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Reconstructive Flap 101: Basic Principles, Imaging, and Beyond
eEdE#: eEdE-88
E Supsupin1, I Alava2, D Freet3, E Bonfante1, S Garza1, Y Weinstock2
Institutions:
1University of Texas Houston Department of Diagnostic & Interventional Imaging,
Houston, TX,
2University of Texas Houston Department of Otorhinolaryngology, Head & Neck
Surgery, Houston, TX,
3University of Texas Houston Department of Plastic Surgery, Houston, TX
Author disclosures
None
Basics of flaps
Case illustrations (including imaging): Flaps for restitution of function Flaps for restitution of function and cosmesis Flap for cosmesis
Reconstructive flaps in head &neck surgery
A “Flap” can be defined as a piece of tissue that is moved from one part of the body to another part of
the body with a blood supply intact.
Define “Flap”
Flaps A flap is referred to as a “Pedicled” flap if its blood supply is
left intact at its origin when it is moved to the new site.
A flap is referred to as a “Free” flap if the blood supply of the donor tissue to be moved is severed from its origin and then re-connected to a new artery and vein at the recipient site.
A flap can be made of any type of tissue: bone, cartilage, fascia, subcutaneous tissue, skin, or any combination of these.
Flaps Flaps are required for reconstruction of large composite
defects resulting from trauma or cancer extirpation.
A flap is referred to as a “Free” flap if the blood supply of the donor tissue to be moved is severed from its origin and then re-connected to a new artery and vein at the recipient site.
A flap can be made of any type of tissue: bone, cartilage, fascia, subcutaneous tissue, skin, or any combination of these.
Flaps
Flaps can be used for cosmetic purposes, functional purposes, or a combination of both depending on the needs of the patient.
Flaps
Flaps can be used for cosmetic purposes, functional purposes, or a combination of both depending on the needs of the patient.
What are commonly used flaps for head and neck reconstruction?
Pectoralis major Latissimus dorsi Rectus Abdominis Radial Forearm Free Fibula Free Iliac Crest
Pectoralis major Is considered a “work horse” in head and neck
reconstruction
Can be used as a muscle-only flap or can include skin
Most commonly transferred as a pedicled flap based on the pectoral branch of the thoracoacromial arterial trunk
Can be used for intra-oral lining, head and neck skin resurfacing or tubed for creation of a neopharynx
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Latissimus Dorsi
Can be used as a pedicled flap or free flap
Large bulky muscle or muscle and skin flap based on the thoracodorsal branch of the subscapular artery
In head and neck reconstruction, this flap is used to fill large defects.
Can provide a very large amount of skin if needed
Not commonly used secondary to its bulky nature
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Rectus abdominis
Always used as a free flap
Muscle or muscle and skin flap based on the deep inferior epigastric artery
Used to fill large defects such as that of a total glossectomy
Disadvantage is abdominal wall weakness.
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Radial Forearm
This is a free flap based on the radial artery.
Thin fasciocutaneous (fascia and skin) flap that can be used for intra-oral lining, used to resurface a tongue defect or can be tubed to create a neo-pharynx
Donor site can be problematic (poor healing).
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Anteriolateral thigh Free flap that is based on the descending branch of the lateral
circumflex femoral artery.
Fasciocutaneous flap that can be made very large for large complex defects.
Can be used for intra-oral lining, can be tubed for neo-pharynx, can be used for head and neck resurfacing, or can be a combination of any of these
Minimal donor site morbidity
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Free Fibula
Free flap based on the peroneal artery that uses a portion of the fibula and sometimes the overlying skin of the leg for complex reconstruction of the mandible and intra-oral lining
An excellent source of a large amount of bone.
Minimal donor site morbidity
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Free Iliac Crest
Free flap that is based on the deep circumflex iliac artery.
Can be bone only or can be bone and skin
Used mostly for mandibular reconstruction. Skin can be used for intra-oral lining.
Donor site can be very painful.
Image: AO Foundation
Flap for subtotal glossectomy
Necrotic, malignant infiltrating mass in the left tongue/floor of mouth. Resection of the mass and free flap reconstruction was planned.
Neck dissection prior to extirpation of mass.Apron flap is lifted up (yellow arcs).
Flap for subtotal glossectomy
Tongue mass is resected.Apron flap is lifted up (yellow arcs).
Flap for subtotal glossectomy
Flap is harvested from the anterolateral thigh
Flap (bracket) with its vascular (arrows) pedicle is shown.
Flap for subtotal glossectomy
Free flap sawn into tongue stump and floor of mouth
Harvested flap from thigh
Immediate postoperative result
Flap for total glossectomy
Images taken Intraoperatively and 1 month after surgery
This case illustrates the use of free flap mainly for restoration of function.
Flap for layngopharyngectomy
This patient presented with advanced transglottic laryngeal squamous cell cancer that ruptured into the skin (brackets & circle). The mass has obliterated the upper airway requiring tracheostomy (red arrow). Total laryngopharyngectomy with Free flap reconstruction was planned.
Flap for layngopharyngectomy
Large flap harvested from anterolateral thigh for free flap reconstruction and creation of neopharynx
Flap for layngopharyngectomy
Defect after neck dissection and extirpation of mass
Flap for layngopharyngectomy
Creation of tube/neopharynx from free flap harvested from thigh
Flap for layngopharyngectomy
Creation of tube/neopharynx from free flap harvested from thigh
Uvula – yellow arrow
Flap for layngopharyngectomy
This case illustrates the use of free flap for creation of neopharynx and closure of a large soft tissue defect. Flap is employed both forrestitution of function and cosmesis.
Pectoralis flap
A diabetic woman with poor glycemic control who developed multicompartmental abscesses in the suprahyoid neck and necrotizing fasciitis (CT). Full thickness loss of tissue in the face and neck after debridement with exposed mandible (arrow). Flap reconstruction is required to close the defect.
Pectoralis flap
Pectoralis flap is used to fill the soft tissue defect.
Pectoralis flap - postop
Free flap used to fill the soft tissue defect in the left face and neck, and create the lining of the oral cavity. There is persistent enhancement in the masticator space on MR (circle) a year after surgery, with no clinical signs of active infection.
Pectoralis myocutaneous flap - postop
Postoperative CT showing the pectoralis myocutaneous flap (arrows). M – muscle F- FatIn this case the flap serve both purposes of restoration of function and cosmesis
MF
This patient presented with oral tongue mass, later proven to be squamous cell carcinoma. The plan was resection of the tongue mass including the mandible, with free flap reconstruction.
Total glossectomy and mandibular resection with free flap reconstruction
Resection of tongue and mandible
Total glossectomy and mandibular resection with free flap reconstruction
Courtesy of James Melville DDS
Specimen removed
Total glossectomy and mandibular resection with free flap reconstruction
Courtesy of James Melville DDS
Harvesting flap from thigh
After resection of tongue and mandible
Total glossectomy and mandibular resection with free flap reconstruction
Courtesy of James Melville DDS
Mandibular reconstruction with Titanium chain
Total glossectomy and mandibular resection with free flap reconstruction
Courtesy of James Melville DDS
Total glossectomy and mandibular resection with free flap reconstruction
Flap implantation
Courtesy of James Melville DDS
Immediate postoperative result – this case illustrates use of flap for both restoration of function and cosmesis
Total glossectomy and mandibular resection with free flap reconstruction
Courtesy of James Melville DDS
Preoperative CT with cosmeticdefect on the right (bracket)after prior parotidectomy 10 years earlier for adenoid cystic carcinoma. Free flapreconstruction was decidedafter a negative workup fordisease recurrence.
Flap harvested from the thigh
Neck dissection in preparation forfree flap reconstruction
Immediate postsurgical result
SCM – sternocleidomastoid muscleCCA – common carotid artery bifurcation
Example of free flap reconstruction for cosmesis
Example of free flap reconstruction for cosmesis
Before After
Summary
Reconstructive flaps in the head and neck are used for restitution of function or cosmesis, or both, depending on the needs of the patient.
Case illustrations are provided.
Bibliography of illustrations
Slides 11-14; 16-19; 21; 23-26; 28-31; 33-36; 38
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Slide 36:
“Reconstruction: Harvesting.” AOfoundation.org. Web. 23 Mar. 2015.