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Local and Regional Flaps In
Head and Neck Cancer
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indianden...
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
TEMPORALIS FLAP
STERNOCLIEDOMASTOID FLAP
MASSETER FLAP
DELTOPECTORAL...
PECTORALIS MAJOR MYOCUTANEOUS
FLAP
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Ariyan 1970

www.indiandentalacademy.com
Anatomy
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Origin
Vessels
Function

www.indiandentalacademy.com
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large fan-shaped muscle that covers much of the
anterior thoracic wall. To a variable extent, it overlies
the pector...
vessels

www.indiandentalacademy.com
PECTORALIS MAJOR MYOCUTANEOUS FLAP
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Superior and lateral
thoracic arteries additional pedicles
Overlying skin
addi...
functions
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adduct and medially rotate the arm
It becomes active in internal rotation of the arm only
when wo...
PECTORALIS MAJOR MYOCUTANEOUS FLAP

Types

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PECTORALIS MAJOR MYOCUTANEOUS FLAP

ADVANTAGES
 One stage
 Generous portion of skin & soft tissue(400cm2)
 Consistent b...
PECTORALIS MAJOR MYOCUTANEOUS FLAP

DISADVANTAGES
 Arc of rotation limited for oromaxillary defects
 It can be too bulky...
Methods to Improve the Arc of
Rotation
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Ariyan's -incorporated a long segment of skin that
extended from the...
www.indiandentalacademy.com
Methods to Deal with Excessive Bulk
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Sharzer et al. - harvesting a vertically
oriented "parasternal” skin paddle that
ex...
Methods to Deal with Excessive Bulk
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Murakami et al. -eliminating the skin paddle
entirely.
two-stage procedure
a ...
Methods to Achieve Two Epithelial Surfaces for
Reconstruction of Compound Defects

www.indiandentalacademy.com
“Gemini” flaps

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POTENTIAL PITFALLS
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Incidence of total flap necrosis was reported
to be 1.0%, 1.5%, 3%, and 7%.
Partial flap necr...
www.indiandentalacademy.com
TEMPORALIS MUSCLE FLAP
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Golovine 1898 - orbital
exenteration
Gilles - reanimation of
paralyzed face
Fan - shape...
TEMPORALIS MUSCLE FLAP
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Main blood supply - anterior &
posterior deep temporal artery
Anterior deep temporal arter...
TEMPORALIS MUSCLE FLAP
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Mobilized flap consists of
fascia, muscle, & pericranium
Two distinct fascial layers, t...
TEMPORALIS MUSCLE FLAP
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Hemicoronal flap provides excellent access
Incision ends above the superior tempora...
TEMPORALIS MUSCLE FLAP
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If the muscle is split in coronal plane posterior
portion of muscle is transposed anter...
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It is relatively short (3 to 5 cm) and thin (2 to
3mm) and has a contraction capability of 1 to
1.5 cm
flap has a ...
TEMPORALIS MUSCLE FLAP
ADVANTAGES
 Ease of elevation
 Reliable blood supply
 Proximity
 Camouflage of incision
with in...
www.indiandentalacademy.com
www.indiandentalacademy.com
STERNOCLEDOMASTOID
MYOCUTANEOUS FLAP

www.indiandentalacademy.com
STERNOCLEDOMASTOID MYOCUTANEOUS FLAP

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Long strap muscle
Muscular origin Tendinous
origin
Insertion
Branc...
STERNOCLEDOMASTOID MYOCUTANEOUS FLAP

REPORTED INDICATIONS
 Provision of epithelial lining for mucosal
reconstruction
 C...
STERNOCLEDOMASTOID MYOCUTANEOUS FLAP

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Superior blood supply
6 x 8 cm paddle of skin
Skin paddle should be kep...
STERNOCLEDOMASTOID MYOCUTANEOUS FLAP

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Inferior blood supply
Branches of superior
thyroid artery are noted
to enter th...
MASSETER FLAP
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Lexer and Eden in 1911
Short, flat, thick quadrangular
muscle
Superior belly - downwards &
b...
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Does not restore emotional mimetic
movements
Muscle eliminated in extensive ablative
surgery
Limited in size ...
DELTOPECTORAL FLAP
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First axial pattern skin flap
The base of flap is parasternal includes the first three
o...
DELTOPECTORAL FLAP
ADVANTAGES
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High biologic
dependability
Readily accessible
Arc of rotation 45 - 135
May be ...
DELTOPECTORAL FLAP
DISADVANTAGES
 Donor site require skin grafting
 Moderate amount of scarring & deformity is
unaccepta...
DELTOPECTORAL FLAP
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Superior incision is placed just below the clavicle
inferior one run parallel to it
Fl...
www.indiandentalacademy.com
PLATYSMA FLAP
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Extremely thin band like & variable muscle
forming superficial boundary of neck
Arises from clavi...
PLATYSMA FLAP
ADVANTAGES
 Proximity & Regionality
 Thin & delicate
 Reliable when vascu-lar criteria adhered
 Arc of r...
TRAPEZIUS FLAP
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Mutter 1842
Originally described as
superior based cutaneous
flap
Flat & triangular and co...
TRAPEZIUS FLAP
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Lateral positioning of patient
to elevate flap
Ideally suited for radical
parotidectomy
Limite...
TRAPEZIUS FLAP
ADVANTAGES
 Flap is versatile
 Regionality of flap
 Strong vascular security
 Supplies considerable bul...
TRAPEZIUS FLAP
DISADVANTAGES
 Venous system difficult to preserve
 Vascular supply in general difficult to preserve
 Ca...
LATISSIMUS DORSI MYOCUTANEOUS FLAP

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Distant flap, provides largest possible skin paddle,
involves the most comple...
LATISSIMUS DORSI MYOCUTANEOUS FLAP

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Insertion on the intertubercular groove of the
humerus
Extend, adduct, & me...
LATISSIMUS DORSI MYOCUTANEOUS FLAP

ADVANTAGES
 Size – largest flap in
the body
 Flap location
 Arc of rotation - 180
...
LATISSIMUS DORSI MYOCUTANEOUS FLAP

DISADVANTAGES
 Repositioning of the patient
 Skin paddle is thick & has strong attac...
conclusion
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Success in reconstruction of the craniofacial
region by local and regional flaps requires
knowledge ,care...
Thank you
www.indiandentalacademy.com
REFERENCES
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




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Oral and Maxillofacial surgery clinics of North America November
1993
Flaps in Head and Ne...
REFERENCES
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


Oral and Maxillofacial surgery clinics of North
America NOVEMBER 1993
Flaps in Head and Neck Surge...
Defect

PMMC

ORAL
MUCOSA
mnd intact
Centrl mnd
defects
Lateral mnd
- male
- female

EXT FACIAL
DEFECT
Mand intact
Mand de...
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Local and regional flaps in head & neck cancer /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Transcript of "Local and regional flaps in head & neck cancer /certified fixed orthodontic courses by Indian dental academy "

  1. 1. Local and Regional Flaps In Head and Neck Cancer INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2.          PECTORALIS MAJOR MYOCUTANEOUS FLAP TEMPORALIS FLAP STERNOCLIEDOMASTOID FLAP MASSETER FLAP DELTOPECTORAL FLAP TRAPEZIUS FLAP LATISSIMUS DORSI FLAP CONCLUSION REFFERENCES www.indiandentalacademy.com
  3. 3. PECTORALIS MAJOR MYOCUTANEOUS FLAP  Ariyan 1970 www.indiandentalacademy.com
  4. 4. Anatomy    Origin Vessels Function www.indiandentalacademy.com
  5. 5.   large fan-shaped muscle that covers much of the anterior thoracic wall. To a variable extent, it overlies the pectoralis minor, subclavius, serratus anterior, and intercostal muscles. origins -three portions. 1 cephalad -medial third of the clavicle. 2 central,-sternocostal-sternum &cartilages of the first six ribs 3 aponeurosis of the external oblique, is variable in size. www.indiandentalacademy.com
  6. 6. vessels www.indiandentalacademy.com
  7. 7. PECTORALIS MAJOR MYOCUTANEOUS FLAP    Superior and lateral thoracic arteries additional pedicles Overlying skin additionally supplied by intercostal perforators 3 subunits each with its own vascular & motor supply www.indiandentalacademy.com
  8. 8. functions       adduct and medially rotate the arm It becomes active in internal rotation of the arm only when working against resistance. upper muscle fibers help to flex the arm to the horizontal level; the lower fibers assist in arm extension. Contraction helps to extend the arm to the individual's side, but it plays no role in hyperextension beyond that point. loss of the dynamic activity of the pectoralis major appears to be well tolerated Much of the adductor activity is compensated for by the powerful, latissimus dorsi muscle, which makes up the posterior axillary fold. www.indiandentalacademy.com
  9. 9. PECTORALIS MAJOR MYOCUTANEOUS FLAP Types www.indiandentalacademy.com
  10. 10. PECTORALIS MAJOR MYOCUTANEOUS FLAP ADVANTAGES  One stage  Generous portion of skin & soft tissue(400cm2)  Consistent blood supply – highly reliable  Adequate arc of rotation for facial defects  Donor site can be closed primarily  Two skin islands on the same muscle paddle  Protects the carotid artery  Technically, the flap is ease to elevate www.indiandentalacademy.com
  11. 11. PECTORALIS MAJOR MYOCUTANEOUS FLAP DISADVANTAGES  Arc of rotation limited for oromaxillary defects  It can be too bulky  There is distortion of symmetry at the donor site  Shoulder function is impaired  Distal skin of the flap is not reliable www.indiandentalacademy.com
  12. 12. Methods to Improve the Arc of Rotation      Ariyan's -incorporated a long segment of skin that extended from the clavicle to the caudal extent of the muscle. Distal skin paddle placed over the caudal extent of the muscle Maghee- skin paddle extended over rectus abdominus Lee and Lore -removal of a segment of the clavicle to gain up to 3 cm of length. Wilson et al. -tunneling the muscle pedicle deep to the clavicle in a subperiosteal plane . www.indiandentalacademy.com
  13. 13. www.indiandentalacademy.com
  14. 14. Methods to Deal with Excessive Bulk  Sharzer et al. - harvesting a vertically oriented "parasternal” skin paddle that extended across the sternum to the opposite internal mammary perforators. www.indiandentalacademy.com
  15. 15. Methods to Deal with Excessive Bulk    Murakami et al. -eliminating the skin paddle entirely. two-stage procedure a split-thickness skin graft was placed over the muscle  3 to 4 weeks later harvest the muscle-skin graft unit. Maintain nerve supply or not www.indiandentalacademy.com
  16. 16. Methods to Achieve Two Epithelial Surfaces for Reconstruction of Compound Defects www.indiandentalacademy.com
  17. 17. “Gemini” flaps www.indiandentalacademy.com
  18. 18. POTENTIAL PITFALLS     Incidence of total flap necrosis was reported to be 1.0%, 1.5%, 3%, and 7%. Partial flap necrosis- 14%-30% Pedicle compression In male patients may lead to problems with excessive hair growth in the oral cavity or pharynx www.indiandentalacademy.com
  19. 19. www.indiandentalacademy.com
  20. 20. TEMPORALIS MUSCLE FLAP     Golovine 1898 - orbital exenteration Gilles - reanimation of paralyzed face Fan - shaped muscle arising from temporal fossa & the superior temporal line The muscle is bipennate, with an additional superficial origin from the temporalis fascia www.indiandentalacademy.com
  21. 21. TEMPORALIS MUSCLE FLAP    Main blood supply - anterior & posterior deep temporal artery Anterior deep temporal artery & Posterior deep temporal enter the muscle approximately 1cm anterior & 1.7cm posterior to coronoid process respectively This vascular anatomy allows splitting of muscle into anterior & posterior flap www.indiandentalacademy.com
  22. 22. TEMPORALIS MUSCLE FLAP     Mobilized flap consists of fascia, muscle, & pericranium Two distinct fascial layers, the superficial & deep temporal fascia Superficial temporal fascia is a thin, highly vascular layer of moderately dense Connective tissue The absence of vascularity between this two layers www.indiandentalacademy.com
  23. 23. TEMPORALIS MUSCLE FLAP       Hemicoronal flap provides excellent access Incision ends above the superior temporal line Dissections proceeds down to the deep temporal fascia until the entire muscle is exposed Dissection in this plane protects the temporal branch of facial nerve Reflection of the muscle of the temporal bone should be performed in a strict subperiosteal plane Rotation can be improved by dividing ZA & base of the coronoid www.indiandentalacademy.com
  24. 24. TEMPORALIS MUSCLE FLAP     If the muscle is split in coronal plane posterior portion of muscle is transposed anteriorly Donor site - secondarily reconstructed by alloplastic implants Alopecia avoided by careful placement of coronal incision parallel to hair shaft Bradley & Brock hank - flap does not require skin grafting & rapid mucolization occur www.indiandentalacademy.com
  25. 25.    It is relatively short (3 to 5 cm) and thin (2 to 3mm) and has a contraction capability of 1 to 1.5 cm flap has a rotational radius of 8 cm it is possible to cover defects of the mastoid, cheek, pharynx, and palate. www.indiandentalacademy.com
  26. 26. TEMPORALIS MUSCLE FLAP ADVANTAGES  Ease of elevation  Reliable blood supply  Proximity  Camouflage of incision with in hair line  Muscle support graft & alloplast well DISADVANTAGES  Sensory disturbances  Potential facial nerve injury  Temporal hallowing www.indiandentalacademy.com
  27. 27. www.indiandentalacademy.com
  28. 28. www.indiandentalacademy.com
  29. 29. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP www.indiandentalacademy.com
  30. 30. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP        Long strap muscle Muscular origin Tendinous origin Insertion Branch of spinal accessory nerve Dominant blood supply – branches of occipital artery & its draining vein Middle third of the muscle Inferior third of the muscle www.indiandentalacademy.com
  31. 31. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP REPORTED INDICATIONS  Provision of epithelial lining for mucosal reconstruction  Closure of orocutaneous fistulas  Release of scar contracture in submandibular & angle region  Provision of additional vascularized tissue around a bone graft when the tissue bed has been heavily irradiated www.indiandentalacademy.com
  32. 32. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP      Superior blood supply 6 x 8 cm paddle of skin Skin paddle should be kept overlying the muscle above the level of clavicle Skin paddle is tacked down to the muscle fascia Muscle dissected & elevated by incising the fascia www.indiandentalacademy.com
  33. 33. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP   Inferior blood supply Branches of superior thyroid artery are noted to enter the anterior aspect of muscle at the level of carotid bifurcation www.indiandentalacademy.com
  34. 34. MASSETER FLAP       Lexer and Eden in 1911 Short, flat, thick quadrangular muscle Superior belly - downwards & backwards Deep belly - vertically & slightly forwards Massetric nerve & artery Hemimandiblectemy. suturing the masseter to the hyoid bone to assist in laryngeal elevation during swallowing. www.indiandentalacademy.com
  35. 35.      Does not restore emotional mimetic movements Muscle eliminated in extensive ablative surgery Limited in size & volume Does not have skin paddle Restricted arc of rotation www.indiandentalacademy.com
  36. 36. DELTOPECTORAL FLAP       First axial pattern skin flap The base of flap is parasternal includes the first three or four perforating branches of internal mammary artery, second perforator is largest Artery as rich anastomosis, accompanied by Vein It extend laterally over the upper chest at the level of clavicle on to the deltoid muscle & shoulder Width 8 - 12 cm, Length 18 - 22 cm reverse of deltopectoral flap - Thoracoacromial flap www.indiandentalacademy.com
  37. 37. DELTOPECTORAL FLAP ADVANTAGES      High biologic dependability Readily accessible Arc of rotation 45 - 135 May be used in male, female & children Hairless skin www.indiandentalacademy.com
  38. 38. DELTOPECTORAL FLAP DISADVANTAGES  Donor site require skin grafting  Moderate amount of scarring & deformity is unacceptable in women  Physiologic disadvantage in malnourished patient or post operative irradiation  Flap should not be used if previous scarring on donor area www.indiandentalacademy.com
  39. 39. DELTOPECTORAL FLAP        Superior incision is placed just below the clavicle inferior one run parallel to it Flap raised from lateral extent medially Incision is carried down through the pectoral fascia Plane of dissection is sub fascial Dissection proceeds up to 2 cm of lateral border of sternum Back cut on medial aspect - improve the flap rotation 90% success rate www.indiandentalacademy.com
  40. 40. www.indiandentalacademy.com
  41. 41. PLATYSMA FLAP     Extremely thin band like & variable muscle forming superficial boundary of neck Arises from clavicle superiorly continues with the attachment to the mandible Submental branch of the facial artery Flap size Muscle - 10 x 10 cm to 10 x 20 cm skin paddle - 3 x 6 cm to 6 x 20 cm www.indiandentalacademy.com
  42. 42. PLATYSMA FLAP ADVANTAGES  Proximity & Regionality  Thin & delicate  Reliable when vascu-lar criteria adhered  Arc of rotation - 180  No donor site disability DISADVANTAGES  Lack of bulk  Hair bearing in male  Reliability 85%  Complication like skin loss & fistula www.indiandentalacademy.com
  43. 43. TRAPEZIUS FLAP       Mutter 1842 Originally described as superior based cutaneous flap Flat & triangular and cover the superoposterior aspect of the neck & shoulder Dominant pedicle, the transverse cervical artery Functions to rotate the scapula & to elevate, rotate & adduct upper arm 10 x 20 cm in size www.indiandentalacademy.com
  44. 44. TRAPEZIUS FLAP      Lateral positioning of patient to elevate flap Ideally suited for radical parotidectomy Limited to small defects in oral cavity Generous amount of soft tissue & large portion of skin island 90 – 95 % of success www.indiandentalacademy.com
  45. 45. TRAPEZIUS FLAP ADVANTAGES  Flap is versatile  Regionality of flap  Strong vascular security  Supplies considerable bulk  Arc of rotation 90 – 180 degree  One stage procedure  Minimum deficit at donor area www.indiandentalacademy.com
  46. 46. TRAPEZIUS FLAP DISADVANTAGES  Venous system difficult to preserve  Vascular supply in general difficult to preserve  Can present with excessive bulk  Cannot be easily tubed  Moderate shoulder drop postoperatively www.indiandentalacademy.com
  47. 47. LATISSIMUS DORSI MYOCUTANEOUS FLAP    Distant flap, provides largest possible skin paddle, involves the most complex donor site dissection, and arc of rotation extremely versatile Donor site skin paddle measures 40 by 25 cm & still allows primary closure The latissimus dorsi is very broad muscle of the back with a fascial origin from T7 to T12, from the lumbar & sacral vertebrae, from posterior crest of the ilium & also minor origination from the last four ribs www.indiandentalacademy.com
  48. 48. LATISSIMUS DORSI MYOCUTANEOUS FLAP     Insertion on the intertubercular groove of the humerus Extend, adduct, & medially rotate the arm Major pedicle is thoracodorsal artery, a terminal branch of the subscapular artery Perforators enter the muscle medially along the spine – secondary supply www.indiandentalacademy.com
  49. 49. LATISSIMUS DORSI MYOCUTANEOUS FLAP ADVANTAGES  Size – largest flap in the body  Flap location  Arc of rotation - 180  Large, reliable unicentric neurovascular pedicle  Donor area  90% success rate www.indiandentalacademy.com
  50. 50. LATISSIMUS DORSI MYOCUTANEOUS FLAP DISADVANTAGES  Repositioning of the patient  Skin paddle is thick & has strong attachment to the underlying muscle  Considerable bulk – postoperative sagging & pendulosity  Donor area may need skin graft  It is in competition with other very suitable flaps www.indiandentalacademy.com
  51. 51. conclusion   Success in reconstruction of the craniofacial region by local and regional flaps requires knowledge ,careful preop planning, skilled tecqniques, and meticulous care after operation The goal is to return the patient as closely as possible to the preop aesthetic and functional level www.indiandentalacademy.com
  52. 52. Thank you www.indiandentalacademy.com
  53. 53. REFERENCES          Oral and Maxillofacial surgery clinics of North America November 1993 Flaps in Head and Neck Surgery 1989 John Conley and Carl Patow Oral cancer Jatin P shah GRABB’S Encyclopedia of flaps Volume 1 Maxillofacial Surgery Vol. 1 Peter Ward Booth Atlas of Regional and Free Flaps for head and neck reconstruction Mark L. Urken Plastic surgery –McCarthy.vol-1 Fonseca –OMFS Vol-7 Mastery in plastic and reconstructive surgery-Mimis Cohen www.indiandentalacademy.com
  54. 54. REFERENCES      Oral and Maxillofacial surgery clinics of North America NOVEMBER 1993 Flaps in Head and Neck Surgery 1989 John Conley and Carl Patow Oral cancer Jatin P shah GRABB’S Encyclopedia of flaps Maxillofacial Surgery Vol. 1 Peter Ward Booth www.indiandentalacademy.com
  55. 55. Defect PMMC ORAL MUCOSA mnd intact Centrl mnd defects Lateral mnd - male - female EXT FACIAL DEFECT Mand intact Mand defect VERTICAL TREPIZIUS PLATYSAMA DELTO PECTROL 1st 1st 1st 2nd 3rd 2nd 2nd 1st 2nd 1st www.indiandentalacademy.com 1st 2nd
  56. 56. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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