Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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
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