Dr. Ajay ManickamJunior Resident ENT & Head Neck SurgeryR.G. Kar Medical College

Simple injury/ surgical

Repairable ….??? Many defects can be

directly closed if small & enough tissue available locally

If the defect becomes larger...... Ablative cancer surgery

Larger defects 1. Grafts2. Local flaps3. Pedicled flaps4. Free flaps5. Combination

These are parallel to natural skin wrinkles Surgical incision placed parallely Least tension as skin contraction is at its

greatest

Ellipse three times as long as its wide If ellipse is too short dog ear deformity

Eye lid Helical rims of ear Lips Not only skin – composite tissue - closed in layers1. Lips – mucosa, orbicularis

oris, skin2. Ear – cartilage and skin

both anterior & posterior3. Eyelids – conjunctiva,

tarsal plate, orbicularisoculi and skin

1817 – Sir Astley Cooper 1871 – Lawson – elective

full thickness graft 1872- Ollier – split skin

graft 1929 – Brown & Blair –

differentiated full thickness and split thickness skin grafts advantages & disadvantages

Split thickness – part of dermis

Full thickness – all of dermis

Composite – skin & another tissue

Graft origin1. Auto graft – same person2. Isograft – identical twin3. Allograft –same species4. Xenograft – diff species5. Alloplastic - synthetic

SPLIT THICKNESS

More likely to take Contracts more Pigment abnormal Limited sensory recovery

FULL THICKNESS

High risk for graft loss Less Better colour match Better sensory recovery

Imbibition – plasma – 48 hours Inosculation - Graft revascularization – graft

anastomosis Neovascularization – atleast a month

Relies on skin elasticity Modified in a number of ways – burow

triangle Simple

Rintalla flap Modified

V-Y flap (axial flap) Bipedicled flap

Tripier flap

Simple flap lesions in nasal tip

Kind of advancement flap modified

Lower eyelid reconstruction Bipedicled flap – receives blood supply from

both ends

Moves around a pivot point – transposition flap or rotation flap

Rhomboid flaps – transposition flaps – donor defect closed directly

Flag or banner flaps – transposition flaps –donor site closed directly

Bilobed flaps – two transposition flaps

Pivot flap Rhomboid needs to be 120 & 60 degree So that scar becomes parallel

Pivot flap – axial transposition flap

Flap lengh 3 times the length of base

Primary defect closed directly

Two transposition flaps Defects in tip of nose

Large flaps that rotate into primary defect

Flap circumference should be atleast 8 times

Repairs defect of scalp or cheek

Based on named arterial pedicle runs within skin superficial to the underlying muscle layer parallel to the skin overlying

Forehead flapNasolabial flapSubmental island flapFacial artery myomucosal flapTemporo parietal fascial flap

Mc gregor Cutaneous axial

median forehead flap – supra trochlear artery

Cheek , External nose

Forehead flap contracts excessively

Susruta 600 Bc – defects around face – anterior oral cavity

Based on distal branches of the facial artery Extremely reliable based inferiorly Anterior floor of mouth , gingiva – simple & effective

Reconstruction of facial skin or intra oral lining

Supplied by facial artery branches

Can be tunneledunder mandible through submentaland submandibular space for oral reconstruction / tranposed onto face for soft tissue coverage

Pribaz Oral mucosa

and buccinatormuscle branches of facial artery

Small mucosal defects of the oral cavity, mucosa of lip, tongue, palate

Golovine Free facial flap for

reconstruction of head & neck

Superficial temporal artery – external carotid artery

Teardrop, elliptical shape Orbital reconstruction,

auricular reconstruction, palate reconstruction, buccal mucosal reconstruction.

Deltopectoral flap Myocutaneous and muscle only axial distant

flaps 1. Pectoralis major2. Lattissimus dorsi3. Sternomastoid4. Trapezius5. Platysma

Bakamjian and littlewood 1964 Upper 3 perforating internal mammary artery

branches Single stage reconstruction – anterior neck skin Two stage reconstruction – over neck structures to

resurface distant sites

Ariyan described it in 1970 pectoral branch of acromio thoracic artery Large skin territory – can be harvested in

supine position

Local flaps & regional flaps plays an important role in head & neck reconstruction

When using local flaps in the head & neck preoperative planning of the flap is prime importance

Grafts are reliant on blood supply of recipient site but flaps takes their blood supply with them