LOCAL AND REGIONAL FLAPS IN ORAL SURGERY.pptx

OMFS

1. LOCAL AND REGIONAL FLAPS PART I

2. CONTENTS History of Flaps Flap Classification Physiology of Flaps General Considerations Local Flaps

3. HISTORY OF FLAPS “ Flappe ” - Dutch word Sushruta Samita , ca. 700 B.C. - Indian Flap Gaspari Tagliacozzi , 1597 - Italian Flap

4. Evolution of flaps may be divided in to 3 periods 1950- Flaps where confined to skin and subcutaneous fat. 1950s - late 1960s, new flaps related mainly to H & N reconstruction. McGregor & Jackson described axial pattern skin flaps 1970s & 1980s. A wider knowledge of blood supply to the skin led to use of musculocutaneous flap

5. FLAPS DEFINITION A local flap is defined as movement of adjacent skin and subcutaneous tissue from one location to another with a direct vascular supply – Shan R Baker . “A sheet (or sheets) of soft tissue partially or totally detached to gain access to structures underneath or to be used in repairing defects in an adjacent or a remote part of the body.”

6. GENERAL CONSIDERATION Lines of Relaxed Skin Tension (RSTL) Lines of Maximum Extensibility (LME)

7. ESTHETIC REGION & UNITS

8. BLOOD SUPPLY PATTERN TO THE SKIN

9. PHYSIOLOGY OF FLAPS Donor site Interrupts vascular & lymphatic continuity Stimulates immunologic & reparative procedure Initiates neural & hormonal compensatory reflexes Accelerates metabolic requirement of the healing donor bed

10. FLAP PHYSIOLOGY Relative anoxia Hypoperfusion Lymphatic & venous stasis Gravitational stress Multiple secondary compensatory & reparative process act within the flap tissue

11. RECIPIENT SITE Size & shape different than that of the flap Presence of saliva Different vascular architecture than the donor site Total systemic & local physiological response of the donor site, recipient site & the flap itself ultimately determine whether the flap will survive

12. VASCULAR SPASM May result from Sympathetic neural vasoconstriction Vessel wall smooth muscle injury Release of local agents Its is generally agreed that major cause of flap failure is inadequate arterial inflow to the flap. Poor venous out flow may also be a factor

13. GOALS OF LOCAL & REGIONAL FLAPS Suitable color match Compatible thickness Retention or recovery of sensory innervations Protection of carotid artery system Minimal scaring Assistance in restoration of physiology Minimal donor site morbidity

14. BASIC PRINCIPLES OF FLAP SURGERY Plan Design Arc of rotation Transfer Positioning Support

15. LOCAL FLAPS IN HEAD & NECK 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 Standard plane of elevation Face - subdermal, superficial to facial muscles Neck - deep to platysma Forehead - deep to frontalis Scalp - deep to galea

16. FLAPS CLASSIFICATION Based on :- Blood supply Location Configuration Tissue content Method of transfer

17. BLOOD SUPPLY Proposed by McGregor (First classification) Random flap Axial flap Blood supply is usually the limiting factor in flap success

18. 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

19. LOCAL FLAPS (RANDOM PATTERN FLAPS)

20. AXIAL FLAP Most regional flap of H & N 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

21. DIRECT CUTANEOUS SYSTEM

22. MUSCULOCUTANEOUS FLAP

23. FASCIOCUTANEOUS FLAP

24. CLASSIFICATION OF VASCULAR ANATOMY OF MUSCLE Mathes & S. J. F. Nahai *Type I - 1 vascular pedicle. *Type II - Dominant pedicle(s) and minor pedicle(s). *Type III - 2 dominant pedicles. * Type IV - Segmental vascular pedicles. * Type V - 1 dominant pedicle and secondary segmental pedicles.

25. CONFIGURATION Geometric configuration

26. LOCAL FLAPS CLASSIFICATION - BAKER Local random flaps Sliding :- Advancement Rotation combination Alphabets ( O>T, A->T) Lifting Single transposition Bilobed transposition Rhombic and variations Melolabial interpolation Local axial pattern flaps Sliding Reiger Island pedicle Lifting Forehead direct Forehead interpolation

27. LOCATION Local flap Regional flap Distant flap Distant flap may be either pedicled (transferred while still attached to their original blood supply) or “ free “.

28. METHOD OF TRANSFER Advancement flap Rotation flap Transposition Interposition Interpolation Microvascular tissue transfer

29. ADVANCEMENT FLAP L inear configuration Advanced into the defect along a single vector S urrounding skin - good tissue laxity Resulting incision lines can be hidden in natural creases Created by parallel incisions approximately the width of the defect Burow’s triangle may be performed at the base of the flap, reducing the standing cutaneous deformities Limited wound tension Used in Forehead, lips, and cheek region

30. ROTATION FLAP Curvilinear configuration Defects reconstructed should be ~ triangular or modified in to a triangular defect 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

31. To minimize standing cutaneous deformity For symmetric orientation of flap

32. TRANSPOSITION FLAP Rotated and advanced over adjacent skin to close a defect Straight linear axis Design - One border of the flap is also a border of the defect The secondary defect is larger than the primary defect & should always be covered with skin graft Nasal tip and ala, the inferior eyelid, and the lips

33. VARIOUS CONFIGURATION OF TRANSPOSTITION FLAPS Rectangular Parabola Triangular Note 30 degree webster Bilobe Rhombic 60-120 degree limberg Dufourmental flap Z plasty Island

34. INTERPOSITION Incomplete bridge of adjacent skin is also elevated and mobilized Z- plasty .

35. INTERPOLATION C ontain a pedicle that must pass over or under intact intervening tissue Disadvantage - pedicle must be detached during a second surgical procedure Single-stage procedure by de-epithelializing the pedicle and passing it under the intervening skin

36. Z - PLASTY Originally used in releasing contracted scar Center limb of the Z is positioned along the line of contracture

37. Z - PLASTY Flap transposition follows naturally from the change in shape of the parallelogram.

38. Z - plasty Single & Multiple Z-plasty

39. VARIATIONS TO INCREASE BLOOD SUPPLY

40. V-Y PLASTY & Y-V PLASTY

41. Bilobed flap 1918- Esser first described the bilobed flap Consists of 2 lobes separated by an angle and based on a common pedicle - Zimany Bilobed flap is a double transposition flap A llows for the movement of more skin over a longer distance Random flap Used where skin is less mobile

42. 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

43. 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

44. RHOMBOID FLAP (LIMBERG) In 1946, Limberg first described a technique for closing a 60° rhombus-shaped defect with a transposition flap.

45. 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

46. RHOMBOID FLAP

47. RHOMBOID FLAP

48. 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

49. FOREHEAD FLAP 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

50. FOREHEAD FLAP Outline of various forehead flaps for intraoral use

51. FOREHEAD FLAP

52. FINGER FOREHEAD FLAP

53. AXIAL PARAMEDIAN FOREHEAD FLAP

54. MIDLINE FOREHEAD SKIN FLAP (SEAGULL FLAP)

55. FOREHEAD FLAP Various forms of forehead flap

56. GILLIES- McGREGOR 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

57. BILATERAL FAN FLAP WITH TONGUE FLAP

58. 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

59. LIP-SWITCH (ABBE) FLAP

60. 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

61. KARAPANDZIC FLAP

62. JOHNNSEN FLAP R.A. Ord, A.E. Pazoki / Oral Maxillofacial Surg Clin N Am 15 (2003) 497–511 503

63. LIP RECONSTRUCTION McCarn KE, Park SS, Lip reconstruction. Facial Plast Surg Clin N Am 13 (2005) 301 – 314

64. PALATAL FLAP Axial flap based on greater palatine artery 180-360° rotation. Hard palatal, partial soft palatal, and retromolar defects; OAF. Maximum - 10 cmsq . of tissue.

65. BUCCAL FAT Egyedi Allowed to heal secondarily & rapid mucolization takes place within weeks A defect of 4 cms can be covered adequately

66. 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 cheek following ablative surgical procedure Commonly used to reconstruct posterior maxilla & soft palat e Donor site complication rare Facial asymmetry following transfer - possible complication

67. NASOLABIAL FLAP Reconstruction of facial skin defects of the upper lip, nose & cheek following extirpation of skin cancer & in OSMF I nferiorly based /superiorly based Unilaterally / bilaterally Is a axial flap based on the nasolabial branch of the facial artery

68. Disadvantages Limited donor tissue Facial scarring Second surgical procedure Extremely difficult to use in dentate patient Hair growth 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

69. TONGUE FLAP B ased anteriorly, dorsally, posteriorly or bipedicled A muscular random pattern flap Anteriorly based - vermilion or floor of the mouth Dorsally based - palatal fistula Posteriorly based - tonsillar, retromolar or lateral floor of the mouth defect Bipedicled dorsally based - replacement of vermillion Best results are obtained if tongue tip are not violated

70. TONGUE AS AN AXIAL FLAP

71. END OF PART I

72. LOCAL AND Regional flaps – PART 2

73. MASSETER FLAP Lexer and Eden for facial reanimation in 1911. Indications: Facial reanimation Reconstruction of mucosal defects of posterior oral cavity, Lateral pharyngeal wall. Advantages Ease of transfer Dependable neurovascular supply Ability to depress paralyzed lower lip.

74. TEMPORALIS MUSCLE FLAP Golovine 1898 - orbital exenteration Gilles - reanimation of paralyzed face Fan - shaped muscle arising from temporal fossa & the superior temporal line

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

76. HARVESTING

77. HARVESTING

78. TEMPORALIS MUSCLE FLAP ADVANTAGES Ease of elevation Reliable blood supply Proximity Camouflage of incision with in hair line Muscle support graft & alloplast well DISADVANTAGES Sensory disturbances Potential facial nerve injury Temporal hallowing

79. TEMPOROPARIETAL FLAP Fascial or Fasciocutaneous flap Thin, pliable, abundant & well vascularized Superficial temporal artery Anterior & posterior division occur about 2cm above & 2cm anterior to superior attachment of helix in 80% of cases Venous drainage is STV - superficial to artery

80. TEMPOROPARIETAL FLAP Vascularised pedicle is carefully skeletonized ZA can be osteotomised Flap is allowed to epithelialised or skin grafted Donor site - alopecia

81. TEMPOROPARIETAL FLAP ADVANTAGES Rich blood supply Thinner Lack of hair Well camouflaged donor site Ease of elevation Vascularised Autogenous bone graft ( calvarial ) DISADVANTAGES Limited rotation Lack of skin paddle to monitor flap Numbness of donor site Alopecia

82. CERVICAL FLAP Regional flap with random pattern circulation Superiorly or Posteriorly - Based Vertical or Transverse plane - Orientation Anterior Cervical Flap Posterior Cervical Flap (Mutter flap) 250 sq cm of neck skin May or may not contain regional muscles of neck

83. ADVANTAGES Regionality Delicate & flexible Lack of bulk One stage Used with other regional flap Arc of rotation Donor site - minimal DISADVANTAGES In male upper cervical flap is hair bearing Neck may be scarred No sufficient bulk Obviated by other ablative procedure Atrophic cervical tissue in elderly patients Effect of heavy irradiation in some neck It may not be large enough Since the blood supply of flap is random, width to length ratio should not exceed 1 : 3

84. POSTERIOR CERVICAL FLAP Blood supply - occipital & posterior auricular Random blood supply to distal part of flap Lateral aspect of neck & retromadibular area Esthetic deformity - donor site Not preferred choice for intra oral reconstruction

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

86. PLATYSMA FLAP ADVANTAGES Proximity & Regionality Thin & delicate Reliable when vascu- -lar criteria adhered Arc of rotation - 180 No donor site disability DISADVANTAGES Lack of bulk Hair bearing in male Reliability 85% Complication like skin loss & fistula

87. PECTORALIS MAJOR MYOCUTANEOUS FLAP Ariyan 1979 Broad triangular muscle Arises from bony portion of 4 th , 5 th & 6 th ribs, cartilaginous portion of the first six ribs & medial half of clavicle Insertion in to greater tubercle of humerus Thoracoacromial artery, 1 st or 2 nd division of axillary artery

88. Superior and lateral thoracic arteries - additional pedicles Overlying skin additionally supplied by intercostal perforators Action - adduct, flex & medially rotate the humerus 3 subunits each with its own vascular & motor supply

89. HARVESTING

90. HARVESTING

91. HARVESTING

92. ADVANTAGES One stage Generous portion of skin & soft tissue Consistent blood supply – highly reliable Adequate arc of rotation for facial defects Donor site can be closed primarily Two skin islands on the same muscle paddle Protects the carotid artery Technically, the flap is ease to elevate

93. DISADVANTAGES It can be to bulky Arc of rotation limited for oromaxillary defects There is distortion of symmetry at the donor site Shoulder function is impaired Distal skin of the flap is not reliable

94. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP Long strap muscle Muscular origin Tendinous origin Insertion Branch of spinal accessory nerve Dominant blood supply – branches of occipital artery & its draining vein Middle third of the muscle Inferior third of the muscle

95. INDICATIONS Provision of epithelial lining for mucosal reconstruction Closure of orocutaneous fistulas Release of scar contracture in submandibular & angle region Provision of additional vascularized tissue around a bone graft when the tissue bed has been heavily irradiated

96. 6 x 8 cm paddle of skin Skin paddle should be kept overlying the muscle above the level of clavicle Skin paddle is tacked down to the muscle fascia Muscle dissected & elevated by incising the fascia

97. Inferior blood supply Branches of superior thyroid artery are noted to enter the anterior aspect of muscle at the level of carotid bifurcation Spinal accessory nerve enters the posterior dorsal surface of the muscle just below the level of the carotid bifurcation

98. TRAPEZIUS FLAP Flat & triangular and cover the superoposterior aspect of the neck & shoulder Type 2 Pedicle system - Dominant pedicle, the transverse cervical artery Functions to rotate the scapula & to elevate, rotate & adduct upper arm 10 x 20 cm in size

99. ADVANTAGES Flap is versatile Regionality of flap Strong vascular security Supplies considerable bulk Arc of rotation 90 – 180 degree One stage procedure Minimum deficit at donor area

100. DISADVANTAGES Venous system difficult to preserve Vascular supply in general difficult to preserve Can present with excessive bulk Cannot be easily tubed Moderate shoulder drop postoperatively

101. DELTOPECTORAL FLAP First axial pattern skin flap The base of flap is parasternal includes the first three or four perforating branches of internal mammary artery, second perforator is largest Artery as rich anastomosis, accompanied by Vein Width 8 - 12 cm, Length 18 - 22 cm

102. ADVANTAGES High biologic dependability Readily accessible Arc of rotation 45 - 135 May be used in male, female & children

103. DISADVANTAGES Donor site require skin grafting Moderate amount of scarring & deformity is unacceptable in women Physiologic disadvantage in malnourished patient or post operative irradiation Flap should not be used if previous scarring on donor area

104. Superior incision is placed just below the clavicle inferior one run parallel to it Flap raised from lateral extent medially Incision is carried down through the pectoral fascia Plane of dissection is sub fascial Dissection proceeds up to 2 cm of lateral border of sternum Back cut on medial aspect - improve the flap rotation 90% success rate HARVESTING

105. LATISSIMUS DORSI MYOCUTANEOUS FLAP Distant flap, provides largest possible skin paddle, involves the most complex donor site dissection, and arc of rotation extremely versatile Donor site skin paddle measures 40 by 25 cm & still allows primary closure Major pedicle is thoracodorsal artery, a terminal branch of the subscapular artery Perforators enter the muscle medially along the spine – secondary supply- type 5

106. Repositioning of the patient in lateral or prone position Skin paddle sutured to the fascia Full extent of the muscle is identified (midline, laterally, superiorly, caudally) Elevation – inferiomedially Fully mobilized – passed through the axillary tunnel

107. ADVANTAGES Size – largest flap in the body Flap location Arc of rotation - 180 Large, reliable unicentric neurovascular pedicle Donor area 90% success rate Relatively flat muscle can be used for reconstruction of tubular structure like pharynx.

108. COMPLICATIONS OF LOCO-REGIONAL FLAPS Flap failure Necrosis Infection Scar formation Unaesthetic results Donor site complications Haemorrhage Plueral tears Temporal hollowing( temporalis flap) Inappropriate flap design Recurrent malignancy Muscle atrophy

109. CONCLUSION Local & regional flaps have been used in the reconstruction of head and neck defects. Due to extensive blood supply in the head and neck, these flaps are generally safe & predictable.

110. REFERENCES Local Flaps in Facial Reconstruction – 2 nd Edition : Shan Baker GRABB’S Encyclopedia Of Flaps -2 nd Edition Oral Cancer - Jatin P Shah Oral cancer- Stell and Maran Atlas of flaps – Urken L Maxillofacial Surgery Vol.1 Peter Ward Booth Oral And Maxillofacial Surgery Clinics Of North America: August2014 Oral And Maxillofacial Surgery Clinics Of North America:- September 2006 Atlas Of Oral And Maxillofacial Surgery Clinics Of North America – November 2003.