Flaps in Head & Neck Reconstruction

Contents

INTRODUCTION

HISTORY

RECONSTRUCTIVE LADDER

PLANNING CONSIDERATIONS

SKIN FLAP PHYSIOLOGY

CLASSIFICATION

LOCAL FLAPS

REGIONAL FLAPS

DISTANT FLAPS

FREE FLAPS

MONITORING OF FLAP

MEASURES TO INCREASE THE VIABILITY OF FLAPS

FATE OF FLAP

COMPLICATIONS

SALVAGING

REFERENCES

A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply.

1440 : Dutch word "flappe" : something that hung broad and loose, fastened only by one side

Introduction

Tansini first described the latissimus dorsi flap in 1896

Before 1963, oral and pharyngeal defects were closed primarily and reconstructed with random pattern skin flaps or tubed-pedicled flaps of skin from the trunk.

In 1973, Daniel and Taylor reported the first free flap,

In 1976, Panje and Harashina simultaneously described the use of free flaps to reconstruct defects of the oral cavity.

In the late 1980s and early 1990s, the use of osteocutaneous free flaps to reconstruct mandibular defects was advanced.

HISTORY

Reconstruction Ladder

The anatomy & physiology of skin, including color, texture, appearance & amount.

Local muscle anatomy : vascular, nerve supply & lymphatic drainage

The aesthetics of the area

Possible sites for incision placement

Areas of local tissue availability i.r.t the area to be reconstructed

Planning considerations

NEUROVASCULAR SUPPLY TO LOCAL SKIN FLAPS

•The sensory nerves are distributed in a segmental fashion•Sympathetic nerves – in the area of cutaneous arterioles•Precapillary sphincter- nutritive blood flow, local stimuli•Preshunt sphincter- thermoregulation, sympathetic stimulation

Segmental

Perforators

Cutaneous• Musculocutaneous• Septocutaneous

The subunit principle is only a starting point, but it is the foundation for adequate reconstruction of facial defects.

With the subunit principle, skin color, skin texture, skin thickness, hair growth, and surrounding contours at subunit junctions are considered; these features can provide optimal camouflage for incisions and transition

The facial subunits

Based on blood supply• Axial Random

Mathes and Nahai classification

CLASSIFICATION

CLASSIFICATION

By method of movement from the donor site• 1) Advancement flaps 2) Transposition flaps

3) Rotation flaps 4) Interposition flaps

By distance from donor site• Local Flaps• Regional flaps

By the tissues they contain• Skin flaps• Composite flap• Free flaps

Advancement flaps• Linear or rectangular configuration• Sub classification

• Single pedicle • Bipedicle• V-Y flaps

Single-pedicle advancement flap• A rectangle of skin is moved forwardly – elasticity of skin• The advancement creates a length discrepancy which creates

standing cone deformities

Local Flap

Bipedicle advancement flaps• Advanced into the adjacent defect in a

vector that is perpendicular to the flap axis• Used to close a defect in an area of high

visibility by moving the defect into an area of low visibility

The V-Y advancement flap• Pushed rather than stretched into the defect• The donor flap, which usually is triangular,

is advanced, and the resulting donor defect is closed in a straight line

• This approach results in a suture line with a Y configuration

Local Flap

Pivotal flaps• Moved about a pivotal point from the donor site to the

defect • Rotation • Transposition • Interpolation flaps

Interpolation flaps • The flap is moved about the pedicle and the pedicle rests

over the intervening tissue.• The most common interpolation flap is the forehead flap.

Local Flap

Rotation flaps• The leading edge of the flap also is a border of the defect• Based inferiorly to promote lymphatic drainage• The border perpendicular to the axis of rotation usually is

curvilinear and designed to contact at the junction of 2 facial subunits for optimal scar camouflage

• The length of the flap should be larger than the defect by a 4:1 ratio.

Local Flap

Transposition flaps• The flap is moved about the pedicle and transposed

over the intervening tissue into the defect• Versatile and offer a choice of flaps of similar color

and texture from various donor sites -defects in the head and neck

• In the head and neck the length-to-width ratio exceeds 3:1

Z-plasty • 2 transposition flaps with identical angles to the

direction of the defect and transposing them in opposite directions

Local Flap

Rhombic flaps –Limberg• specially designed transposition flap used to

correct a rhombus-shaped surgical defect• The classic rhombus defect has sides of equal

length, with 2 opposing 60° angles and 2 opposing 120° angles.

• This configuration creates a short diagonal of the same length as that of the sides of the rhombus.

The Dufourmentel flap is a variation of the classic Limberg rhombic flap with any 2 opposite angles rather than the 60° and 120° angles.

Local Flap

Bilobed flaps• 2 transposition flaps that share a common

pedicle• 1st -to reconstruct the defect• 2nd -to repair the donor site for the flap• The angle between each flap is 90°, with a

total transposition of 180°• Standing cone deformities, Pincushioning

Zitelli's modification – 45° & 90°• The key to the success of the bilobed flap

is the distribution of tension over both limbs of the flap.

Local Flap

Abbe cross-lip flap• 1/2-2/3 lip defects.• Flap width should approximate half width of excised

tissue. The recommended limit of flap width is 2 cm.• The flap blood supply is based upon the labial artery• The advantage is maintenance of sensory and motor

competent lip segment.• The disadvantage is second stage requirement and

relative microstomia.• Potential complications include vascular

compromise, vermilion notching, lip asymmetry, and scarring extension beyond the sublabial crease

Local Flap

Estlander flap• 1/2-2/3 lip defects.• The Estlander flap involves rotating the upper lip tissue

around the lateral edge of the mouth to correct defects involving the oral commissure.

• It is based upon the labial artery.• The flap maintains motor and sensory competence of

lip.• The pedicle is divided at 2-3 weeks• It requires commissure plasty at 3 months.

Local Flap

Karapandizic flap• A complete lip is formed by rotating the upper lip and

perioral tissue by bilateral advancement flaps.• The disadvantage of this technique is frequent loss of

sensory and motor innervation• Potential complications include microstomia, difficulty of

introducing full dentures, inversion of the vermilion and flattened mentolabial junction, and dysesthesia/anesthesia of the lip

Local Flap

Axial flap- to reconstruct defects below the level of eyes

Anterior branch of temporal A

Cutaneous axial median forehead flap- supratrochlear A

Uses :

• For nasal reconstruction – defects larges than 2.5 cm in length along the horizontal transverse plane.

• Defects of medial canthal region, upper or lower eyelids, medial cheek, melolabial region, upper lip

• In combination with other larger flaps – complex facial defects

FOREHEAD FLAPMcGregor

Eiselberg – 1901

Advantages • Adjacent tissue

• Excellent blood supply

• Low morbidity

• Reinnervated from adjacent host tissue

• Provide – 90 to 100 cm2 of mucosal surface for rotation

• Half of tongue can be used – without compromising the functions.

• Can be used in irradiated patients

TONGUE FLAPREGIONAL FLAPS

Vasculature : • Suprahyoid artery • Dorsal lingual artery • Sublingual artery • Deep lingual artery

Types :

I : Random flap design • a) Dorsal tongue flap

• - Posteriorly based – to treat defects of soft palate, retromolar region.

• - Anteriorly based – hard palate anterior buccal mucosa, anterior FOM, lips

TONGUE FLAPREGIONAL FLAPS

Lateral tongue flap

• Treatment of defects - buccal mucosa, lateral palate, alveolus, orointral communication

Double door tongue flap

• Used to reline large defects of buccal mucosa extending form the commissure to the anterior mandibular ramus.

TONGUE FLAPREGIONAL FLAPS

II. Axial flap design • Sliding posterior tongue flap

• Coverage of lateral tongue defect measuring 4-6 cm.

• Created by releasing the tongue from the hyoid bone and maintaining the dorsolingual branch of the lingual artery

TONGUE FLAPREGIONAL FLAPS

Blood supply – 3 sources :• Anterior deep temporal artery

• 21 % of the muscle • Middle temporal artery

• 38% of the muscle • Posterior deep temporal artery

• 41% of the muscle

TEMPORALIS FLAP Verneuil – 1872 – gap arthroplasty of TMJ

REGIONAL FLAPS

Uses • Obliteration of oral defects• Gap arthroplasty of TMJ• Cranial base reconstruction• Obliteration of orbital defects after enucleation• Facial reanimation• Midface suspension or orbital repair with the coronoid

process, attached to temporalis after maxillectomy

TEMPORALIS FLAP Verneuil – 1872 – gap arthroplasty of TMJ

REGIONAL FLAPS

TEMPORALIS FLAP

Advantages• Ease of elevation• Reliable blood supply• Proximity to maxillofacial

skeleton• Camouflage of incision within

hair line

Disadvantages• Sensory disturbance• Potential facial N injury• Temporal hollowing

REGIONAL FLAPS

Monks, Golovine and Brown – 1898 – repair eyelid and orbital defects, and perform auricular reconstruction

TPGF is pedicled on the superficial temporal vessels and is a component of the SMAS

TPGF can be made as wide as 14 cm on a 18 cm superficial temporal vascular pedicle.

Superficial temporal V is posterior & superior to A

Uniform location of vascular pedicle – micro vascular transfer

Temperoparietal Galea FlapREGIONAL FLAPS

Uses• Obliteration of oral defects• Cranial base reconstruction• Obliteration of orbital defects after enucleation• Malar augmentation, maxillary & mandibular reconstruction

with vascularised osseous cranial bone• As a skin island flap- hair bearing upper lip/ brow

reconstuction

Temperoparietal Galea FlapREGIONAL FLAPS

Temperoparietal Galea Flap

Advantages• Relatively constant & reliable

blood supply• Ultrathin ~ 2-4 mm• Surface area ~ 120 cm.sq• Lack of hair• Well camouflaged donor site

Disadvantages• Limited rotation• Lack of skin paddle for flap

monitoring• Numbness of donor site• Potential for development of

alopecia

REGIONAL FLAPS

In 1987 – Tiwari –as a cross-over flap in the tonsillar repair and retromolar trigone

Origin:• Superficial – anterior 2/3 lower border of zygomatic arch• Deep – inner surface of zygomatic

Insertion:• Superficial – lower portion of mandibular ramus • Deep – lateral surface of the coronoid process

Innervations:• Masseteric nerve (CN V3)

Blood supply:• Masseteric artery (internal maxillary artery)

Masseter FlapREGIONAL FLAPS

Uses• Reconstruction of ablative procedures of parotid gland,

mandible, palate and nasopharyma

Advantages• Usefull, readily available local tissue for site specific defects of

oral cavity

Disadvantages• Limited tissue volume• Potential for devolopment of trismus• Training for emotional mimetic movement• Limited arc of rotation

Masseter FlapREGIONAL FLAPS

1887 – 1st used by – Gersony– through and through cheek defect.

1951 – Edgerton – lateral cervical island flap

1959 – Desprez and Klehn modified apron flap

Arterial supply• Anterior superior

• Sub mental A

• Posterior superior • Occipital and posterior auricular arteries

• Anterior midportion • Superior thyroid artery

• Inferiorly• Transverse or superficial cervical arteries

• Skin • Fasciocutaneous perforators

Plastysma Myocutaneous FlapREGIONAL FLAPS

Venous drainage• Postrior- EJV• AJV, sub mental V, anterior communicating V

Innervation• Cervical branches of 7th CN

Contraindications• Previous radiotherapy to neck• Dominant blood supply violated due to previous surgery• Muscle previously transected

Flap designs• Posteriorly based• Superiorly based• Inferiorly based

Plastysma Myocutaneous FlapREGIONAL FLAPS

Occipital A- fascia at the anterior border of SCM

Collaterals- sup. Thyroid & post. Auricular A

EJV

Arc of rotation is suitable for reconstruction of • Lower lip• FOM• Ventral tongue• Lower 1/3rd of face

SOND / SND – preserving SCM & associated fascia

Posteriorly Plastysma Myocutaneous Flap

REGIONAL FLAPS

Dominant A – submental branch of facial A near inferior border of mandible

Submental V

Arc of rotation is suitable for reconstruction of • Ant. & lateral FOM• Buccal mucosa• Retromolar trigone• Skin of lower cheek & parotid region• Facial animation- Cervical branch of 7th CN

Superiorly Plastysma Myocutaneous Flap

REGIONAL FLAPS

Plastysma Myocutaneous Flap

Advantages• Good color match• Easy access to donor site• Minimal donor site morbidity• Easy primary closure of donor

site• Appropriate flap thickness for

oral & facial defects

Disadvantages• Blood supply unreliable• When based on submental A,

requires preservation of muscularity in a area of oncologic significance which may have to be addressed in resection

• Removal of platysma interferes with the blood supply to the overlying skin, which can have disastrous results

REGIONAL FLAPS

Sushrutha samhitha, 700 BC

Diffenbach , 1830- nasal alae reconstruction

Nasolabial crease• 1cm superior- lateral alar rim• 1cm lateral- corner of mouth• Medially- orbicularis oris muscle• Superior & lateral – cheek

Buccal & zygomatic branches of facial N

Nasolabial Flap REGIONAL FLAPS

Facial A

Uses• Reconstructing perioral defects

• Upper or lower lips• Comissure • Buccal mucosa

• Full thickness defects immediately following trauma• Reconstruction of upper lip scarring secondary to

trauma

Inferiorly Based Nasolabial Flap REGIONAL FLAPS

Infra-orbital & transverse facial A

Used to reconstruct• Maxillary lip• Buccal mucosa • Nasal defect• Columella• Moderately sized maxillary defect

Superiorly Based Nasolabial FlapREGIONAL FLAPS

Origin • Medial 11/2 – 2/3 of clavicle• Lateral portion of entire sternum• Adjacent cartilages of first 6 ribs• Bony portion of 4th ,5th ,6th ribs

Insertion• Intertubercular groove of humerus

Action• Abducts , Flexes & Medially Rotates Arm

Pectoralis Major FlapAryian 1977

DISTANT FLAPS

Segmental subunits- PMMC

Clavicular • Arises from clavicle• Deltoid branch of thoracoacromial A• Lateral pectoral N

Sternocostal segment • Most muscle mass• Pectoral branch of thoracoacromial A & parasternal

perforators of internal mammary A• Lateral pectoral N

External segment • Medial pectoral N• Lateral thoracic A / Pectoral branch of thoracoacromial

A/ combination

DISTANT FLAPS

Pectoralis Major Flap

Advantages • Familiar, accessible• Large skin territory• Rich vascular supply• Large arc of rotation• Used with other flaps

Disadvantages• Bulk• Nerve sectioning• Poor colour match• In females , breast size limits

its use• Hair bearing

DISTANT FLAPS

Complications- PMMC

Recipient site• Flap necrosis• Poor healing• Infections• Fistulization• seroma

Donor site• Uncontrolled bleeding• Hematoma• Wound dehiscence• Infection & seroma

Rarely • Rib osteomyletis• Seeding of tumor• Metastasis

DISTANT FLAPS

Origin • Clavicular head• Sternal head

Insertion• Mastoid process of temporal bone

Innervation • Spinal accessory N• Proprioception – cervical spinal N

Blood supply• Occipital A / direct from ECA• Superior thyroid A• Transverse cervical A

Sternocleidomastoid flapowens 1955DISTANT FLAPS

Flap types• Composite skin muscle flap• Myocutaneous skin island flap• Composite muscle – bone flap

Use• Reconstruction- oral cavity, cheek lip• Particularly as superiorly based muscle flap –

small defects of pharynx & oral cavity• Split along its length & rotated anteriorly – to

cover vessels of compromised neck

Sternocleidomastoid flapDISTANT FLAPS

Sternocleidomastoid Flap

Advantages• Accessible• Good colour match• Proximity to defect site• Lack of requirement of

another incision when used in conjunction with neck dissection

• Good thickness tissue coverage

Disadvantages• Upper scm composite skin

flap is poorly viable• Vascularity of lower muscle

flap is unreliable• Upper & lower ends are of

oncologic significance

DISTANT FLAPS

Perforator flap

Based on lateralcircumflex thoracic A- descending branch

Pedicle descends down b/w rectus femoralis & vastus lateralis muscles

Venous drainage- 2 vena comitans of LCFA

Sensate flap – lateral cutaneous N of thigh

Anterolateral Thigh FlapSong 1984

DISTANT FLAPS

Anterolateral Thigh Flap

Uses

Thicker flaps• Total glossectomy• Hypopharyngeal defects• Laterl temporal defects

Thinner flaps• Orophyngeal /• Hypopharyngeal

reconstruction

Contraindicatios• Previous thigh injury• Prior surgery of upper thigh

DISTANT FLAPS

Anterolateral Thigh Flap

Advantages• Low donor site morbidity• Primary closure• Two team approach• Long vascular pedicle ~15cm• Large vessels ~ 2-4 cm• Large skin paddle ~ 10 x 20 cm• Pliable, hairless skin

Disadvantages• Elevation difficulty –

musculocutaneous perforator• Obese pt, esp. women – bulky• Inconsistent vascular pedicle

– transverse branch

DISTANT FLAPS

Is an axial pattern flap

Composed of fascia, subcutaneous tissue and skin; muscle is not transferred with this flap

Boundaries• Clavicle superiorly• Acromium laterally• A line running through the anterior axillary fold

to above the nipple inferiorly

Based medially on the upper chest in the upper 3 or 4 perforating branches of internal mammary A from medial end of intercostal spaces

DELTOPECTORAL FALP Bakanjian –1965

DISTANT FLAPS

Extends to any site in neck & occasionally up to zygoma

Flexibility of the flap• Retracts from side to side• Anomolous pivot point

Uses• To cover whole anterior neck without any subsequent

revision• To reconstruct a defect by passing as a bridge over normal

tissues where conventionally the pedicle may be tubed• Repair of pharyngeal fistula but lacks muscle bulk• Reconstruct defects – lower face & upper neck

Deltopectoral FalpDISTANT FLAPS

Deltopectoral Falp

Advantages• Usually not delayed• Unilateral or bilateral• Deltoid portion usually not

hair bearing• Excellent blood supply,

with dependent venous drainage

• Donor site hidden, thus cosmetically acceptable

• Outside radiation field

Disadvantages• Failure rate is 9 to 18%.• If flap is used to cover the

carotid vessels, blow out of the carotid artery is a hazard if the flap fails.

DISTANT FLAPS

Tanzini,1896- 1st myocutaneous flap in medical literature

Quillen,1978- head & neck reconstruction

Origin• Sacrum & lumbar vertebrae• Posterior iliac crest• Lower 6 thoracic vertebrae• Slips from lower 3 ribs

Insertion• Intertubercular groove of humerus

Latissimus Dorsi Myocutaneous FlapDISTANT FLAPS

Thoracodorsal vessels from subscapular A

Venacommitans draining into axillary V

10 x 8 cm- easily harvested with primary closure

Musculocutaneous flap ~ 40 x 20 cm – skin grafting

As a free tissue- dividing circumflex scapular A , pedicle – 10cm long, 3 mm diameter

Latissimus Dorsi Myocutaneous FlapDISTANT FLAPS

Latissimus Dorsi Myocutaneous Flap

Advantages• Large amount of tissue can be

transferred• Pedicled or free tissue transfer• Cosmetic advantage, esp.

females• Versatile ; tubed/ multiple/

osseous components• When pedicled can reach

upper face & scalp

Disadvantages• Very bulky• Occasional donor site

dehiscence• Reduction in upper limb

power• Need to move pt to harvest.

DISTANT FLAPS

Criteria for selection• The length & diameter of vascular pedicle available• The type, thickness & color match of the skin required• Whether associated tendon, fascia or nerves are needed• Whether a large composite free flap is required• The morbidity caused by harvesting the flap should be

considered

Free Flap

As a fasciocutaneous flap- volar forearm skin, antebrachial fascia & intermuscular fascia containing vascular pedicle.

Radial A- deep palmer branch of hand , b/w brachis radialis & flexor carpi radialis muscle

Ulnar A- superficial palmer branch of hand• Anastomosis –prevents ischemia & necrosis of hand

particularly index finger & thumb• Allens test

Venae comitantes {1-2mm} / cephalic vein{3-4mm}

Radial Forearm Free Flap1978-China

As a sensate flap- Lateral antebrachial cutaneous nerve

Composite flap - bone, tendon, brachioradialis muscle and vascularized nerve.

Use • Oral cavity, base of tongue, pharynx, soft palate, cutaneous

defects, base of skull, small volume bone and soft tissue defects of face

Radial Forearm Free Flap

Radial Forearm Free Flap

Advantages• Consistent vascular anatomy• Up to 20 cm long• Vessel caliber 2 – 2.5 mm• Location allows 2 team

approach• Pedicle can be outlined prior

to incision• Composite flap• Acceptable donor site

cosmesis

Disadvantages• Partial skin graft loss• Tendon exposure• Delayed healing of STSG

donor site• # radius at harvest• Sensory loss in distribution of

superficial radial N• Restricted forearm function

Tubular shaped with Thick cortical bone

Nutrient A from peroneal A – enters the medial surface of bone just above its midpoint

Pedicle up to 8cm

Venacommitans

Fasciocutaneous- skin paddle centered over intermuscular septum & including deep fascia

The Free Fibula Flap Hidalgo 1989

The Free Fibula Flap

Indications • Short & long, anterior &

lateral segment reconstruction of mandible

• Reconstruction of hemimandible

• Ideal – angle to angle mandibular reconstruction

Contraindication • Peripheral vascular disease

Complications • Partial loss of donor site

STSG• Ankle stiffness• Donor site pain• Ankle instability• Peroneal N motor & sensory

loss• Decreased knee extension• Decreased flexion strength

The Free Fibula Flap

Advantages• Good vessel quality with

regard to both length & diameter

• Up to 27cm of bone• Segmental & intraosseous

blood supply- multiple osteotomies

• Long bicortical bone- osseointegration

• Allows for reshaping of bone• Two team approach

Disadvantages• Ltd cutaneous paddle• Soft tissue bulk often

requiring a second free flap

In 1978, Saijo was 1st to describe the scapular fasciocutaneous flap anatomy based on the circumflex scapular artery (CSA).

This donor site was popularized for head and neck reconstruction by Swartz et al in 1986

Based on the subscapular artery and vein, branches of the third part of the axillary artery and vein.

Scapular Flaps

Indications:• Oromandibular defects, • scalp defects, • Palatal / midface defects

Flaps based on the subscapular arterial system• Scapular/parascapular fasciocutaneous flap • Scapular/parascapular osteocutaneous flap • Latissimus dorsi muscle flap • Latissimus dorsi musculocutaneous flap • Serratus anterior muscle flap • Serratus anterior musculocutaneous flap • Dorsal thoracic fascia flap

Scapular Flaps

Osteocutaneous, osteomusculocutaneous

Segmental mandibular defects

Up to 16 cm bone

Oromandibular reconstruction

No motor or sensate reconstruction

With or without simultaneous implant placement.

Skin paddle is not ideal for relining the oral cavity as it is too thick

Denervated muscle undergoes atrophy that leaves a thin, fixed, soft tissue coverage over the bone.

Iliac crest flaps

Deep circumflex iliac artery from lateral aspect of external iliac artery

1 – 2 cm cephalic to inguinal ligament

Ascending branch of deep circumflex iliac artery supplies internal oblique muscle

Pedicle to internal oblique can arise separately from deep circumflex iliac artery

Deep circumflex iliac vein – 2 venae comitantes

Can pass either superficial to deep to artery

Iliac crest flaps

Signs of abnormal perfusion• Arterial compromise

• Skin – Pale, slow capillary refill; cool.• Muscle – Pale; no brisk bleeding; skin graft not adherent; no

doppler signal.• Fascia – No palpable pulse; skin graft not adherent; no doppler

signal.• Venous compromise

• Skin – patchy; bluish fast capillary refill; cool.• Muscle – Dark; dark red bleeding; skin graft not adherent.• Fascia – Dark; greyish, doppler signal may remain normal for

a longer period

Monitoring of Flaps

Inflow• Arterial kinking• Inset too tight• Damage to pedicle• Arterial insufficiency• Thrombosis in extremity.

Outflow• Venous occlusion• Tunnel too tight.• Venous thrombosis in major veins.• Kinking of pedicle.

Hematoma under flap

Possible causes of impaired perfusion

Clinical tests:• Skin colour• Temperature of flap• Capillary refill and bleeding characteristics

Chemical methods• Fluorescein (resorcinol pthalein)• Atropine – subcutaneous injection in flap to check the systemic effects.• Fiberoptic flurometry• Fiberoptic dermoflourometer – with flourescein delivery.

Radioisotopic methods• 24Na, 131I, 99mTc, 133Xe

Instrumental methods• Temperature• Transcutaneous gas measurements.• Photoelectric method – photoplathysmography & reflection spectophotometry.• Doppler shift flowmetry• Electromagnetic flowmetry• Interstitial fluid pressure measurement.

Monitors for Cutaneous Microcirculation

ATTEMPTS TO ALTER SKIN FLAP VIABILITY

Incise and undermine• 10 to 21 day delay most common• No benefit at 3 wks to 3 mos• Improved blood supply

• AV shunt closure• Conditioning to ischemia• Alignment of vessel

Delay in Flaps

Delay• Four facts are accepted about the delay phenomenon

• Surgical trauma to flap• Large percentage of the neurovascular supply to the flap must be

eliminated. • Delay results in increased flap survival at the time of tissue transfer. • Beneficial effects can last upto 6 weeks.

Three theories • Delay improves blood flow

• Depletion of vasoconstricting substances • Formation of collateral and reorientation of vascular channels • Stimulation of inflammatory response • Release of vasodilating substance

• Conditions tissue to ischemia • Closure of arteriovenous shunts

In surviving flaps, the blood flow gradually increases if the flap is in a favorable recipient site,

A fibrin layer forms with in the first 2 days.

Neovascularization of the flap begins 3 to 7 days after flap transposition.

Revascularization adequate for division of the flap pedicle by 7th day

The return of blood flow to a flap that is ischemic due to excessive release of norepinephrine occurs in approximately 12 – 48 hours.

Fate of flap

CAUSES OF FLAP COMPLICATIONS

Preoperative• Poor flap design • Pre morbid condition

of the patient

Intraoperative • Technical errors.• Design errors• Poor choice of

recipent vessels

Post operative • Extrinsic

• Pedicle kinking • Infection• Vascular thrombosis

• Intrinsic• Distal ischemia

Releasing the sutures to relieve any tension which may be compromising the circulation

Venous congestion can be relieved by elevating the flap or changing it from a dependent position

Hynes (1951) designed a mechanical intermittent ve nous occluder device, which could be applied to the distal end of the flap

Leeches

Cooling

Hyperbaric oxygen

Dextran

SALVAGING THE FLAPS OF MARGINAL VIABILITY.

Head & Neck Surgery- Stell & Maran

Grabb’s Encyclopedia of Head and Neck Reconstruction:1998

Plastic Surgery, McCarthy, Vol 5 , Tumours of Head & Neck

Cancer of Face and the Mouth, Pathology and management for surgeon - Mcgregor.

Basic principles of oral and maxillofacial surgery, Peterson

Facial Plastic and Reconstructive surgery, Ira A Papel. 1992

Local Flaps in Facial Reconstruction, Shan Ray Baker & Neil A Swanson

Maxillofacial Surgery Vol 2; P W Booth, Stephen A Schendel

OCNA- 1994, August 2001

OMFSCNA- NOV 2003

AOMFSC- SEPT 2006, MARCH 2007

References