local flaps in head and neck surgery -Maroti.pptx

local flaps

1. LOCAL FLAPS IN HEAD AND NECK RECONSTRUCTION DR MAROTI

2. Complicated wounds on the head and neck often require advanced techniques for ideal closure

3. Factors The location, size, adjacent structures, aetiology ( eg , trauma, malignancy, or cosmetic defect), expected functional outcome, and medical comorbidities

4. Classification of local flaps 1. Vascular supply 2. Composition 3. Method of transfer and design

5. Skin flap physiology

6. RANDOM CUTANEOUS FLAP B/S musculocutaneous ARTERIAL CUTANEOUS FLAP B/S septocutaneous

7. DOES INCREASING WIDTH OF FLAP ALLOW TO INCREASE LENGTH OF FLAP?

8. PIVOTAL FLAPS Fixed at one point Should not exceed greater than 90 Indication - Cheeck defect 3-4cm - scal defect <2cm

9. 1.1 rotation flap Minimal benefit – beyond 90 Larger the flap lesser the secondary defect

10. Length of the flap should be 4 times the width of base of triangle

11. Arc of rotation

12. Transposition flaps Linear configuration the 3 : 1 ratio of length to width. transposition flaps may be designed so that one border of the flap is also a border of the defect; however, the transposition flap may also be designed with borders that are removed from the defect whenever possible, transposition flaps should be designed not to pivot more than 90°

13. advantages greatest advantage is the ability to harvest a flap at some distance from the location of the defect allows placement of donor site scars in the most advantageous locations, providing the best possible donor scar Designed in a number of configurations lengthy flap relative to the width of the base can be developed, and this facilitates closure of the donor defect without excessive wound closure tension.

14. Classic design Note flap allows one to close a circular defect with a triangular transposition flap

15. Z-PLASTY designing a Z with three limbs of equal length that form two triangular flaps of equal angles- double transposition flap technique

16. Advancement flaps True advancement flaps have a linear configuration and are moved by sliding toward the defect.

17. BILOBE FLAPS original design of the bilobe flap is attributed to Esser double transposition flaps first lobe is immediately adjacent to the defect and has a surface area that is less than the surface area of the defect cheek, the first lobe may be designed considerably smaller than the size of the defect (up to 25% less in surface area)

18. Rhombic flaps first rhombic transposition flap was initially described by Alexander A. Limberg in 1946 and was later published in 1963. internal angles of 60° and 120°

19. WEBSTER 30° FLAP two modifications in an attempt to decrease wound closure tension at the donor site and to reduce the size of the standing cutaneous deformity excision of the standing cutaneous deformity is per- formed as a W- plasty Second, the apex of the flap is designed with an angle of 30°

20. MELOLABIAL FLAPS Sushruta 600bc Popularized by Esser melolabial crease delineates the cheek from the caudal nose and from the upper and lower lips. created by the insertion of the superficial muscular aponeurotic system into the skin at the junction of the cutaneous lips and the cheek pivotal, advancement, and hinge.

21. MELOLABIAL TRANSPOSITION FLAPS pivotal flaps with a linear configuration. inferiorly or superiorly based Greater the arc of pivotal movement, the greater will be the size of the standing cutaneous deformity

22. MELOLABIAL ADVANCEMENT FLAPS moved by sliding toward the defect created by parallel incisions that allow a sliding movement of skin in a single vector toward the defect.

23. Melolabial Island Advancement Flaps leaving at least one-third of the total flap surface area attached to the underlying subcutaneous tissue no need to resect standing cutaneous deformities considerably less dead space beneath the flap

24. MELOLABIAL INTERPOLATED SUBCUTANEOUS TISSUE PEDICLE FLAPS advantage of maintaining a lymphatic drainage route through the pedicle of the flap avoid a circumferential scar detached from the cheek 3 weeks after the initial transfer to the nose

25. INTERPOLATED PARAMEDIAN FOREHEAD FLAPS  first described in an Indian medical treatise, the Sushruta Samita Supratrochlear artery was consistently found to exit the superior medial orbit approximately 1.7 to 2.2 cm lateral to the midline and continued its course vertically in a paramedian position approximately 2 cm lateral to the midline.

26. FOREHEAD FLAP- Mcgregor B/S STA and PAA

27. buccinator myomucosal flaps 1989, Bozola et al. first proposed pedicled on the buccal artery 1991, Carstens et al. anteriorly based buccinator myomucosal island flap Pribaz et al. proposed the facial artery musculomucosal flap^ (FAMM) 1999, Zhao et al. two buccinator myomucosal island flaps, with two different vascular patterns: the buccinator myomucosal neurovascular flap posteriorly based^ supplied by the buccal artery and the buccinator myomucosal reversed-flow arterial island flap superiorly based^ supplied by the lateral nasal artery

28. Facial Artery Myomucosal Flap Anatomy

29. Inferiorly based FAMM Flap Superiorly based FAMM flap Islanded

30. RELATIVE contraindications Neck dissection. Preoperative radiation therapy- high complication rate of 32%-36%

31. Tongue flap 1901, Eiselsberg was among the first to use pedicled tongue flaps for repair of intraoral defects 1909- Laxer- for tonsillar and RMT defects 1956, Klopp and Schurter - for soft palate defect Domarus HV. The double-door tongue flap for total cheek mucosa defects. Plast Reconstr Surg 1988;80: 351–6.

32. anatomy

33. vasculature

34. Flap designs- Random flap design (3-10mm thickness) Dorsal tongue flap – posterior (most predictable)/anterior

35. Lateral tongue flap – ventral and dorsal surface

36. Double-door tongue flap Domarus HV. The double-door tongue flap for total cheek mucosa defects. Plast Reconstr Surg 1988;80: 351–6.

37. Median transit tongue flap

38. Ventrally based tongue flap

39. Complications 1- Immediate 2- postoperative

40. Axial flap design Set back tongue flap

41. Sliding posterior tongue flap

42. evidences Dorsal tongue flap is a simple and reliable flap for intra oral reconstruction. It provides good functional results without much morbidity.

43. Buccal fat pad flap An axial flap Heister et al. introduced the BFP for the first time in 1732. glandula molaris ” first clinical use of the BFP by Egyedi in 1977,

44. anatomy average volume of the fat pad is 9.6 mL (range, 8.3–11.9 mL). can cover an area of 10 cm2 B/S

45. Complications partial or complete loss of flap, Dehiscence limitation in mouth opening, hematoma, hemorrhage, postoperative infection, and depressed cheek

46. evidences Defect sizes exceeding 4 cm × 4 cm × 3 cm have higher failure rates In OSMF , When BFP graft was compared tongue flap, nasolabial flap, and free skin graft, there was no difference in mouth-opening ability during follow-up. buccal fat pad rotation is superior to other procedures, because it offers ease of surgery In ORN, The overall success rate was 60%.

47. Palatal flap initially described in 1922 by Victor Veau vessels supplying the palate are the greater and lesser palatine of maxillary a the ascending branch of the facial, and the palatine branch of the ascending pharyngeal.

48. advantages are as follows: (1) local source of tissue, (2) a strong flap due to the excellent blood supply, (3) its mobility in that it can be positioned anywhere through 180°, (4) adequate bulk and length, (5) one-stage procedure, (6) excellent take rate, at approximately 97%, (7) limited impairment of speech failure rate of 5%

49. incisions are placed approximately 1 cm medial to the teeth and 1 cm anterior to the junction of the soft and hard palate posteriorly 90% of the mucoperiosteum of the hard palate can be based solely on one greater palatine artery and used to resurface 8 to 10 sq cm of a defect.

50. offers a reliable method of primary reconstruction for limited lesions of the retromolar trigone and hard and soft palate.  no intraoperative complications during the flap harvest nor was there any donor site morbidity associated with the 6 flaps no flap dehiscences , flap necroses, postoperative infections, or associated long-term donor site morbidity.

51. TEMPORALIS FLAP first described by Lentz in 1895 Sir Harold Gillies in 1917 described a series of cases Golovine used the flap to repair an orbital exenteration  

52. anatomy

53. the vessels were located mainly on the lateral and medial aspects of the muscle with a significantly lower vascular density in the midline.

54. EBM 12 cases seven cases are maxillary tumours , of which, one is rhabdomyosarcoma of maxilla, one is muco epidermoid carcinoma, five cases are squamous cell carcinomas (one recurrent case), three cases of squamous cell carcinoma of upper alveolus survival rate was 100%. 13 CASES reconstruction of the tonsillar fossa, pharynx, hard and soft palate, maxilla, and skull base NO FLAP LOSS 1 case of paralysis of temporal 2 cases with partial dehiscence

55. Maintaining the attachment of the superficial temporal fat pad protects the temporal branch of the facial nerve and prevents hollowing.

56. Cordeiro and Wolfe suggest: rotating the temporal fat pad into the anterior temporal region, 2) harvesting a large pericranial flap from the frontal and contralateral parietal regions and folding them into the defect, and 3) reconstruction of the defect with bone or cartilage grafts. Others have reported the use of rib cartilage, bone graft, rolled dermis, fat, free flaps, and alloplastic materials to fill unacceptable temporal defects How to prevent temporal hallowing?

57. submental artery island flap introduced by Martin et al in 1993 Axial fasciocutaneous flap based on the submental artery Skin paddle of as much as 10 x 16cms, extending from one angle of the mandible to the other. flap comprises skin, subcutaneous fat, platysma muscle, submental fat,and lymph nodes; the anterior belly of di- gastric and mylohyoid muscles may also be included.

58. anatomy The submental artery starts at 27.5 mm from the facial artery origin, 5.0 mm from the mandibular border, and 23.8 mm from the mandibular angle. pedicle length ranges from 5 to 8 cm.

59. Oncologic safety The 5-year recurrence-free survival was 88.73% vs. 86.93% for the pN0 and pN + groups, respectively (p = .847). With careful neck dissection and appropriate postoperative adjuvant treatment, the ap- plication of SIF did not increase the risk of locoregional tumor recurrence in patients with pN + T1–2 OSCC compared with those with pN0 T1–2 OSCC. Prospective clinical study, over 5 year with 45 pt RFFF vs SAIF Recurrence-free survival was also comparable at 5 years, with 80.5% in the submental flap group and 74.8% in the radial forearm group. submental island flap does not reduce the oncological prognosis of oral cancer patients

60. 9 cases Six tumors were classified as a T2 tumor and 3 as T3 recurrence rate of disease was 44,4%. Four of 9 patients experienced a local (1/9) or cervical relapse (3/9). submental flap should be carefully indicated in oncological reconstruction, especially in case of suspicion of lymph node involvement at level Ib.

61. represents a excellent alternative to free flaps, particularly in elderly patients or in high-ASA risk patients where the reduced operative time and the easily concealable donor-site incision make it a really neat solution.

62. series of 21 patients who underwent oral cavity reconstruction clinically N0 Regional recurrence occurred in 20%. One of the patients who recurred did not have a neck dissection; other three recurrences were in the submandibular triangle at the site of the fl ap tunnel. fi rst several patients of their series, in which they raised the fl ap prior to performing the neck dissection (essentially not removing the level 1 lymph nodes). No regional recurrences occurred after they changed their practice to performing the neck dissection prior to raising the fl ap.

63. https:// journals.lww.com / plasreconsurg / fulltext /2021/11000/increasing_the_reach_of_the_submental_artery.33.aspx

64. Complications Dehiscence Flap loss Post op hematoma Injury to MMN

65. INFRAHYOID MUSCLE FLAP First by Clairmont and Conley in 1977- for r/c of FOM In 1984 Eliachar et al. IHM with skin for laryngeal defect 1 st large population study by wang et al-1986 skin paddle can reach up to 40 cm2 (10 9 4 cm) without any neck closure problem

66. Anatomy

67. No longitudinal axial vessels were found. The blood supply to infrahyoid muscles consists of two main sources The sternocleidomastoid branch of the STA, which provides the superior portions of the infra hyoid muscles down to the level of the cricoid ring. The ITA, which supplies the infrahyoid muscles from the jugular notch below, and up to the level of the cricoid cartilage. There are two additional minor vascular sources: 1. The hyoid branch of the STA (may arise from the lingual artery), which gives vascularization to the hyoidal attachments of the infrahyoid muscles. 2. The sternal branch of the IMA, which supplies the sternal attachments of the sternothyroid and sternohyoid muscles up to the level of the jugular notch.

68. Surgical technique infrahyoid muscles included in this flap are the sternohyoid muscle, the superior belly of the omohyoid muscle and the sternothyroid muscle. Usually the flap is unilateral and the side is determined by the location of the defect 2005 Dolivet et al. introduced a modification for the neck incision proposing an S instead of the original T shaped incision,

69. Technical modifications

70. venous drainage is anatomically ensured by both the external and internal jugular systems

71. The modified infrahyoid flap is a reliable, quick, and simple procedure with a reasonable cost that makes it a valuable option for the reconstruction of the oropharynx and oral cavity with minimal donor site morbidity and good outcomes.

72. Limitations maximal length of the flap is usually around an average of 10 cm, depending on the length of the patient’s neck. If the width of the flap exceeds 5 cm, a further flap (usually a deltopectoral flap) is required to close the donor site previous thyroid surgery, neck dissection, and presence of metastatic disease localized to level III or IV of the neck restrict the use patients diagnosed with N3 neck metastasis

73. COMPLICATIONS Complication rates after reconstruction are reported to range from 3% to 47% and to mostly be due to insufficient venous return Partial or complete flap necrosis

74. Twenty-eight studies containing 1027 IHMCF rate of flap survival was 99%. Total skin necrosis and partial skin necrosis were minor complications that occurred in 2.5% and 5.8% of cases respectively. Poor speech and swallowing outcomes were reported in 6.4% and 6.5% of cases respectively.