Local and Regional Flaps in Head and Neck PRT 1 (NXPowerLite) / Orthodontic Courses by Indian Dental Academy

Local and Regional Flaps In
Head and Neck Cancer

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

WHY RECONSTRUCTION?
HISTORY OF FLAP SURGERY
PRINCIPLES OF
RECONSTRUCTION
CLASSIFICATION OF FLAPS
TYPES OF LOCAL FLAPS
ROTATION FLAP
BILOBED FLAP
RHOMBIC FLAP
NASOLABIAL FLAP
BUCCAL FAT PAD
TOUNGE FLAP
FOREHEAD FLAP
REGIONAL FLAPS

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

INTRODUCTION
The human face is unique in its nature ability
to express emotions, temper, and personality
It is the most important means of
communication
The esthetic and functional impact of major
cancer surgery can be devasting for patient .
Why reconstruction ?
To restore and replace both hard and soft
tissue
maxillofacial form, quality of tissues, oral
competence and oral cavity functions .allowing
the patient to return and adopt into the society.
addition to these means of rehabilitation
,psychosocial and occasional counseling help
through support group and emotional
counseling are necessary for complete
recovery
History of flap surgery
The term "flap" originated in the 16th century
from the Dutch word "flappe," meaning
something that hung broad and loose,
fastened only at one end ..
600 BC, when Sushruta Samita described
nasal reconstruction using a cheek flap.
The French were the first to describe
advancement flaps, which transfer skin from
an adjacent area without rotation.
During the First and Second World Wars, pedicled flaps
were used extensively
The next period occurred in the 1950s and 1960s, when
surgeons reported using axial pattern flaps (flaps with
named blood supplies).
1970s a distinction was made between axial and random
flaps (unnamed blood supply) and muscle and
musculocutaneous (muscle and skin) flaps. This was a
breakthrough in the understanding of flap surgery that
eventually led to the birth of free tissue transfer.
1980s free tissue transfer
History of flap surgery
PRINCIPLES OF RECONSTRUCTION
Confirmation of tumor free margins should be
done prior to flap reconstruction if a
malignant lesion has been excised
PRINCIPLE I: REPLACE LIKE WITH
LIKE

"When a part of one's person is lost, it should
be replaced in kind, bone for bone, muscle
for muscle, hairless skin for hairless skin, an
eye for an eye, a tooth for a tooth. -Ralph Millard
If this cannot be accomplished, use the next,
most similar tissue substitute
PRINCIPLE II: THINK OF RECONSTRUCTION IN
TERMS OF UNITS
human beings may be divided into seven
main parts: the head, neck, body and
extremities- Millard.
The head, for example, is composed of
several regional units: scalp, face, and ears.
The most important aspects of a regional unit
are its borders, which are demarcated by
creases, margins, angles and hair liners
PRINCIPLE III: ALWAYS HAVE A
PATTERN AND A BACK-UP PLAN
As with all surgery, it is of utmost importance to
compare the pros and cons of each surgical option.
The reconstructive ladder is a mental exercise that
provides the surgeon with options ranging from the
simplest to most complex.
it is best to keep things as simple as possible. This
benefits both the surgeon and the patient; the
simplest plan is often the safest
Avoid settling for the simplest procedure just for the
sake of simplicity. More complex problems may
require more complex solutions
reconstruction should be designed to fit its
use and location, rather like the philosophy
used by architects when designing buildings .
, "Form and function thus become one in
design and execution, if the nature of
materials and methods and purposes are all
in unison.", Frank Lloyd Wright twentieth-century architecture
Wright had been asked to build a hotel in
Tokyo. As Japan was in an earthquake zone
Wright designed the hotel to withstand
shocks using a mud of sea to support the
foundations. Following the Japanese
earthquake of 1923, Wright's hotel was
apparently the only building left standing in
Tokyo.
Once you have decided on a plan, rehearse it. Trace
the defect or cut a pattern to fit the defect. Transpose
the pattern and experiment with it to decide on the
best donor area and orientation
Finally, ask yourself "what do I do next if this fails?"
Proceed to the operating room only after answering
this question definitively. Once in the operating
room, it is important to keep an open mind and be
ready to adjust the surgical plan as the situation
dictates.
PRINCIPLE IV: STEAL FROM PETER
TO PAY PAUL
Robin Hood" principal: steal from Peter to
pay Paul, but only when Peter can afford it.
Using what the body has to reconstruct a
deficit is essentially "robbing the bank
The goal to achieve is ultimate efficiency, or,
according to Millard, "getting something for
almost nothing."
advancing tissue to the deficient area should
be done completely without tension
Tension is to be feared the most.
Recognize and prevent it .
PRINCIPLE IV: STEAL FROM
PETER TO PAY PAUL
PRINCIPLE V: NEVER FORGET THE
DONOR AREA
Always consider both defects equally
The significance of providing coverage of a
defect with minimal deformity and disability is
one of the foremost principles on which our
specialty is based.
If reconstruction of the primary defect is too
costly in terms of resultant deformity or
disability, it is better to re-evaluate and use
another reconstructive options
Remember that donor areas are not limitless.
One cannot continuously use tissue without
paying back in some way.
Carelessness or overuse of a donor area
eventually causes damage that may be far
greater than the original defect
PRINCIPLE V: NEVER FORGET
THE DONOR AREA
FINAL THOUGHTS
Be thoughtful. Consider all options, simple to
complex prior to any flap surgery.
Be knowledgeable. Know and understand the
anatomy, blood supply, and quality of tissue
available.
Be prepared for failure. Have several backup plans
available if the first plan fails!
Reconstructing facial defects can be both
challenging and rewarding

RECONSTRUCTION - LADDER
Secondary intention
Primary closure
Skin grafting
Local flap
Regional flap
Free flap

CLASSIFICATION OF FLAPS

Arrangement of their blood supply
configuration
Location
Tissue content ,and
Method of transferring the flap.
Blood supply
Proposed by McGregor (First classification)
Random flap
Axial flap

Blood supply is usually the limiting factor in flap success

This system recognized the importance of the presence or absence of
a major vessel running axially to the axis of the flap
Random flap
Blood supply is not derived from recognized artery
Unnamed vessels
Limited in size
Facial random pattern flaps (local flaps) unique in having rich
dermal-subdermal vascular plexus
This permits flaps of long length to width ratio
Excellent viability & used with out delay
Random flap
Axial flap
Most regional flap of head & neck
Incorporate anatomically distinct arteriovenous
system running along the axis of the tissue to be
transferred
Flaps are of high length to breath ratios
Single type of tissue or multiple type of tissue
Axial flap
Direct Cutaneous System
Musculocutaneous flap
Fasciocutaneous flap
Classification of Vascular Anatomy of Muscle
Marthes & S. J. F. Nahai
Location

Local flap

Regional flap

Distant flap

Distant flap may be either pedicled (transferred while still attached to their
original blood supply) or free .
Configuration geometric
Method of transfer
Advancement flap
Rotation flap
Transposition
Interposition
Interpolation
Microvascular tissue transfer
Advancement flap
Advancement flaps have a linear configuration and are advanced into
the defect along a single vector
surrounding skin should exhibits good tissue laxity
resulting incision lines can be hidden in natural creases
limited wound tension
forehead, lips, and cheek region
created by parallel incisions approximately the width of the defect
Burows triangle may be performed at the base of the flap, reducing
the standing cutaneous deformities
Rotation flap
Rotation flaps have a curvilinear
configuration
Defects reconstructed should be
somewhat triangular or modified in to a
triangular defect
These flaps have a large base, random
or axial in vascularity
Increasing the size of the flap in relation
to the defect reduces the tension of the
transfer
Pivot point lies at the extremity of the
semicircle opposite the defect
Back-cut is made along the diameter
line of the semicircle
Transposition flap
They are rotated and advanced
over adjacent skin to close a
defect
They have a straight linear axis
and are usually designed so that
one border of the flap is also a
border of the defect
Nasal tip and ala, the inferior
eyelid, and the lips
The secondary defect is larger
than the primary defect & should
always be covered with skin graft

Interpolation
They contain a pedicle that must pass over or under intact intervening tissue
The disadvantage is pedicle must be detached during a second surgical
procedure
Occasionally it is possible to perform a single-stage procedure by
deepithelializing the pedicle and passing it under the intervening skin
What are the advantages ?of local and
regional flaps
Suitable color matches
Compatible thickness
Immediate resurfacing
Retention or recovery of sensory innervations
Protection of carotid artery system
Minimal scaring
Assistance in restoration of physiology
Minimal donor site morbidity
Local flaps
Face with free of wrinkles are un suitable for local flaps

Richness of vascularity permits a degree of laxity in design

Below the level of ZA - dermal & subdermal circulation

Above the level of ZA - wealth of vessels with sizeable caliber
Random pattern flaps
Standard plane of elevation
Face - subdermal, superficial
to facial muscles
Neck - deep to platysma
Forehead - deep to frontalis
Scalp - deep to galea
Bilobed flap
In 1918, Esser first described the bilobed
flap
A flap consisting of 2 lobes separated by an
angle and based on a common pedicle
defined by Zimany
Bilobed flap is a double transposition flap
allows for the movement of more skin over a
longer distance
Used where skin is less mobile
bilobed flap is a random flap

Esser technique
2 flaps identical in size &
form & separated by angles
of 90 degree
This design resulted in
prominent tissue protrusion
at the point of rotation
Skin flap transposed over
180 degree


Modified technique
Lobes are not identical in size
Larger flap is slightly narrower
than the defect
Second flap is half the width of
the larger flap
Length are identical
Angles b/w lobes < 90
Second flap elliptical tip
Each flap transposed over 45
degree
Bilobed flap
In nasal reconstruction, biloded flaps are most practical for
defects less than 1.5cm in diameter
Bilobed flap
Rhomboid flap (Limberg)

In 1946, Limberg first described a technique for closing a
60 rhombus-shaped defect with a transposition flap.

Rhomboid flap
Length of all sides & short
diagonal are equal
Distal end of flap
Side of the flap next to the
defect
Side of the flap farthest from
defect
Pivot point
Four potential donor sites
Rhomboid flap
Rhomboid flap
Rhomboid flaps
Rhomboid flap
Inferiorly based rotation flap
Used to reconstruct defect
of the check
Anterior margin of flap is
slightly longer than the
defect
Passing back from the
defect the curve of the flap
initially rises
Inferiorly based rotation flap
Superiorly based rotation flap
Uses skin creases as
the line of the flap

Resection carried up
towards the glabellar
area to counter the
effect of the gravity

Superiorly based rotation flap
Lip reconstructions
1/3 of lip defect can be
closed by primarily
Other reconstructive
procedure are
Using residual lip tissues
abbe lip switch
Estlander lip transfer
Karapandzic
maneuver
The lip-switch (Abbe) flap
Most commonly switched
from the lower to the upper
lip
Composite flap based on
one inferior/superior labial
vessel
One-third of lip
Donor lip is closed directly &
reduced in width

The lip-switch (Abbe) flap
The modified lip-switch (Abbe-Estlander) flap
Defect extending to the angle of the mouth, same method can still be
used, pedicle becoming the new angle
Karapandzic maneuver
The Fan flap
Used for very large central full
thickness defects of both upper
& lower lips
Axial flap with small pedicle
Angle of mouth remains in its
original site
Donor site primary closure
Secondary procedure -
commissuroplasty

Forehead flap
Provides largest area of donor site (25cm) with matching
color & texture to facial skin
One of the safest cutaneous flap
85% to 95% success
Long enough to reach any part of the ipsilateral face
Provides approximately 90sqcm of tissue
Different types due to variation in flap pedicle
Forehead Skin Flap
Lateral forehead flap Zygomatic &
anterior branch
Main artery
STA superficial to ZA divides into
Anterior STB & posterior STB
Cadaver studies
Point of origin
Failure to include the large Zygomatic
branch may be reason for reported
cases of failure
Forehead Skin Flap
ASTB sends perforating
branches through the
frontalis muscle to supply
the skin
Centrally forehead is
supplied bilaterally by
1. Supratrochlear
2. Supraorbital

Forehead Flap
Forehead Flap
Variations of pedicle of forehead flap
McGregor
Millard Wilson
Forehead Flap
Operative technique
STA lies Superficial to the
epicranial aponeurosis
Periosteum from frontal
bone should not be lifted
Coagulation diathermy
should be minimal
Small defect direct closure
Marginal step deformity
should be kept to a minimum
Forehead Flap

Outline of various forehead flaps for intraoral use
Forehead Flap
Forehead Flap
Various forms of forehead flap
The finger forehead flap
The Axial Paramedian Forehead flap
Island Forehead Skin Flap
Midline Forehead Skin Flap (Seagull Flap)
Forehead Flap
Forehead Flap
Buccal fat
Egyedi was first to use buccal fat pad as pedicle flap

Buccal fat
Technique
Horizontal vestibular incision or directly from the margin of
surgical resection
Mobilized by blunt dissection & delivered passively
The fat pad is typically encased with a thin fascial envelop which
aids in this dissection
Fat is sutured in position with absorbable suture
Allowed to heal secondarily & rapid mucolization takes place
within weeks
A defect of 4 cms can be covered adequately
Buccal fat
Easy to harvest
Low rate of complication
Partial necrosis as been reported in irradiated tissue
Necrosis can result from inappropriate tension on the flap if it is
transferred to great distance
Reconstruction of appropriately sized defects of maxilla or check
following ablative surgical procedure
Commonly used to reconstruct posterior maxilla & soft palate
Donor site complication rare
Facial asymmetry following transfer - possible complication
Nasolabial flap
Has been used for reconstruction of facial skin defects of the
upper lip, nose & check following extirpation of skin cancer

Flap may be inferiorly based or superiorly based
Can be used unilaterally or bilaterally
Is a axial flap based on the nasolabial branch of the facial artery

Nasolabial flap
Disadvantages
Limited donor tissue
Facial scarring
Second surgical procedure
Extremely difficult to use in dentate patient
Uses
Major use is in closure of oro-antral fistula &
coverage of small defect of anterior floor of the
mouth in edentulous patient
Oral submucous fibrosis
When simple reconstruction is advantageous

Tongue flap
They can be based anteriorly, dorsally, posteriorly or bipedicled
A muscular random pattern flap
Anteriorly based are used for vermilion or floor of the mouth
Dorsally based are palatal fistula
Posteriorly based used for the tonsillar, retromolar or lateral
floor of the mouth defect
Bipedicled dorsally based for replacement of vermillion
Best results are obtained if tongue tip are not violated

Tongue flap
Technique
Finger shaped flap is marked out on the lateral surface of
the tongue from the circumvallate papilla to 1-2 cms behind
the tongue tip
Silk traction suture are used to provide traction
Flap is raised with a combination of blunt & sharp dissection
Multiple small bleeders will be encountered
Width can be increased by longitudinally scoring the muscle
with a scalpel blade allowing it to unroll
Tongue flap
The site is closed in two layers & shortening of tongue is
avoided by closing it on itself
Main disadvantage limited arc of rotation & small size
Decreased mobility in patient who have undergone
radiotherapy
In cases of pt with field changes the surgeon runs the risk of
transferring tissue to the site of the ablative operation that has
potential for malignant degenration
In palatal reconstruction it should be securely anchored
The flap remain the best means of restoring bulk with an
adequate color match in the region of the vermillion
Tongue flap
Thank
you
REFERENCES

References
Oral and Maxillofacial surgery clinics of North America November 1993
Flaps in Head and Neck Surgery 1989 John Conley and Carl Patow
Oral cancer Jatin P shah
GRABBS Encyclopedia of flaps Volume 1
Maxillofacial Surgery Vol. 1 Peter Ward Booth
Atlas of Regional and Free Flaps for head and neck reconstruction
Mark L. Urken
Plastic surgery McCarthy.vol-1
Fonseca OMFS Vol-7
Mastery in plastic and reconstructive surgery-Mimis Cohen

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