Microvascular Free Flaps Used in Head and Neck Reconstruction. / orthodontic courses by Indian dental academy

Microvascular Free Flaps Microvascular Free Flaps Used in Head and Neck Used in Head and Neck

Reconstruction.Reconstruction. INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.comwww.indiandentalacademy.com

OutlineOutline► Radial Forearm FlapsRadial Forearm Flaps► Lateral Arm FlapsLateral Arm Flaps► Lateral Thigh FlapLateral Thigh Flap► Anterolateral Thigh FlapAnterolateral Thigh Flap► Rectus Abdominis FlapsRectus Abdominis Flaps► Latissimus Dorsi FlapLatissimus Dorsi Flap► Gracilis Flap Gracilis Flap ► Temperoparietal Fascial FlapTemperoparietal Fascial Flap► Fibular Osteocutanous FlapFibular Osteocutanous Flap► Iliac Crest FlapsIliac Crest Flaps► Scapular FlapsScapular Flaps► Metatarsal FlapMetatarsal Flap► Rib FlapsRib Flaps► JejunumJejunum► Omentum Omentum ► GastroomentumGastroomentum

www.indiandentalacademy.com

Radial Forearm FlapRadial Forearm Flap► 1981 (China), 1985 (pharyngeal recon)1981 (China), 1985 (pharyngeal recon)► Oral cavity, base of tongue, pharynx, soft Oral cavity, base of tongue, pharynx, soft

palate, cutaneous defects, base of skull, palate, cutaneous defects, base of skull, small volume bone and soft tissue defects of small volume bone and soft tissue defects of faceface

► Thin, pliable skinThin, pliable skin Reconstitution of contours, sulci, Reconstitution of contours, sulci,

vestibulesvestibules Tongue mobilityTongue mobility

► Fasciocutaneous flaps are highly tolerant of Fasciocutaneous flaps are highly tolerant of radiation therapy radiation therapy

► Composite flap with bone, tendon, Composite flap with bone, tendon, brachioradialis muscle and vascularized brachioradialis muscle and vascularized nerve.nerve. Sensory recovery reported in patients Sensory recovery reported in patients

even when a neural anastomosis is not even when a neural anastomosis is not performed.performed.► Fasciocutaneous flaps > Fasciocutaneous flaps >

musculocutaneous flapsmusculocutaneous flaps► Incomplete and unpredictableIncomplete and unpredictable

► Skin from entire forearmSkin from entire forearm► 2 team approach2 team approach


Neurovascular pedicleNeurovascular pedicle► Up to 20 cm longUp to 20 cm long► Vessel caliber 2 – 2.5 mmVessel caliber 2 – 2.5 mm► Radial arteryRadial artery► Venae comitantes / Venae comitantes /

cephalic veincephalic vein► Lateral antebrachial Lateral antebrachial

cutaneous nerve (sensory)cutaneous nerve (sensory) Anastomose to lingual nerveAnastomose to lingual nerve Increased two point Increased two point

discrimination after insetdiscrimination after inset


Technical considerationsTechnical considerations► TourniquetTourniquet

► Flap designed with skin Flap designed with skin paddle centered over the paddle centered over the radial arteryradial artery

► Dissection in subfascial level Dissection in subfascial level as the pedicle is approached.as the pedicle is approached.

► Pedicle identified b/w medial Pedicle identified b/w medial head of the brachioradialis, head of the brachioradialis, and the flexor carpi radialisand the flexor carpi radialis

► Radial artery is dissected to Radial artery is dissected to its originits origin Divided distal to the radial Divided distal to the radial

recurrent arteryrecurrent artery

► External skin monitor can be External skin monitor can be incorporated into the flap incorporated into the flap (proximal segment)(proximal segment)

► A -plasty - reduces the A -plasty - reduces the potential for stricturepotential for stricture


Technical considerationsTechnical considerations► Osteocutaneous flapOsteocutaneous flap

MonocorticalMonocortical Cuff of flexor pollicis longusCuff of flexor pollicis longus 10 – 12 cm of radius10 – 12 cm of radius Up to 40% circumferenceUp to 40% circumference Limited by amount of available bone and risk for Limited by amount of available bone and risk for

pathologic fracture. pathologic fracture. ► Pollicis longus tendonPollicis longus tendon

Suspending flap laterally in palatal and Suspending flap laterally in palatal and total lower lip recontotal lower lip recon


Radial Forearm FlapRadial Forearm Flap






Radial Forearm FlapRadial Forearm Flap► MorbidityMorbidity

Hand ischemiaHand ischemia Fistula rates - 42% to 67% in early seriesFistula rates - 42% to 67% in early series

► Subsequent series - 15% and 38%. Subsequent series - 15% and 38%. ► Creation of a controlled fistula or use of a Creation of a controlled fistula or use of a

salivary bypass stent can protect the suture line salivary bypass stent can protect the suture line from salivary soilage and decrease the potential from salivary soilage and decrease the potential for fistulization.for fistulization.

Stricture formation - 9% to 50%.Stricture formation - 9% to 50%. Radial nerve injuryRadial nerve injury Variable anesthesia over dorsum of hand.Variable anesthesia over dorsum of hand.


Radial Forearm FlapRadial Forearm Flap► Preoperative considerationsPreoperative considerations

Allen testAllen test► Tests viability of palmar Tests viability of palmar

arch systemarch system No IVs / blood draws in donor No IVs / blood draws in donor

arm.arm. Skin graft (must preserve Skin graft (must preserve

paratenon layer)paratenon layer) Osteocutaneous flapsOsteocutaneous flaps

► Radius fractureRadius fracture► Weakened supination, Weakened supination,

wrist flexion, grip strength wrist flexion, grip strength and pinch strength.and pinch strength.

Should not be used defect Should not be used defect extends below the thoracic extends below the thoracic inletinlet

► Postoperative managementPostoperative management Forearm and wrist Forearm and wrist

immobilization w/volar immobilization w/volar splintsplint

7-10 days7-10 days Oral intake can generally Oral intake can generally

begin within 7 to 10 daysbegin within 7 to 10 days► 2 weeks is best if the 2 weeks is best if the

patient has been previously patient has been previously irradiated.irradiated.


Lateral Arm FlapLateral Arm Flap► Described by Song in 1982 Described by Song in 1982 ► Moderately thin fasciocutaneous Moderately thin fasciocutaneous

flapflap► Donor site skin 6-8 cm (1/3 Donor site skin 6-8 cm (1/3

circumference of arm)circumference of arm)► Fascial flapFascial flap

Augmentation of subcutaneous Augmentation of subcutaneous defects from lateral temporal defects from lateral temporal bone resection or total parotidbone resection or total parotid

► Portion of humerus can be taken.Portion of humerus can be taken.► Oropharyngeal reconstructionOropharyngeal reconstruction

Incorporates thin skin from the Incorporates thin skin from the proximal forearm.proximal forearm.►Pharyngeal wallPharyngeal wall

Thick skin from the upper armThick skin from the upper arm►Tongue baseTongue base


Neurovascular pedicleNeurovascular pedicle► Terminal branch of profunda brachii Terminal branch of profunda brachii

artery and posterior radial collateral artery and posterior radial collateral arteryartery

► Venae comitantesVenae comitantes► Travel with radial nerve in spiral groove Travel with radial nerve in spiral groove

of humerusof humerus Travels in the lateral intermuscular Travels in the lateral intermuscular

septum septum ► Posterior - Triceps Posterior - Triceps ► Anterior - Brachialis and Anterior - Brachialis and

BrachioradialisBrachioradialis► Artery caliber 1.55 mm diameter (1.25 Artery caliber 1.55 mm diameter (1.25

to 1.75 mm) @ deltoid insertionto 1.75 mm) @ deltoid insertion► Skin blood supply – 4 to 5 Skin blood supply – 4 to 5

septocutaneous perforaters septocutaneous perforaters ► Sensory nerves (from proximal radial Sensory nerves (from proximal radial

nerve)nerve) Posterior cutaneous nerve of the Posterior cutaneous nerve of the

arm (lower lateral brachial arm (lower lateral brachial cutaneous nerve)cutaneous nerve)

Posterior cutaneous nerve of the Posterior cutaneous nerve of the forearm (post antebrachial cut forearm (post antebrachial cut nerve)nerve) www.indiandentalacademy.com

Technical considerationsTechnical considerations► No tourniquet.No tourniquet.► Central axis of flap design based on Central axis of flap design based on

intermuscular septumintermuscular septum Lateral intermuscular septum - 1 Lateral intermuscular septum - 1

cm posterior to line drawn from cm posterior to line drawn from insertion of deltoid and lateral insertion of deltoid and lateral epicondyleepicondyle

Can be extended distally over Can be extended distally over the upper forearmthe upper forearm

► Radial nerve identified along the Radial nerve identified along the anterior aspect of the pedicleanterior aspect of the pedicle

► Radial nerve and pedicle are Radial nerve and pedicle are followed into the spiral groovefollowed into the spiral groove

► Must identify and preserve muscular Must identify and preserve muscular branches from radial nervebranches from radial nerve

► Osteocutaneous flapOsteocutaneous flap Humerus segmentHumerus segment

► 10 cm in length10 cm in length► 20% of the circumference20% of the circumference


Lateral Arm FlapLateral Arm Flap►MorbidityMorbidity

Radial nerve damageRadial nerve damage►Palsy 2/2 constrictive Palsy 2/2 constrictive

dressings or tight wound dressings or tight wound closure.closure.

Primary closure if less Primary closure if less than 1/3 of armthan 1/3 of arm►Use STSG if closure Use STSG if closure

under too much tension.under too much tension.


Lateral Arm FlapLateral Arm Flap►Preoperative ConsiderationsPreoperative Considerations

Easy scar camouflageEasy scar camouflage Male patients may have less Male patients may have less

hair in this region when hair in this region when compared to forearmcompared to forearm►Consider for intraoral Consider for intraoral

reconstructionreconstruction Flap becomes thinner more Flap becomes thinner more

distallydistallywww.indiandentalacademy.com

Lateral Thigh FlapLateral Thigh Flap►Described by Baek in 1983Described by Baek in 1983► Large surface areaLarge surface area► Expendable tissueExpendable tissue► Flap size up to 25 x 14 cmFlap size up to 25 x 14 cm► Fasciocutaneous flap – Fasciocutaneous flap –

thin to moderately thickthin to moderately thick► Intraoral and pharyngeal Intraoral and pharyngeal

reconstructionreconstruction► Reinnervated via lateral Reinnervated via lateral

femoral cutaneous nervefemoral cutaneous nerve


Neurovascular pedicleNeurovascular pedicle► Third perforator of profunda Third perforator of profunda

femorisfemoris► Travels w/in intermuscular Travels w/in intermuscular

septumseptum► Pedicle 8 – 12 cmPedicle 8 – 12 cm► Vessel caliber 2 – 4 mmVessel caliber 2 – 4 mm► Lateral femoral cutaneous Lateral femoral cutaneous

nerve of the thighnerve of the thigh Anterosuperior entry into Anterosuperior entry into

flapflap Does not travel with Does not travel with

vascular pediclevascular pedicle

► Terminal cutaneous branch of Terminal cutaneous branch of second or fourth perforators second or fourth perforators are the dominant arterial are the dominant arterial supply (rare)supply (rare) 44thth perforator usually perforator usually

included in dissection to included in dissection to account for variationsaccount for variations

When 2When 2ndnd perforator perforator dominant – pedicle length dominant – pedicle length limited by muscular branch limited by muscular branch vessels to preserve femoral vessels to preserve femoral blood supply.blood supply.


Lateral Thigh FlapLateral Thigh Flap


Lateral Thigh FlapLateral Thigh Flap


Technical considerationsTechnical considerations► Centered over lateral intermuscular Centered over lateral intermuscular

septumseptum Separates vastus lateralis and iliotibial Separates vastus lateralis and iliotibial

tract (fascia lata) anteriorly from the tract (fascia lata) anteriorly from the biceps femoris posteriorlybiceps femoris posteriorly

► Septum located by line b/w greater Septum located by line b/w greater trochanter and lateral epicondyle of trochanter and lateral epicondyle of femurfemur

► 33rdrd perforator at midpoint of line perforator at midpoint of line Terminates in the intermuscular septum Terminates in the intermuscular septum

between the long head of the biceps between the long head of the biceps femoris and the vastus lateralisfemoris and the vastus lateralis

► Lateral femoral cutaneous nerve provides Lateral femoral cutaneous nerve provides sensation to the skin of the lateral thigh sensation to the skin of the lateral thigh and may be incorporated into the flapand may be incorporated into the flap

► Dominant perforator identified in Dominant perforator identified in subcutaneous plane and then traced subcutaneous plane and then traced through the biceps femoris to the main through the biceps femoris to the main pediclepedicle

► Release of the adductor magnus from the Release of the adductor magnus from the linea aspera facilitates dissection of the linea aspera facilitates dissection of the main pediclemain pedicle www.indiandentalacademy.com

Lateral Thigh FlapLateral Thigh Flap►MorbidityMorbidity

Atherosclerosis of profunda femoris and Atherosclerosis of profunda femoris and its branchesits branches

Avoid in pts with h/o PVDAvoid in pts with h/o PVD Sciatic nerve injurySciatic nerve injury


Lateral Thigh FlapLateral Thigh Flap► Preoperative Preoperative

ConsiderationsConsiderations Assess for PVD Assess for PVD

(palpate peripheral (palpate peripheral pulses)pulses)

Not advised for use Not advised for use in obese individuals in obese individuals or in those with or in those with previous surgery or previous surgery or trauma to the thightrauma to the thigh

► Postoperative Postoperative managementmanagement Primary closure of Primary closure of

donor site donor site Early walkingEarly walking


Anterolateral thigh flapAnterolateral thigh flap► First reported by Song et alFirst reported by Song et al► Subcutaneous, fasciocutaneous, Subcutaneous, fasciocutaneous,

myocutaneous, adipofascialmyocutaneous, adipofascial► Laryngopharynx, oral cavity, Laryngopharynx, oral cavity,

oropharynx, external skin and oropharynx, external skin and maxillamaxilla

► Flap may be thinned or Flap may be thinned or suprafascial flaps taken for suprafascial flaps taken for thinner flapsthinner flaps

► Popular in AsiaPopular in Asia► Less popular in Europe and Less popular in Europe and

AmericaAmerica Difficult perforator dissection Difficult perforator dissection

(bountiful subcutaneous tissue)(bountiful subcutaneous tissue) Variation in vascular anatomyVariation in vascular anatomy


Neurovascular pedicleNeurovascular pedicle► Descending branch of lateral Descending branch of lateral

circumflex femoral artery circumflex femoral artery SeptocutaneousSeptocutaneous

►Traverse the fascia lataTraverse the fascia lata Musculocutaneous Musculocutaneous

perforatorsperforators►Traverse the vastus Traverse the vastus

lateralis muscle and lateralis muscle and the deep fasciathe deep fascia

► Venae comitantesVenae comitantes► Descending branch travels Descending branch travels

inferiorly in intramuscular inferiorly in intramuscular space b/w rectus femoris and space b/w rectus femoris and vastus lateralisvastus lateralis

► Caliber – 2.1 mm artery, 2.6 Caliber – 2.1 mm artery, 2.6 mm veinmm vein

► Vascular pedicle up to 16 cmVascular pedicle up to 16 cm

► Lateral femoral cutaneous Lateral femoral cutaneous nerve – sensory nervenerve – sensory nerve Branch of lumbar plexusBranch of lumbar plexus Enters thigh deep to Enters thigh deep to

lateral aspect of inguinal lateral aspect of inguinal ligament near ASISligament near ASIS

Runs with deep Runs with deep circumflex iliac artery circumflex iliac artery and veinand vein

Runs anterior, posterior Runs anterior, posterior or through sartorius, or through sartorius, continuing through fascia continuing through fascia latalata


Neurovascular pedicleNeurovascular pedicle► Musculocutaneous variationsMusculocutaneous variations

Vertical musculocutaneous perforators (descending lateral Vertical musculocutaneous perforators (descending lateral circumflex femoral artery)circumflex femoral artery)►Pass through vastus lateralis perpendicularly into fascia Pass through vastus lateralis perpendicularly into fascia

latalata Horizontal musculocutaneous perforators (transverse Horizontal musculocutaneous perforators (transverse

branch of lateral circumflex femoral artery)branch of lateral circumflex femoral artery)►Pass through vastus lateralis horizontallyPass through vastus lateralis horizontally

► Skin blood supplySkin blood supply Septocutaneous perforators – 10.7%Septocutaneous perforators – 10.7% Musculocutaneous perforators from descending branch – Musculocutaneous perforators from descending branch –

89%89% Musculocutaneous perforator from transverse branch – Musculocutaneous perforator from transverse branch –

3.5%3.5%www.indiandentalacademy.com

Anterolateral thigh flapAnterolateral thigh flap




Technical considerationsTechnical considerations► Draw line from ASIS to lateral patellar borderDraw line from ASIS to lateral patellar border► Cutaneous perforator exit point from Cutaneous perforator exit point from

intermuscular septum or from vastus lateralisintermuscular septum or from vastus lateralis 2 cm lateral to and 2 cm inferior to midpoint 2 cm lateral to and 2 cm inferior to midpoint

of line from ASIS and lateral border of patellaof line from ASIS and lateral border of patella► Use Doppler to mark perforatorsUse Doppler to mark perforators► Dissect (medial to lateral) to intermuscular Dissect (medial to lateral) to intermuscular

septum b/w rectus femoris and vastus lateralis.septum b/w rectus femoris and vastus lateralis.► Retract rectus femoris medially exposing Retract rectus femoris medially exposing

perforators perforators Leave muscle cuff around myocutaneous Leave muscle cuff around myocutaneous

perforatorsperforators► Fasciocutaneous flap, suprafascial flap, Fasciocutaneous flap, suprafascial flap,

cutaneous flap (up 5 mm thickness), adipofascial cutaneous flap (up 5 mm thickness), adipofascial flapflap

► May include lateral cutaneous nerve of thighMay include lateral cutaneous nerve of thigh► Max size – horizontal line from greater trochanter Max size – horizontal line from greater trochanter

down to a parallel line 3 cm above patella down to a parallel line 3 cm above patella 25 x 18 cm25 x 18 cm 20 x 26 cm20 x 26 cm

► Close donor site primarily if less than 8 cm wideClose donor site primarily if less than 8 cm widewww.indiandentalacademy.com



Anterolateral thigh flapAnterolateral thigh flap►MorbidityMorbidity

Possible STSGPossible STSG Depends on extent of injury to vastus Depends on extent of injury to vastus

lateralislateralis Thinned flaps with more complications in Thinned flaps with more complications in

intraoral defectsintraoral defects


Anterolateral thigh flapAnterolateral thigh flap►Preoperative ConsiderationsPreoperative Considerations

Reduced donor site morbidity compared Reduced donor site morbidity compared to RFFto RFF

Can be as thin as RFFCan be as thin as RFF Contraindicated in pts with prior upper Contraindicated in pts with prior upper

thigh surgery, vascular procedures, big thigh surgery, vascular procedures, big eaters…eaters…


Rectus abdominisRectus abdominis► Easy to harvestEasy to harvest► Long pedicleLong pedicle► Skin from abdomen and lower chestSkin from abdomen and lower chest► Myocutaneous flap or muscle only flapMyocutaneous flap or muscle only flap► Not used for functional motor reconstructionNot used for functional motor reconstruction► Can include entire muscle or only small portion in Can include entire muscle or only small portion in

paraumbilical regionparaumbilical region► Plentiful people – thinner flap created by skin Plentiful people – thinner flap created by skin

grafting the musclegrafting the muscle► Skinny peopleSkinny people

Flap used for moderately volume defectsFlap used for moderately volume defects► Poor color matchPoor color match► Tends to become ptoticTends to become ptotic► Skull base defectsSkull base defects

Muscular component used to seal subarachnoid Muscular component used to seal subarachnoid spacespace

► Able to fill large tissue deficitsAble to fill large tissue deficits► Total glossectomy defectsTotal glossectomy defects


Neurovascular pedicleNeurovascular pedicle► Two dominant pediclesTwo dominant pedicles

Deep superior epigastric artery/veinDeep superior epigastric artery/vein Deep inferior epigastric artery and Deep inferior epigastric artery and

veinvein► Based on inferior epigastrics Based on inferior epigastrics

when used for h/n recon when used for h/n recon because of larger pedicle sizebecause of larger pedicle size

► Inferior epigastric diameter – 3 Inferior epigastric diameter – 3 to 4 mmto 4 mm

► Reinnervated with any of the Reinnervated with any of the lower six intercostal nerves.lower six intercostal nerves.

► Pedicle may travel along lateral Pedicle may travel along lateral aspect of muscle before taking aspect of muscle before taking intramuscular routeintramuscular route


Technical considerationsTechnical considerations► Cutaneous blood supplyCutaneous blood supply

Harvest anterior rectus sheath in Harvest anterior rectus sheath in paraumbilical region (dominant perforators paraumbilical region (dominant perforators located here)located here)

Skin paddle designed with epicenter above Skin paddle designed with epicenter above the umbilicusthe umbilicus

► Primary closurePrimary closure► Hernia prevention depends on restoring Hernia prevention depends on restoring

abdominal wall.abdominal wall.► Arcuate line (level of ASIS)Arcuate line (level of ASIS)

Superior – posterior sheath with Superior – posterior sheath with transversalis fascia, internal oblique and transversalis fascia, internal oblique and transversus abdoministransversus abdominis► Closure of posterior sheath prevents Closure of posterior sheath prevents

herniationherniation Inferior – only transversalis fascia posterior Inferior – only transversalis fascia posterior

to muscleto muscle► Must close anterior sheath to prevent Must close anterior sheath to prevent

herniationherniation


Technical considerationsTechnical considerations1.1. Dissect superiorly firstDissect superiorly first2.2. Dissect down to underlying muscleDissect down to underlying muscle3.3. Split fascia to the costal marginSplit fascia to the costal margin4.4. Lateral and inferior portions of skin Lateral and inferior portions of skin

paddle incised nextpaddle incised next5.5. Small cuff of anterior rectus fascia Small cuff of anterior rectus fascia

preserved medially and laterally, to preserved medially and laterally, to preserve cutaneous perforatorspreserve cutaneous perforators

6.6. Split fascia vertically down to the Split fascia vertically down to the public regionpublic region

7.7. Divide rectus superiorly and free Divide rectus superiorly and free from posterior rectus sheathfrom posterior rectus sheath

8.8. Dissection below the arcuate line Dissection below the arcuate line 9.9. Vascular pedicle identified below Vascular pedicle identified below

arcuate line along the lateral deep arcuate line along the lateral deep aspect of the muscle. aspect of the muscle.

10.10. Divide rectus inferiorlyDivide rectus inferiorly11.11. Pedicle dissected inferiorly to origin Pedicle dissected inferiorly to origin

off the external iliac systemoff the external iliac system


Rectus abdominisRectus abdominis






Rectus abdominisRectus abdominis►MorbidityMorbidity

Abdominal weaknessAbdominal weakness HerniaHernia


Rectus abdominisRectus abdominis► Preoperative Preoperative

ConsiderationsConsiderations Prior abdominal Prior abdominal

surgerysurgery Prior inguinal Prior inguinal

herniorrhapy may herniorrhapy may compromise pedicle compromise pedicle dissection 2/2 dissection 2/2 scarringscarring

HerniaHernia Diastasis rectiDiastasis recti

► Postoperative Postoperative managementmanagement IleusIleus Avoid abdominal Avoid abdominal

strain for 6 weeks.strain for 6 weeks.


Latissimus dorsiLatissimus dorsi► Pedicle or free flapPedicle or free flap► Free flapsFree flaps

Better flap positioningBetter flap positioning Cutaneous portion can be centered over pedicleCutaneous portion can be centered over pedicle Less risk of pedicle kinkingLess risk of pedicle kinking

► MusculocutaneousMusculocutaneous Large volume defects of large cutaneous neck Large volume defects of large cutaneous neck

defectsdefects► Muscle-only flapMuscle-only flap

Broad and thinBroad and thin Atrophies to about 4 mmAtrophies to about 4 mm Ideal for scalp reconstructionIdeal for scalp reconstruction Poor for large volume defectsPoor for large volume defects

► Massive scalp defectsMassive scalp defects► STSG for final resurfacingSTSG for final resurfacing► Non sensateNon sensate► Motor reconstruction possibleMotor reconstruction possible► Useful after total glossectomyUseful after total glossectomy


Neurovascular pedicleNeurovascular pedicle► Thoracodorsal arteryThoracodorsal artery► Arise from subscapular vessels Arise from subscapular vessels

off of third portion of axillary off of third portion of axillary artery and veinartery and vein

► Vessel diameter at origin – 2.7 Vessel diameter at origin – 2.7 mm(1.5 to 4.0)mm(1.5 to 4.0)

► Vein diameter – 3.4 mm (1.5 to Vein diameter – 3.4 mm (1.5 to 4.5)4.5)

► Pedicle length 9.3 cm (6 to 16.5)Pedicle length 9.3 cm (6 to 16.5) Can be lengthened by sacrificing Can be lengthened by sacrificing

branch to serratus anteriorbranch to serratus anterior► Numerous variationsNumerous variations

Most common: independent origin Most common: independent origin of thoracodorsal vein/arteryof thoracodorsal vein/artery


Technical considerationsTechnical considerations► Lateral decubitis positionLateral decubitis position

If at 15 degrees, flap may If at 15 degrees, flap may be harvested be harvested simultaneously with primary simultaneously with primary lesion resectionlesion resection

Anterior muscle border Anterior muscle border along line b/w midpoint of along line b/w midpoint of axilla and point midway b/w axilla and point midway b/w ASIS and PSISASIS and PSIS

► Vessels enter undersurface of Vessels enter undersurface of muscle 8 to 10 cm below muscle 8 to 10 cm below midpoint of axillamidpoint of axilla

► Serratus vessels ligated during Serratus vessels ligated during harvestharvest

► Can design two paddle flap Can design two paddle flap based on medial and lateral based on medial and lateral branches of thoracodorsal branches of thoracodorsal vesselsvessels

► Total glossectomy insetting.Total glossectomy insetting. Muscle inset as a sling on Muscle inset as a sling on

undersurface of mandible undersurface of mandible Sutured to pterygoid, masseter, Sutured to pterygoid, masseter,

or superior constrictor... or superior constrictor... Thoracodorsal nerve Thoracodorsal nerve

anastomosed to a hypoglossal anastomosed to a hypoglossal nervenerve► Gives reconstructed tongue the Gives reconstructed tongue the

ability to elevate superiorly ability to elevate superiorly toward the palatetoward the palate


Latissimus dorsiLatissimus dorsi


Latissimus dorsiLatissimus dorsi►MorbidityMorbidity

Marginal flap necrosisMarginal flap necrosis Pedicled flaps pass b/w pec major and Pedicled flaps pass b/w pec major and

minorminor►Changes in arm position may occlude pedicleChanges in arm position may occlude pedicle►Should immobilize arm in flexed positionShould immobilize arm in flexed position


Latissimus dorsiLatissimus dorsi► Preoperative Preoperative

ConsiderationsConsiderations Relative Relative

contraindications - contraindications - prior axillary LN prior axillary LN dissectiondissection

Preop angiography Preop angiography advocated to assess advocated to assess vessel patencyvessel patency

► Postoperative Postoperative managementmanagement Suction drainsSuction drains High incidence of High incidence of

seromaseroma


Gracilis flapGracilis flap►19761976►Thin muscle flapThin muscle flap►Dynamic facial Dynamic facial

reanimationreanimation►Muscle revasularized Muscle revasularized

and reinnervatedand reinnervated►Long vascular pedicleLong vascular pedicle►Easy dissectionEasy dissection


Neurovascular pedicleNeurovascular pedicle► Terminal branch of adductor artery from Terminal branch of adductor artery from

profunda femorisprofunda femoris► Runs b/w adductor longus (anterior) and Runs b/w adductor longus (anterior) and

adductor brevis and magnus (posterior)adductor brevis and magnus (posterior) Enters gracilis at junction of upper Enters gracilis at junction of upper

third and lower two thirdsthird and lower two thirds 8 – 10 cm inferior to pubic tubercle8 – 10 cm inferior to pubic tubercle

► 2 venae comitantes – drain into profunda 2 venae comitantes – drain into profunda femorisfemoris

► Artery caliber – 2 mmArtery caliber – 2 mm► Vein caliber 1.5 – 2.5 mmVein caliber 1.5 – 2.5 mm► Motor innervation – anterior branch of Motor innervation – anterior branch of

obturator nerveobturator nerve 2 – 3 cm cephalic to vascular pedicle.2 – 3 cm cephalic to vascular pedicle.

► Blood supply to skin variableBlood supply to skin variable Skin supplied mostly by Skin supplied mostly by

septocutaneous perforatorsseptocutaneous perforators


Technical considerationsTechnical considerations► Muscle can be split into at Muscle can be split into at

least two functional least two functional muscular unitsmuscular units

► Single neuromuscular unit Single neuromuscular unit can be transferred to can be transferred to decrease bulkdecrease bulk

► Orient skin paddle Orient skin paddle longitudinallylongitudinally Must be centered over Must be centered over

dominant dominant musculocutaneous musculocutaneous perforatorperforator

► For synchronous mimetic For synchronous mimetic movement when proximal movement when proximal facial nerve not available.facial nerve not available. 2 stage procedure with 2 stage procedure with

cross face sural nerve cross face sural nerve graftgraft

Tinel sign used to Tinel sign used to monitor axonal growth monitor axonal growth across the face – 9-12 across the face – 9-12 monthsmonths

After adequate axonal After adequate axonal regrowth – muscle regrowth – muscle transferredtransferred


Gracilis flapGracilis flap


Temperoparietal Fascia FlapTemperoparietal Fascia Flap► More commonly transferred as More commonly transferred as

a pedicled flap but can be used a pedicled flap but can be used as a free flap when arc of as a free flap when arc of rotation is inadequaterotation is inadequate

► Ultra thin – 2 to 4 mm thickUltra thin – 2 to 4 mm thick► Highly vascular, pliable and Highly vascular, pliable and

durabledurable► Fascial, fasciocutaneousFascial, fasciocutaneous► Up to 17 x 14 cm with Up to 17 x 14 cm with

extensive scalp underminingextensive scalp undermining► Oral cavity, hemilaryngectomy Oral cavity, hemilaryngectomy

defects, middle and upper defects, middle and upper regions of face w/split calvarial regions of face w/split calvarial bone graftbone graft


Neurovascular pedicleNeurovascular pedicle► 5 layers – scalp5 layers – scalp► Temperoparietal fascia (TPF) Temperoparietal fascia (TPF)

deep to skin and subcutaneous deep to skin and subcutaneous tissue.tissue.

► Superficial to temporalis Superficial to temporalis muscular fasciamuscular fascia

► Above superior temporal line Above superior temporal line it’s continuous with galea it’s continuous with galea aponeuroticaaponeurotica

► Base centered over helixBase centered over helix

► Superficial temporal artery and Superficial temporal artery and vein – travel in TPF layervein – travel in TPF layer 3 cm superior to root of helix3 cm superior to root of helix Vessels branch into frontal and Vessels branch into frontal and

temporal divisionstemporal divisions Most commonly based on Most commonly based on

parietal branchparietal branch Ligation of frontal artery 3 – 4 cm Ligation of frontal artery 3 – 4 cm

distal to branching point to avoid distal to branching point to avoid frontal nerve injuryfrontal nerve injury

Venous pedicle may course with Venous pedicle may course with arteries or 2 to 3 cm posteriorlyarteries or 2 to 3 cm posteriorly

► Middle temporal artery – Middle temporal artery – proximal superficial temporal proximal superficial temporal artery at zygomatic arch artery at zygomatic arch (supplies temporalis muscular (supplies temporalis muscular fascia)fascia)

► Including middle temporal artery Including middle temporal artery enables a two-layered fascial enables a two-layered fascial flap on a single pedicle.flap on a single pedicle.


Temperoparietal Fascia FlapTemperoparietal Fascia Flap


Technical considerationsTechnical considerations►Vertical incision over root of helix to Vertical incision over root of helix to

superior temporal linesuperior temporal line►V-shaped extension at superior limit of V-shaped extension at superior limit of

incisionincision►Scalp elevation ant and postScalp elevation ant and post►Dissect deep to flapDissect deep to flap►Loose areolar tissue deep to flapLoose areolar tissue deep to flap


Temperoparietal Fascia FlapTemperoparietal Fascia Flap


Temperoparietal Fascia FlapTemperoparietal Fascia Flap►MorbidityMorbidity

Frontal branch weakness (travels in TPF)Frontal branch weakness (travels in TPF) Secondary alopecia – damage to hair Secondary alopecia – damage to hair

follicles due to superficial dissectionfollicles due to superficial dissection


Temperoparietal Fascia FlapTemperoparietal Fascia Flap►Preoperative ConsiderationsPreoperative Considerations

Relative contraindications - prior XRT, Relative contraindications - prior XRT, neck surgery, bicoronal incision or neck surgery, bicoronal incision or external carotid embolization.external carotid embolization.

Doppler assessment of pedicleDoppler assessment of pedicle


Fibular osteocutaneous flapFibular osteocutaneous flap► 19751975►Hidalgo – mandibular recon Hidalgo – mandibular recon

19891989► Longest possible segment of Longest possible segment of

revasularized bone (25 cm)revasularized bone (25 cm)► Ideal for osseointegrated Ideal for osseointegrated

implant placementimplant placement►Mandible reconstruction Mandible reconstruction

(near total), maxillary (near total), maxillary reconstructionreconstruction


Neurovascular pedicleNeurovascular pedicle► Peroneal artery and veinPeroneal artery and vein► Sensate restoration with lateral Sensate restoration with lateral

sural cutaneous nervesural cutaneous nerve► Peroneal communicating branch Peroneal communicating branch

vascularized nerve graft for lower vascularized nerve graft for lower lip sensationlip sensation

► Skin perforatorsSkin perforators Posterior intermuscular septum Posterior intermuscular septum

(septocutaneous or (septocutaneous or musculocutaneous through flexor musculocutaneous through flexor hallucis longus and soleus)hallucis longus and soleus)

Should always include cuff of flexor Should always include cuff of flexor hallucis longus and soleus in flap hallucis longus and soleus in flap harvestharvest

5-10% of cases blood supply to skin 5-10% of cases blood supply to skin paddle is inadequatepaddle is inadequate


Technical considerationsTechnical considerations► Choose leg based on ease of Choose leg based on ease of

insettinginsetting Intraoral skin paddleIntraoral skin paddle

► Harvest flap from Harvest flap from contralateral side of contralateral side of recipient vesselsrecipient vessels

► 8 cm segment preserved 8 cm segment preserved proximally and distally to proximally and distally to protect common peroneal verve protect common peroneal verve and ensure ankle stabilityand ensure ankle stability

► Center flap over posterior Center flap over posterior intermuscular septumintermuscular septum Anterior to soleus and Anterior to soleus and

posterior to peroneusposterior to peroneus► Doppler cutaneous perforatorsDoppler cutaneous perforators► Greatest number of perforators Greatest number of perforators

present in the 15 to 25 cm present in the 15 to 25 cm rangerange

► Distal skin paddle increases Distal skin paddle increases pedicle lengthpedicle length

► Thigh tourniquet to 350 mm HgThigh tourniquet to 350 mm Hg► Vascularity to skin running Vascularity to skin running

through the septocutaneous through the septocutaneous perforators may be enhanced perforators may be enhanced by harvesting a segment of by harvesting a segment of soleus to capture additional soleus to capture additional musculocutaneous perforatorsmusculocutaneous perforators


Fibular osteocutaneous flapFibular osteocutaneous flap






Fibular osteocutaneous flapFibular osteocutaneous flap►MorbidityMorbidity

Donor site complicationsDonor site complications►EdemaEdema►Weakness in dorsiflexion of great toeWeakness in dorsiflexion of great toe

Skin loss in 5 – 10% of flapsSkin loss in 5 – 10% of flaps►reliability of the skin is questionable, and both the reliability of the skin is questionable, and both the

surgeon and the patient should be prepared for surgeon and the patient should be prepared for the possible need for a second soft tissue flap, the possible need for a second soft tissue flap, either free or pedicled, when reconstructing either free or pedicled, when reconstructing composite defects with a fibular osteocutaneous composite defects with a fibular osteocutaneous flapflap

May need STSG over donor site closureMay need STSG over donor site closurewww.indiandentalacademy.com

Fibular osteocutaneous flapFibular osteocutaneous flap► Preoperative Preoperative

ConsiderationsConsiderations AngiographyAngiography MRAMRA h/o distal lower h/o distal lower

extremity fractureextremity fracture Look for varicose Look for varicose

veins, edemaveins, edema

► Postoperative Postoperative managementmanagement Distal pulses Distal pulses

monitoredmonitored Posterior splint for Posterior splint for

10 days10 days


Iliac crest flapsIliac crest flaps► Osteocutaneous, Osteocutaneous,

osteomusculocutaneousosteomusculocutaneous► Segmental mandibular defectsSegmental mandibular defects► Up to 16 cm boneUp to 16 cm bone► Oromandibular reconstructionOromandibular reconstruction► No motor or sensate reconstructionNo motor or sensate reconstruction► Only vascularized bone used Only vascularized bone used

extensively with simultaneous or extensively with simultaneous or delayed endosteal dental implant delayed endosteal dental implant placementplacement

► Skin paddle was not ideal for relining Skin paddle was not ideal for relining the oral cavitythe oral cavity Too thick for accurate restoration of Too thick for accurate restoration of

the 3D anatomythe 3D anatomy► Inclusion of internal oblique flapInclusion of internal oblique flap

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


Neurovascular pedicleNeurovascular pedicle► Deep circumflex iliac artery from Deep circumflex iliac artery from

lateral aspect of external iliac arterylateral aspect of external iliac artery 1 – 2 cm cephalic to inguinal 1 – 2 cm cephalic to inguinal

ligamentligament► Ascending branch of deep Ascending branch of deep

circumflex iliac artery supplies circumflex iliac artery supplies internal oblique muscleinternal oblique muscle

► Deep circumflex iliac vein – 2 venae Deep circumflex iliac vein – 2 venae comitantescomitantes Can pass either superficial to deep Can pass either superficial to deep

to arteryto artery► Artery caliber – 2 to 3 mmArtery caliber – 2 to 3 mm► Vein caliber – 3 to 5 mmVein caliber – 3 to 5 mm► Pedicle to internal oblique can arise Pedicle to internal oblique can arise

separately from deep circumflex separately from deep circumflex iliac arteryiliac artery


Iliac crest flapsIliac crest flaps


Technical considerationsTechnical considerations► Skin paddle centered on axis Skin paddle centered on axis

from ASIS to inferior tip of from ASIS to inferior tip of scapulascapula

► Cutaneous perforatorsCutaneous perforators 9 cm posterior to ASIS and 2.5 9 cm posterior to ASIS and 2.5

cm medial to iliac crestcm medial to iliac crest► Generous cuff of external Generous cuff of external

oblique, internal oblique and oblique, internal oblique and transversus abdominis layers transversus abdominis layers must be preserved to must be preserved to maintain cutaneous maintain cutaneous perforatorsperforators Internal oblique muscleInternal oblique muscle

► axial-pattern blood supplyaxial-pattern blood supply► Skin paddle bulky and Skin paddle bulky and

immobileimmobile► Do not rotate skin in order to Do not rotate skin in order to

prevent sheer injuryprevent sheer injurywww.indiandentalacademy.com





Iliac crest flapsIliac crest flaps►MorbidityMorbidity

HerniaHernia►Need to approximate cut edge of iliacus muscle to Need to approximate cut edge of iliacus muscle to

transversus abdoministransversus abdominis►Can be reinforced by drilling holes into cut edge of iliac Can be reinforced by drilling holes into cut edge of iliac

bonebone►Approximate external obliques and aponeurosis to Approximate external obliques and aponeurosis to

tensor fascia lata and gluteus musclestensor fascia lata and gluteus muscles►Keep inferior oblique inferior and anterior to ASISKeep inferior oblique inferior and anterior to ASIS

Skin loss from perforator sheer injurySkin loss from perforator sheer injury poor color matchpoor color match


Iliac crest flapsIliac crest flaps►Preoperative ConsiderationsPreoperative Considerations

h/o hernias, prior iliac bypass grafth/o hernias, prior iliac bypass graft Severe PVD,Severe PVD, Preop angioPreop angio


Scapular flapsScapular flaps► Fasciocutaneous, Fasciocutaneous,

osteofasciocutaneous, cutaneous flap, osteofasciocutaneous, cutaneous flap, parascapular cutaneous flap, latissimus parascapular cutaneous flap, latissimus dorsi myocutaneous flap, and serratus dorsi myocutaneous flap, and serratus anterior flapanterior flap

► Thin, hairless skinThin, hairless skin► Two cutaneous flaps may be harvestedTwo cutaneous flaps may be harvested

Horizontally oriented flap – transverse Horizontally oriented flap – transverse cutaneous branchcutaneous branch

Vertically oriented flap parascapular flap Vertically oriented flap parascapular flap – descending cutaneous branch– descending cutaneous branch

► Long pedicle lengthLong pedicle length► Large surface areaLarge surface area► Complex composite midfacial or Complex composite midfacial or

oromandibular defects oromandibular defects ► Up to 10 cm boneUp to 10 cm bone► Osseointegrated implants possibleOsseointegrated implants possible► Single team approachSingle team approach www.indiandentalacademy.com

Neurovascular pedicleNeurovascular pedicle► Subscapular artery and veinSubscapular artery and vein

Circumflex scapular artery and vein emerge Circumflex scapular artery and vein emerge from triangular space (teres major, teres from triangular space (teres major, teres minor and long head of triceps)minor and long head of triceps)

Paired venae comitantesPaired venae comitantes Artery caliber – 4 mm at takeoff from Artery caliber – 4 mm at takeoff from

subscapularsubscapular► Subscapular caliber – 6 mm at takeoff from Subscapular caliber – 6 mm at takeoff from

axillary arteryaxillary artery Pedicle length – 7 to 10 cm, 11 to 14 cm (from Pedicle length – 7 to 10 cm, 11 to 14 cm (from

axillary artery)axillary artery) Preservation of thoracodorsal vessels allows Preservation of thoracodorsal vessels allows

simultaneous transfer of latissimus and simultaneous transfer of latissimus and portion of serratus flapportion of serratus flap► Largest amount of tissue available for transferLargest amount of tissue available for transfer

► Thoracodorsal artery and circumflex Thoracodorsal artery and circumflex scapular artery can have separate origins scapular artery can have separate origins from axillary artery.from axillary artery.

► Non-sensate flapsNon-sensate flaps► Scapular vessels - very rarely affected by Scapular vessels - very rarely affected by

atherosclerosisatherosclerosiswww.indiandentalacademy.com

Scapular flapsScapular flaps


Technical considerationsTechnical considerations► Decubitis positioningDecubitis positioning

15 degree angle15 degree angle Separate axillary incision Separate axillary incision

helpful in dissecting pedicle helpful in dissecting pedicle to axillary artery and veinto axillary artery and vein

Bone harvestBone harvest►Teres major, Teres major,

subscapularis and subscapularis and latissimus dorsi need to latissimus dorsi need to be reattached to scapulabe reattached to scapula

► Flap harvest opposite side of Flap harvest opposite side of modified or radical neck modified or radical neck dissectiondissection


Scapular flapsScapular flaps


Scapular flapsScapular flaps►MorbidityMorbidity

Brachial plexus injury 2/2 lateral decubitis Brachial plexus injury 2/2 lateral decubitis positioningpositioning►Use axillary rollUse axillary roll

Stay 1 cm inferior to glenoid fossa Stay 1 cm inferior to glenoid fossa Detach teres major and minor to harvest Detach teres major and minor to harvest

bonebone►Can cause shoulder weakness and limit range Can cause shoulder weakness and limit range

of motion.of motion.


Scapular flapsScapular flaps► Preoperative Preoperative

ConsiderationsConsiderations Prior axillary node Prior axillary node

dissection – dissection – contraindicationcontraindication

► Postoperative Postoperative managementmanagement Immobilize for 3 to 4 Immobilize for 3 to 4

daysdays Early ambulationEarly ambulation 5 days for bone 5 days for bone

harvestharvest PTPT


Rib flapRib flap► First vascularized bone to be First vascularized bone to be

used in mandibular used in mandibular reconstruction. reconstruction. (osteocutaneous)(osteocutaneous)

► Blood supply to the rib Blood supply to the rib Internal mammary arteryInternal mammary artery Posteriorly or Posteriorly or

posterolaterally on the posterolaterally on the posterior intercostal vesselsposterior intercostal vessels

Transferred with the Transferred with the pectoralis major, serratus pectoralis major, serratus anterior, or latissimus dorsi anterior, or latissimus dorsi muscle muscle

► Poor bone stock except for Poor bone stock except for condylar reconstructioncondylar reconstruction

► Not commonly usedNot commonly used


Neurovascular pedicleNeurovascular pedicle


Metatarsus flapMetatarsus flap►Osteocutaneous flap Osteocutaneous flap

based on the first based on the first dorsal metatarsal dorsal metatarsal artery artery

►Thin sensate skin Thin sensate skin with the second with the second metatarsal. metatarsal.

►Limited bone Limited bone volumevolume

►Not commonly usedNot commonly usedwww.indiandentalacademy.com

Neurovascular pedicleNeurovascular pedicle


Jejunal flapJejunal flap► 19591959► Circumferential Circumferential

pharyngoesophageal defectspharyngoesophageal defects► Patch graftPatch graft► Diameter of jejunum – good Diameter of jejunum – good

match to cervical esophagusmatch to cervical esophagus► Ideal mucosal surfaceIdeal mucosal surface► Two team approachTwo team approach► AdvantagesAdvantages

Better superior positioningBetter superior positioning► DisadvantageDisadvantage

Inferior positioning limited by Inferior positioning limited by thoracic inletthoracic inlet

3 anastomoses3 anastomoses


Neurovascular pedicleNeurovascular pedicle►Mesenteric Mesenteric

arcade vesselsarcade vessels Usually 2Usually 2ndnd

arcade is best arcade is best for pharyngeal for pharyngeal reconstructionreconstruction


Technical considerationsTechnical considerations► Harvest distal to Ligament of Harvest distal to Ligament of

TreitzTreitz► Up to 20 cmUp to 20 cm► Laparoscopic harvest has been Laparoscopic harvest has been

reportedreported► Mark proximal graft with suture – Mark proximal graft with suture –

isoperistaltic placementisoperistaltic placement► Proximal end divided along Proximal end divided along

antimesenteric border to antimesenteric border to facilitate tongue base closurefacilitate tongue base closure

► Distal end – end to end Distal end – end to end anastomosisanastomosis Lock and key closureLock and key closure

► Exteriorize a monitoring segmentExteriorize a monitoring segment


Jejunal flapJejunal flap


Jejunal flapJejunal flap►MorbidityMorbidity

Most susceptible to primary ischemiaMost susceptible to primary ischemia Fistula formation – 18%Fistula formation – 18% 11% rate of anastomotic stricture11% rate of anastomotic stricture

►Higher rate if cervical anastomosis stapledHigher rate if cervical anastomosis stapled Wet voice (TEP)Wet voice (TEP) Functional obstruction 2/2 peristalsisFunctional obstruction 2/2 peristalsis DysgeusiaDysgeusia Harvest site complicationsHarvest site complications


Jejunal flapJejunal flap► Preoperative Preoperative

ConsiderationsConsiderations Absolute contraindicationsAbsolute contraindications

► Disease extension into Disease extension into proximal thoracic proximal thoracic esophagusesophagus

► AscitesAscites► Crohn’s diseaseCrohn’s disease

Relative contraindicationsRelative contraindications► Chronic intestinal diseasesChronic intestinal diseases► h/o abdominal surgeryh/o abdominal surgery

Consider angioConsider angio► Intraperitoneal sepsisIntraperitoneal sepsis

Do not use in laryngeal Do not use in laryngeal sparing proceduressparing procedures

► Postoperative Postoperative managementmanagement Remove monitoring Remove monitoring

segment pod 7.segment pod 7. Jejunostomy tubeJejunostomy tube


Gastroomental flapGastroomental flap► 1961, 19791961, 1979► Greater omentum – double layer of Greater omentum – double layer of

peritoneumperitoneum Hangs from greater curvature of Hangs from greater curvature of

stomach and transverse colonstomach and transverse colon► Omentum - thin and well vascularizedOmentum - thin and well vascularized

Excellent coverage for great vesselsExcellent coverage for great vessels Plasticity allows for variable placementPlasticity allows for variable placement Form adhesions to inflamed, ischemic, Form adhesions to inflamed, ischemic,

or necrotic tissuesor necrotic tissues► Separates them from surrounding tissuesSeparates them from surrounding tissues

Promotes healing in previously radiated Promotes healing in previously radiated fieldsfields

► Large scalp defects, Large scalp defects, ► Extensive midfacial defects w/coverage Extensive midfacial defects w/coverage

of split rib or calvarial graftsof split rib or calvarial grafts► Facial contouring Facial contouring ► Management of osteoradionecrosis or Management of osteoradionecrosis or

osteomyelitis in head and neckosteomyelitis in head and neck► Pharyngoesophageal reconstructionPharyngoesophageal reconstruction


Neurovascular pedicleNeurovascular pedicle► Right gastroepiploic Right gastroepiploic

arteryartery Caliber – 1.5 to 3.0 Caliber – 1.5 to 3.0

mmmm


Gastroomental flapGastroomental flap►MorbidityMorbidity

Intraabdominal complicationsIntraabdominal complications►Gastric leakGastric leak►PeritonitisPeritonitis► Intraabdominal abscessIntraabdominal abscess►VolvulusVolvulus►Gastric outlet obstructionGastric outlet obstruction

If mucosal flap too large or if placed too close to pylorusIf mucosal flap too large or if placed too close to pylorus FistulaFistula

► Preoperative ConsiderationsPreoperative Considerations h/o GOOh/o GOO h/o PUDh/o PUD


Gastroomental flapGastroomental flap


BibliographyBibliography1.1. Chepeha, DB, Teknos, TN. Microvascular Free Flaps in Head and Neck Chepeha, DB, Teknos, TN. Microvascular Free Flaps in Head and Neck

Reconstruction. In: Head and Neck Surgery—Otolaryngology, 3rd ed., Reconstruction. In: Head and Neck Surgery—Otolaryngology, 3rd ed., Bailey, BJ Ed. Philadelphia, Lippincott-Raven Publishers, 2001; 2045 – 2065.Bailey, BJ Ed. Philadelphia, Lippincott-Raven Publishers, 2001; 2045 – 2065.

2.2. Urken, ML, Buchbinder, D, Genden, EM. Reconstruction of the Mandible and Urken, ML, Buchbinder, D, Genden, EM. Reconstruction of the Mandible and Maxilla. In Otolaryngology Head and Neck Surgery, 4Maxilla. In Otolaryngology Head and Neck Surgery, 4 thth Ed. Edited by Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1618 – 1635.Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1618 – 1635.

3.3. Chang, KE, Gender, EM, Funk, G. Reconstruction of the Hypopharynx and Chang, KE, Gender, EM, Funk, G. Reconstruction of the Hypopharynx and Esophagus. In Otolaryngology Head and Neck Surgery, 4Esophagus. In Otolaryngology Head and Neck Surgery, 4 thth Ed. Edited by Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1945.Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1945.

4.4. Taylor, SM, Haughey, BH. Reconstruction of the Oropharynx. In Taylor, SM, Haughey, BH. Reconstruction of the Oropharynx. In Otolaryngology Head and Neck Surgery, 4Otolaryngology Head and Neck Surgery, 4 thth Ed. Edited by Cummings CC, Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1758.St. Louis: Mosby Year Book Inc.; 2004. 1758.

5.5. Lee, KJ. Essentials of Otolaryngology. 891.Lee, KJ. Essentials of Otolaryngology. 891.6.6. Lin, DT, Coppit, GL, Burkey, B. Use of the Anterolateral Thigh Flap in Lin, DT, Coppit, GL, Burkey, B. Use of the Anterolateral Thigh Flap in

Reconstruction of the Head and Neck. Curr Opin Otolaryngol Head Neck Reconstruction of the Head and Neck. Curr Opin Otolaryngol Head Neck Surg. 12: 300-304. 2004. Lippincott Williams and Wilkins.Surg. 12: 300-304. 2004. Lippincott Williams and Wilkins.

7.7. Genden, E, Haughey, BH. Mandibular Reconstruction by Vascularized Free Genden, E, Haughey, BH. Mandibular Reconstruction by Vascularized Free Flap Tissue Transfer. Am Journ Otolaryngol. 1996; 17 (4): 219 – 227.Flap Tissue Transfer. Am Journ Otolaryngol. 1996; 17 (4): 219 – 227.


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Microvascular Free Flaps Used in Head and Neck Reconstruction. / orthodontic courses by Indian dental academy