior
posterior part of the nec& and shoulder. It originates from the nuchal line
of the occipital bone and the spinous processes of :97 through T91. It
courses laterall y to insert on the lateral third of the clavicle, the acromion
and the spine of the scapula. It overlies the semispinal is and splenius
capitis in the nec&, and both rhomboid muscles in the bac&.
The main blood suppl y of the trapezius muscle is by a branch of the
thyrocervical trun&, the transverse cervical artery . !t the border of the
muscle, the vessel divides into an ascending and a descending branch,
"hi ch permits separate flaps based on the lateral and vertical portions of
the muscle. The upper portion of the muscle in the nec& is supplied by the
occipital artery . So this part of the muscle can be used as a separate
myocutaneous flap. The muscle is also supplied by numerous deep
perforating vessels from the intercostal system.
Three flap designs have been described 3 the upper trapezius flap,
the lateral trapezius flap and the lo"er trapezius flap. The upper flap is the
myocutaneous version of the standard nape9of9the9nec& flap in "hi ch a
strip of underl yi ng trapezius is raised along "i th the s&in 54c:ra" et al9
16768. The flap in the form of an island can be rotated to allo" a s&in
paddle to replace a mucosal defect.
Flaps for maxillofacial reconstruction
0
The lateral trepezius flap 5=ertotti, 16?@, -uillamondegui H *arson,
16?18 is based on the transverse cervical arterio9venous system and is
raised from more or less the same s&in area as the upper trepezius island
myocutaneous flap. Its anterior border corresponds to approximatel y to the
anterior margin of trepezius and from there it extends bac&"ards and
do"n"ards in general the 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 s&in should extend above the point at "hi ch the transverse cervical
vessels disappear deep to trepezius. The pivot point of the transfer is the
medial end of its feeding arterio9venous system. The first step is to dissect
the pedicle at its medial end. The island of s&in "i th the underl yi ng muscle
is raised from levator scapulae. The flap can be used in con%unction either
"ith a radical or a functional nec& dissection.
The lo"er trapezius myocutaneous flap may be used as an island
flap or as a solid flap. The vessels must be identified in the nec& and
traced to the anterior border of the muscle. The anterior incision for the
s&in island extends along the anterior border of the trapezius. The muscle
and its blood supply are elevated from the underl yi ng structures. !n
appropriate s&in island is cut and the underl yi ng muscle is incised "ith
care. The pedicle is then isolated and traced to its origin at the
thyrocervical trun&. The island, no" attached onl y by its pedicle, is rotated
into the defect and sutured into place.
The transverse cervical trapezius myocutaneous flap is useful for
repairing defects "ithin the oral cavity, hypopharynx or s&in of the lo"er
chee& and chin. ,or it to be considered, the blood suppl y must be
preserved during the nec& dissection. The horizontal 5shoulder8
fasciocutaneous flap is useful for coverage of nec&.
The flap is a ready source of supple s&in of uniform thic&ness
"ithout excessive muscle bul&, "hich lends itself to more contouring
during reconstruction. The donor area is usuall y hairless and may be
closed primarily in most cases. Scars in this area are not obvious.
The main disadvantages are the short pedicle available, limited arc
of rotation and need for patient repositioning to use the flap. This flap
cannot be used "ith a 4c,ee incision. In%ury or resection of the spinal
accessory nerve causes significant and painful shoulder problems. ,ailure
to heal donor defects is a dreaded complication.
Flaps for maxillofacial reconstruction
7
Latissimus dorsi flap
The latissimus dorsi myocutaneous flap is one of the most useful
and most reliabl e flaps that have been described. This flap "as used by
Tansini 51?608 to cover a mastectomy defect. The use of this flap for
reconstruction of head and nec& defects "as first described by Iuillen et
al in 167?.
The latissimus dorsi muscle extends from the tip of the scapula to
the midline of the bac& posteriorl y, and to the iliac crest inferiorl y. The
anterior border extends on an obli$ue line from the axil la to the midpoint of
the iliac crest. The muscle is triangular and originates from the spinous
processes of the lo"er six thoracic vertebrae, the spines of the lumbar and
sacral vertebrae, posterior iliac crest, inferior angle of scapula and the last
four ribs. The upper an anterolateral borders are free. The insertion is into
the humerus in the intertubercular groove.
The thoracodorsal artery , the terminal branch of subscapular artery
5"hich arises from the axil lary artery8, is the dominant vascular suppl y. Its
vascular arrangement allo"s the muscle to be split into medial and lateral
flaps. The secondary vascular source is from a fe" perforators from the
posterior intercostals and lumbar vessels.
To reach defects in the head and nec& region, the s&in island must
be placed on the anterolateral margin of the inferior half of the muscle.
This area has the least number of perforating vessels. The size of the
island conforms to the size of the defect, and the location of muscle
paddle is distal enough to reach the defect by rotating the flap.
The initial incision is along the anterolateral border of the muscle.
The s&in island is outlined and the incision carried to the muscle. Then a
s&in incisi on is made connecting the island "i th the axi lla along the
proximal border of the muscle. *ateral and medial s&in flaps are raised as
needed to expose the muscle. The muscle is separated from the
underl yi ng bones. !s the dissection proceeds up"ards, the thoracodorsal
pedicle is identified in the undersurface of the muscle.
Several different routes to the head and nec& are available
depending on the location of the defect. The flap may be tunneled over the
pectoralis ma%or and clavicle but under the overl yi ng s&in1 or under the
pectoralis ma%or but over the clavicle. :are should be ta&en to protect the
artery and the s&in island. The flap is delivered to the defect and sutured
Flaps for maxillofacial reconstruction
?
in place. The s&in defect on the bac& may be closed primaril y or split9s&in
grafted. Drainage catheters are used under the bac& flap and also in the
nec& region.
The latissimus dorsi myocutaneous flap has been used to repair
defects of the entire chee&, hemiface, oropharynx, mandible, segments of
cervical oesophagus, posterior scalp, pharynx, etc. Its ma%or advantage is
the large amount of available s&in and the "ide arc of rotation. The blood
suppl y is reliable, the muscle thic& and the s&in hairless. The main
disadvantage is the need to reposition the patient during the operation.
The donor site s&in grafts occasional ly fail to ta&e.
)rior surgery in the axil la or radiation to the axil la ma&es the use of
this flap un"ise. !lso, patients "ho have undergone thoracotomy "ith
latissimus dorsi transection, are not candidates for this flap.
Osteomyocutaneous flaps
The osteomyocutaneous flaps consist of a segment of underl yi ng
bone pedicled on myocutaneous flaps, and are used for simultaneous soft
and hard tissue reconstruction.
Sternocleidomastoid .it# cla!icle/sternum
This flap "as first described by :onley in 167. >e used all or part
of clavicle and a part of sternum "ith sternocleidomastoid muscle. The
main indications are for defects secondary to traumatic mandibular
fractures, mandibul ar osteoradionecrosis and mandibular defects follo"i ng
cancer ablation.
The techni$ue involves raising the contralateral flap "ith clavicle or
sternum or both to reconstruct the mandible. The flap is raised preserving
the occipital, posterior auricular and superior thyroid artery.
The main advantages are the provision for one stage reconstruction,
and the rapid and technical ease of elevation of the flap. The
disadvantages include loss of protection of great vessels, and the minimal
donor site morbidity. The obvious limitation for its use is the presence of
contralateral positive nec& nodes in malignancy, in "hich case the
sternocleidomastoid muscle "il l have to be excised.
Flaps for maxillofacial reconstruction
6
)ectoralis ma+or .it# ri$
This flap "as first developed by !ri yan et al in 16?@. It is based on
success "ith pectoralis myocutaneous flap and good periosteal supply to
ribs form the pectoralis muscle.
The pectoralis muscle has three heads of origin the clavicular head
from anteromedial clavicle, sternocostal head from anterior sternum and
six upper ribs and abdominal head is variable from the external obli$ue
muscle. It is inserted into the lateral lip of the humerus and deep fascia of
the arm.
;ascularised upper six ribs based on the periosteal blood supply
can be harvested along "ith pectoralis flap for maxillary and mandibular
reconstruction. Csuall y /
t h
or 0
t h
ribs are harvested "ith the muscle flap.
This flap combines the advantages of the versatile and durable
myocutaneous flap and the presence of osseous tissue for bone
reconstruction. *arge s&in island "ith soft tissue bul& is available for oral
and facial reconstruction. Its long pedicle allo"s it to be mobilised to
greater distance.
The disadvantages include poor bone stoc& for mandibular
reconstruction, limited vascular suppl y to the bone, chance of
pneumothorax, poor contour stabil ity and limited dental restoration
potential and the significant donor site cosmetic defect.
"rape-ius .it# spine of scapula
Trapezius osteomyocutaneous flap for mandibular reconstruction
"as first described by )an%e and :utting in 16?@. >ere, the spine of
scapula is harvested along "ith trapezius muscle for oromandibul ar
reconstruction.
It has the advantages of a versatile and durable myocutaneous
pedicle in the muscular part, "i th a dependable vascular suppl y. 2ther
advantages are the location of the flap close to the operating site, lo"
morbidity of donor site bone defects less than 1 cm, provision for large
s&in island and improved bone stac& in comparison to rib "i th pectoralis
flap.
Disadvantages include the re$uirement for repositioning during the
procedure for flap harvest, inade$uate bone stoc& for defects larger than
1 cm, limited manipulation of bone relative to soft tissues and the
Flaps for maxillofacial reconstruction
+@
fre$uent complication of shoulder morbidity due to acromion damage and
denervation.
Latissimus dorsi .it# ri$ / iliac crest
4aruyama et al 516?/8 described the use of this flap "ith rib for
reconstruction of a complete hemimandibulactomy defect secondary to
osteoradionecrosis. The vascular supply of the rib graft comprised of
perforating branches from the posterior intercostal artery and the
periosteal supply from the thoracodorsal artery. ,ollo"9up bone graft
biopsy at + months revealed viable bone.
!n innovative latissimus dorsi myocutaneous3i liac crest bone flap
"as described by 4agi et al 516?08. ! segment of iliac crest "as
transplanted beneath the muscle months before raising the flap. The
composite flap "as then used for mandibular reconstruction. The results
"ere disappoi nting in their t"o patients.
"emporalis .it# cal!arium
!s earl y as 1?6@, Eonig and 4uller reported the clinical applications
of calvarial bone transfers "ith osteocutaneous flaps. #atson9Gones in
16++ transferred calvarial bone on periosteal pedicles to repair depressed
s&ull fractures. :onley 51678 designed an osteomuscular flap consisting
of temporalis muscle and clavarial bone. The bone9muscle9fascial9
periosteal flap "as developed by 4c:arthy and Bide in 16?..
The temporalis flap has an excel lent arc of rotation about the
coronoid process. It can be rotated to reconstruct the defects of orbit, oral
cavity and also of face.
The advantages of this flap include minimal morbidity of the donor
site and large volume of bone "ith a curvature. It is claimed that the
viabil ity of the membranous bone is superior to the endochondral bone.
The flap(s "ea&nesses include its bul&iness, anterior mobilisati on
re$uirements, donor site volume defect and possible limitation of %a"
movement. :houng et al 516618 introduced a bone3fascial3periosteal flap
to overcome these limitations.
Flaps for maxillofacial reconstruction
+1
,ree flaps
4icrovascular techni$ues for anastomosis of small vessels allo" the
transfer of s&in flaps from distant sites. ,ree vascularised tissue transfer
is a ma%or advance in maxil lofacial reconstruction by providing tissue "i th
inherent ability to heal. These flaps are particularly useful in cases "here
ade$uate tissue for reconstruction is not available in the vicinity of the
defect, and "here the recipient bed is not vascular enough to facilitate the
ta&e of an ordinary flap.
!n artery and vein of ade$uate size and in proximity to the defect
should be chosen for microvascular anastomosis. It is usually possible to
choose vessels "i th ade$uate pedicle length for donor vessels to reach.
Delicate handling of the vessels is essential to prevent damage to the
intima. The recipient vessels may be sutured end9to9end or end9to9side to
the donor vessels. =ranches of the external carotid artery and internal
%ugular vein may be used as recipient vessels.
Jejunum
The small intestine has been used for reconstruction of cervical
esophagus to provide a reconstructive pharyngeal conduit follo"i ng
pharyngolaryngectomy and for resurfacing the oral cavity defects.
! segment of proximal %e%unum is harvested along "ith mesenteric
vasculature, "hich is capable of providing a single arterial and venous
pedicle suitable for anastomosis. !fter the harvest of %e%unum the
continuity of the intestine is restored.
The advantages of this flap for intra9oral reconstruction is that the
transferred tissue has a mucosal surface "hi ch secrete mucous and that
the vascular pedicle is of ade$uate caliber for anastomosis.
The disadvantages of this flap are that it re$uires abdominal
operation and the operating period is prolonged.
Groin flap
This "as the first free tissue transfer performed "i th micro9vascular
techni$ue. ,irst described by #ood in 1?0+ and reevaluated by 4c-regor
and 4organ in 167+ as an axial pattern flap. The s&in overl yi ng the Iliac
crest and ilium are perfused by arteries "hich anastomose in the vicinity of
Flaps for maxillofacial reconstruction
+
the anterior superior iliac spine, the superficial and deep circumflex
arteries and the superior gluteal artery.
The standard groin flap is based on the superficial circumflex iliac
artery, usually a branch of femoral artery. ;enous drainage is by a
superficial and deep system of veins. *arge area of tissue meassauring up
to . by 10 cm can be successfull y transferred. The donor defect is
minimal. It can also be used as a de9epithelised flat flap for repair of soft
tissue defects.
The disadvantages are a variable pattern of vascularity, short
vascular pedicle and the excess bul& of the groin.
Lateral arm
The lateral arm provides a free flap based on the posterior radial
collateral artery, "hi ch is a direct continuation of the profunda branchii.
The flap is thin and pliable and consists of fascia and s&in. The posterior
cutaneous nerve of the arm accompanies the artery and can be transferred
"ith the flap.
Several branches from the artery provide a periosteal blood suppl y
to the humerus and can allo" harvesting of a small segment of
vascularised bone.
Latissimus dorsi
Described by 4ax"ell 5167?8, the flap consists of latissimus dorsi
muscle and its overl yi ng s&in paddle. The dominant vascular pedicle is the
thoracodorsal artery, arising from the subscapular artery 5branch of
axi llary artery8. The subscapular artery and its branches offer a variety of
flaps suited for free tissue transfer. ;enous drainage is by venae
comitantes, "hich accompany the thoracodorsal and axil lary arteries.
The flap offers a large amount of tissue "i th a good $uality s&in
element, thus ma&ing it useful to fill large and full thic&ness head and nec&
defects. It is very reliable and is easy to use. The disadvantages are the
bul&, ris& of seroma formation and functional incapacitation in certain
occupation groups 5athletes and tennis players8. The muscle bul& settles
slo"l y over time as the denervated muscle shrin&s.
ectus a!dominis
The rectus abdominis muscle can be transferred either as a muscle
flap or as a myocutaneous flap. The muscle is supplied by the superior
Flaps for maxillofacial reconstruction
++
and inferior epigastric vessels. The larger pedicle is the inferior epigastric,
"hi ch forms the basis of the rectus abdominis free flap.
This flap is very useful in cases "here an extensive area of soft
tissue cover is re$uired. !lternativel y, it is possible to ta&e a small amount
of muscle that contains t"o or three perforators, "hich suppl y a large area
of s&in. It has a consistent, reliable, long vascular pedicle "ith vessels
that are easily dissected.
The removal of the muscle causes some abdominal "ea&ness, and
ventral herniation is fre$uent. The flap is often too bul&y.
"orsalis pedis
,irst described by 2(=rics and Shanmughan in 167+, this
fasciocutaneous flap transfers s&in, superficial fascia from the dorsum of
the foot using as its vascular basis the dorsalis pedis artery and the
superficial veins, "hich pass proximally into the long saphenous system.
The vascular pedicle of this flap can be dissected from the leg to a length
of at least 1@ to 1/ cm. If additional venous drainage is re$uired, the
saphenous vein may be included in the flap.
It has been used both to provide s&in cover and an intra9oral lining.
Second metatarsal bone can be harvested along "ith the flap for
mandibular and temporomandibular reconstruction.
#liac crest $ composite groin flap
The iliac bone along "ith its overlying s&in paddle can be harvested
as a free flap based on either the superficial or deep circumflex iliac
arteries. This flap "as first described for mandibular reconstruction by
Daniel 5167?8. Taylor et al 516?+8 sho"ed the superiority of the deep
circumflex iliac arteries. The segmental nature of the vessels supplying the
iliac crest allo"s maintenance of viabil ity "ith multiple osteotomies. The
deep circumflex iliac artery arises from the external iliac artery %ust above
the inguinal ligament. The venous drainage of the flap consists of t"o
venae comitantes "hi ch may unite to form a single trun&.
The flap provides an abundance of "ell9vascularised iliac bone
5corticocancel lous8, "hi ch can be used to ade$uatel y reconstruct large
mandibular defects including hemimandibular or even total mandibular
defects if bilateral flaps are used. The donor defect is minimal.
Flaps for maxillofacial reconstruction
+.
The chief disadvantages are the ris&s of necrosis of the s&in
segment and abdominal "al l herniation. The dissection is tedious.
adial fore%arm flap
The radial forearm free flap, described by Soutar 516?+8, is a
fasciocutaneous flap based on the radial artery. The venous drainage is
dual1 the paired venae comitantes accompanyi ng the radial artery and the
subcutaneous veins. These t"o systems communicate and either can be
used to provide ade$uate venous drainage.
The entire fascia and s&in of the volar aspect of the forearm can be
used for microvascular transfer. The periosteum of the radius is supplied
by a rich net"or& of vessels from the radial artery, and a vascularised
segment of radius l yi ng bet"een the insertion of the pronator teres and the
radial styl oid may be transferred "ith the flap.
The flap is extremel y reliable, has a constant anatomy, and has
large diameter vessels. ! large amount of thin, pliable s&in may be
harvested. The blood suppl y to the bone and s&in arises from a different
system of perforators, thus permitting multiple osteotomies "i thout
compromising s&in viability. ,urthermore, the segmental blood supply
preserves vascularity of all segments. This flap is most useful in mucosal
defects of the floor of the mouth and anterior mandibular defects in
combination "ith floor of the mouth defects.
The main disadvantage is the need to interrupt the radial artery and
the resultant compromise to vascularity of the hand. The amount of bone
available for use is limited to 1@ or 11 cm in length. This limits its use to
small defects.
&capular / parascapular flap
The scapular and parascapular free flaps are based on transverse
and descending branches, respectively, of the circumflex scapular artery,
"hi ch is the largest branch of axi llary artery. Dach artery is usually
accompanied by t"o venae comitantes.
The flaps are of fasciocutaneous type, though variable amounts of
bone or muscle 5serratus anterior8 can be included in selected cases.
*arge cutaneous paddles based on either of the arteries may be raised.
The descending branch provides multiple segmental vessels to the
Flaps for maxillofacial reconstruction
+/
periosteum of the lateral border of scapula, allo"i ng a vascularised
segment of bone to be harvested.
The flap is relativel y thin, the anatomy reliabl e, and a large area is
available for transfer. It also allo"s a second large myocutaneous area
based on thoracodorsal vessels to be harvested. The donor site can be
closed primarily and the flap hidden in clothing.
The chief disadvantage is the need to reposition the patient. The
dermis of the bac& is thic&, and the scar tends to "iden in course of time.
'i!ula free flap
Introduced in 167/ by Taylor et al, the free fibula flap "as one of
the earliest osseous free flaps "ith extensive application in long bone
reconstruction. In 16?+, :hen and <an described the vascular suppl y of
free fibular osteocutaneous flap. >idal go 51668 reported the first
application in mandibular reconstruction. >ayden 51668 described the
nerve supply to the cutaneous paddle and advocated a neurosensory
potential. >e also demonstrated successful primary osseointegration "ith
titanium implants in the fibula.
! long segment of fibula can be harvested as a free flap based on
the peroneal artery. The blood supply is rich, consisting of both medullary
and periosteal vessels, "hich allo"s osteotomies "ithout %eopardising
viabil ity. The branches of the common peroneal nerve, the lateral
cutaneous nerve of the calf or the sural communicating nerve may be
harvested "i th the flap to provide a neurosensitised s&in paddle.
The dissection is straightfor"ard and provides vessels of moderate
size. The bone is strong and can even be folded on itself to provide a
double strut. Donor site morbidity is unusual as long as the distal / to 0
cm of fibula is left for an&le support.
Flaps for maxillofacial reconstruction
+0
Reconstruction of specific regions
The different techni$ues used in reconstruction of head and nec&
are broadly classified as follo"sJ 9
#ntra%oral reconstruction tec(ni)ues
Reconstruction of tongue
-. S/!ericial $/&or# o $ong/e
a. )rimary closure
b. STS-
c. >eali ng by secondary intention
0. Par$ial glo##ec$o&1 2i$*o/$ &an"i%/lec$o&1
a. )rimary closure
b. *ocal flaps eg. Kasolabial flap
c. Regional flaps eg. 4asseter flap
d. Distant flap eg. )ectoralis ma%or flap
e. ,ree flap eg. Radial fore arm flap, Dorsalis pedis
flap.
3. Par$ial glo##ec$o&1 2i$* an$erior &an"i%/lec$o&1
a. ,ree 2sseocutaneous flap eg. 2sseocutaneous
medial forearm flap
4. Par$ial glo##ec$o&1 2i$* !o#$erior &an"i%/lec$o&1
a. Regional flap and mandibular s"ing
b. Distant flap and mandibular s"i ng
c. Distant flap "ith reconstruction plate
5. To$al glo##ec$o&1 6 lar1ngec$o&1 or lar1ngo!la#$1
a. Regional myocutaneous flap eg. )ectoralis ma%or
flap.
b. ,ree myocutaneous flap eg. Rectus abdominis flap,
*atissmus Dorsi flap
Reconstruction of t#e floor of t#e mout#
1. Reconstruction of the anterior floor of the mouth
. Reconstruction of the posterior floor of the mouth
Reconstruction of t#e $uccal ca!it,
1. Csing temporalis myofascial pedicled flap
Flaps for maxillofacial reconstruction
+7
. Csing buccal fat pad.
Flaps for maxillofacial reconstruction
+?
Closure of oro-antral fistula
Manage&en$ o ac/$e oro'an$ral co&&/nica$ion
1. Soc&et edge reduction and suturing
. Cse of supportive pac&s or protective plate
Manage&en$ o c*ronic / e#$a%li#*e" i#$/la# or Large OAC
1. *ocal flaps
a8 =uccal flaps
5i 8 !dvancement flap 5#el ty, ;on Rehrmann H =erger8.
5i i 8 4odifi ed advancement 5*as&i n H Robi nson8
5i i i 8 Sl i di ng flap 54oczai r8
b8 )alatal flaps
5i 8 Strai ght advancement
5i i 8 Rotati onal advancement
5i i i 8 >i ngi ng and Isl and flaps
5i v8 )alatal submucosal connecti ve ti ssue fl ap.
c8 =ridge flap
d8 :ombined local flaps
5i 8 Doubl e fl ap
. Distant flaps
a8 Tongue flaps
5i 8 !nteri orl y based
5i i 8 )osteri orl y based
5i i i 8 *ateral l y based
b8 Temporalis muscle flap
c8 =uccal fat pad flap
d8 2steoperiosteal flap
3. Grafts
a8 !utogenous bone grafts
b8 !llografts
5i 8 -old foil.
5i i 8 Tantulum foil
5i i i 8 -old plate
5i v8 )ol y methyl methacrylate
5v8 >ydroxy apatite bloc&s.
5vi 8 ,ibrin glue.
Flaps for maxillofacial reconstruction
+6
*+tra%oral reconstruction tec(ni)ues
Reconstruction of midfacial defects
Cla##iica$ion o &i"'acial "eec$#
Type I Loss of mi dfaci al ski n onl y; buttress of the maxi l l a, orbi tal fl oor and
pal ate i ntact
Type II Parti al maxi l l ectomy wi th i ntact pal ate and orbi tal fl oor
Type III Parti al maxi l l ectomy wi th resecti on of a porti on of pal ate; orbi tal fl oor and
Lockwood s l i gament remai n i ntact
Type IV Total maxi l l ectomy and pal atectomy; orbi tal support remai ns i ntact
Type V Total maxi l l ectomy and pal atectomy wi th l oss of orbi tal support or eye
4idface defects produce significant functional and aesthetic
conse$uences. ,eeding and speech can be a problem. 2ro9antral fistula
and velopharyngeal incompetence can develop. Resection of *oc&"ood(s
ligament may result in enophthalmos and orbital dystopia.
T1!e I "eec$#
)atients "ith type I defects suffer from variable loss of soft tissues
of chee& and lips. =ony frame"or& is not affected. )alate and orbital floor
remain intact.
If the defect is small and the surrounding tissue lax, primary closure
may be possible. Small rhomboid flaps or subcutaneous pedicled flaps are
used for superficial midface defects. Tissue expansion has been used
successfull y for superficial defects of chee&. This techni$ue affords
excel lent colour and texture match "i th least amount of scar tissue
formed.
,or larger defects, regional or distant flaps li&e pectoralis ma%or,
deltopectoral, latissimus dorsi, temporalis and forehead flaps have been
used "ith success.
T1!e II & III "eec$#
The traditional method of reconstructing these defects is by s&in9
grafting the internal cavity and the placement of a maxil lofacial prosthesis.
The prosthesis usuall y serves as a denture and a palatal obturator, closing
the oro9antral fistula and providing pro%ection of midface. !n ade$uate
residual palatal arch and surrounding soft tissues are re$uired to support
the prosthesis. !s the size of the defect increases, problems "ith stability
Flaps for maxillofacial reconstruction
.@
often are exacerbated especiall y if the prosthesis must function as a
support for orbital structures or reconstruct a missing cutaneous segment.
Some limited maxill ectomy defects may be reconstructed using
autogenous tissue. :houng et al described the use of ipsilateral or
bilateral temporalis muscle flaps. :alvarial bone may be included in the
flap, ma&ing it a myo9osseous flap. The zygomatic arch may be cut
anteriorl y and posteriorl y so that the muscle is mobilised to its insertion on
the coronoid process. The composite flap is passed into the oral cavity
and sutured to the remaining septum or palate.
T1!e I7 "eec$#
Individuals "ith extensive defects are best served by reconstruction
"ith regional or distant flaps to obturate palatal defects, to provide
complete soft tissue coverage and to aid in retention of a prosthesis. The
reconstuctive goal is to provide a healed "ound, separation of oral and
nasal cavities, support for intracranial contents and obliteration of
maxil lectomy defects.
! variety of pedicled regional flaps have been advocated for
midface resurfacing. They include the deltopectoral flap, pectoralis ma%or
myocutaneous flap, forehead flap etc.
,ree tissue transfers advocated to repair midface defects include
the free omental flap combined "ith non9vascularised bone grafts, the free
latissimus dorsi flap, the rectus abdominis flap, the free scapular
fasciocutaneous flap and the free fibular osseocutaneous flap.
Dach donor site has its o"n advantages and disadvantages. The
rectus abdominis flap allo"s a t"o9team approach, thus reducing
operating time. =oth the latissimus dorsi and scapular flaps re$uire a
change in the patient position, but they provide long vascular pedicles and
large volumes of tissue. =y de9epithelising intervening segments of dermis
bet"een cutaneous paddles, the palatal, maxill ary and orbital components
of the defects may be simultaneousl y reconstructed.
Isolated soft tissue repair "i thout bony reconstruction tends to lose
midfacial pro%ection and result in sagging. :oleman and Sandham noted
that by preserving the angular artery to the tip of scapula, vascularised
bone could be harvested along "ith the scapular flaps. This helps in
closure of massive midface defects. The muscular component helps in the
Flaps for maxillofacial reconstruction
.1
closure of dead space of maxi llary sinus. The cutaneous portion is used to
resurface face and palate.
T1!e 7 "eec$#
#hen orbital floor and *oc&"ood(s suspensory ligament are
resected, reconstruction should obliterate the orbital cavity and restore
facial contour.
Ilan&ovan and Gac&son described the split thic&ness vascularised
calvarial bone either pedicled on the temporalis muscle or "ith a free flap
based on superficial temporal artery, to reconstruct the floor of the orbit.
The temporoparietal fascial flaps have been used for orbital and
eyelid reconstruction. The free vascularised forearm flaps have been used
to reconstruct the orbital floor and provide overlying soft tissue.
In extensive maxillectomy defects, soft and hard tissue
re$uirements are massive, and free tissue transfer is preferred. It offers
the advantage of one9stage reconstruction "i thout the constraint of fixed
point of rotation observed in regional flaps.
Flaps for maxillofacial reconstruction
.
Reconstruction of t#e lip
The successful reconstruction of the lo"er lip must meet some
criteria.
1. The reconstructed lip should be sensate.
. Retain sphincter or muscle function.
+. 2ppose vermilion to vermilion of the upper lip in a
"atertight continent seal.
.. !llo" sufficient space for food, dentures and so on.
/. !cceptable aesthetic appearance.
Defect of up to one third of the lip can be closed primarily. *arger
defects re$uire tissue transfer, and the preferred donor site is ad%acent
chee& or upper lip.
Deec$ o 389 $o 589: '
In moderate9sized defects, reconstructive techni$ues that use lip
tissue "il l yield an excell ent result. Transfer of upper lip tissue 5lip s"itch8
pedicled on the labial artery 5!bbL techni$ue8, preserving the oral
commissure, or rotated around the commissure by the Dstlander method
can be accomplished.
!nother method is Earapandzic techni$ue of advancement rotation
of segments of s&in, orbicularis and mucosa 3 after division of other
supporting muscles. This procedure redistributes remaining lip, yet
preserves the motor and sensory function. The principal disadvantage has
been the relative microstomia and the necessity of extensive circumoral
incision and dissection.
Deec$# o ;59 $o <89: '
! "idel y used techni$ue is the advancement of the chee& tissue by
the #ebster9 =ernard approach. Initial results are good1 the continued
chronic tension of the closure has culminated in a tight lo"er lip that
functioned poorl y.
! more satisfactory procedure for defects of this magnitude has
been the Earapandzic lip rotation, although a microstomia is inevitable.
Denture construction should be modified here.
The Earapandzic approach essentially is dissection of the remaining
lo"er lip segment, modiolus 5bilateral8 and lateral upper lip tissue in the
neurovascular pedicles and advancement of these components to
reconstruct the lo"er lip deficiency. The method re$uires incisi ons
Flaps for maxillofacial reconstruction
.+
extended laterall y and transversel y in ad%acent chee& tissue, curving
up"ard into the nasolabial folds and into the lateral upper lip to"ard the
alar base. 2nce s&in incisions are made, the residual depressions and
elevations are divided, beneath "hi ch lie both the facial nerve and artery
branches to be preserved. Similar incisions need to be made in the
mucosa at the labial sulcus, extending into the labial mucosa.
!fter mobilization of the segments, closure of donor site defect in
the chee& is done in a ; to < fashion. 4icrostomia produced can be
corrected later "ith a lip9s"itch procedure.
To$al re#ec$ion o $*e li!: ' =>ara!an"?ic a!!roac*@
! massive resection of the lip, chin and mandible must be
reconstructed "ith distant flaps and re$uires reconstruction of the lo"er lip
as a separate unit. The transfer of composite flaps of s&in and bone
revascularised and the result allo"s for institution of radiotherapy in the
earl y post postoperative period.
Reconstruction of the lip and chin as a single unit can be
accomplished "ith a radial forearm flap, incorporating a plantaris tendon
as a vascularised unit to provide support. The tendon is sutured into either
modiolus 5if still present8. The provision of sensation to the reconstruction
by suturing the antebrachial cutaneous nerve of the flap into the stump of
the mental nerve has been included.
To effectivel y reconstruct the lo"er lip, one must provide not only
s&in and mucosa, but also functioning mimetic muscle. Dissection of a
platysma myocutaneous flap "ith an extended muscle pedicle to include
the cervical branches of the facial nerve "ould empo"er the muscle
component. =ilateral flaps "ould also provide sufficient tissue for mucosa
reconstruction.
!nother use of a full thic&ness inferiorl y based nasolabial flap or
bilateral flaps as needed for lo"er lip reconstruction.
:onclusions
Defects of the head and nec& region resulting from severe trauma
and ablative procedures for neoplasms, and those associated "ith
congenital deformities, can be functionall y and aestheticall y debilitating.
The primary ob%ective of the reconstructive surgeon is to restore a level of
Flaps for maxillofacial reconstruction
..
form and function that provides the closest approximation of the patient(s
pre9disease state.
Reconstructive options for patients "ith large defects have
significantl y progressed over the last century. The earl y primary closure
techni$ues "i th their poor aesthetic results have no" been replaced by
improved surgical techni$ues, includi ng composite tissue transfer. ,ree
tissue transfer has no" enabled the surgeon to reliably reconstruct the
defects in areas of inade$uate tissue availabil ity and regions of vascular
compromised. Different types of flaps, if used %udici ousl y and carefully,
allo"s reliable aesthetic and functional reconstruction in specific
situations.
Flaps for maxillofacial reconstruction
./
References
1. >ead and nec& microsurgery. #illiam 4 S"artz H Goseph : =anis.
#illiams H #il&ins. 166.
. ,undamental techni$ues of )lastic Surgery and their surgical
applications. 6
t h
edition. I! 4c-regor H !D 4c-regor. :hurchill
*ivingstone 166/.
+. Cse of flaps in reconstructive surgery of the head and nec&. D4
4orris, - Cnhold. In =asic )rinciples of 2ral and 4axi llofaci al
Surgery. 5eds.8 )eterson, 4arciani, Indresano. 1667.
.. :ancer of the ,ace and the 4outhJ )athology and 4anagement for
Surgeons. I! 4c-regor H ,4 4c-regor. :hurchill *ivingstone 16?0.
/. Cse of local flaps for intra9oral reconstructive surgery. 4S =loc&. In
=asic )rinciples of 2ral and 4axi llofacial Surgery. 5eds.8 )eterson,
4arciani, Indresano. 1667.
0. -rabb and Smith(s )lastic Surgery. /
t h
edition. SG !ston, R#
=easley, :>4 Thorne. *ippincott9Raven. 1661.
7. Design of local s&in flaps. #, *arrabee Gr. In ,acial )lastic
Surgery. 2tolaryngology :linics of Korth !merica. 2ct 166@. +J/.
?. Soft tissue augmentation and replacement in head and nec&.
2tolaryngology :linics of Korth !merica. ,eb 166.. 7J1.
6. Reconstruction of the mandible and oropharynx. 2tolaryngology
:linics of Korth !merica. Dec 166.. 7J0.
1@. )edicled 2sseous ,laps. !- *ane, :S Gohnson, )D :onstantino. In
!ugmentation :raniofacial S&eletal !ugmentation and Replacement.
2tolaryngology :linics of Korth !merica. 2ct 166.. 7J/.
Flaps for maxillofacial reconstruction
.0

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