LOCAL & REGIONAL FLAPS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indian...
INTRODUCTION

• The compelling drive of human beings to reconstruct deficient
or missing parts and the desire of victims t...
• The later-day developments in anesthesia, antibiotics,
hematology, instrumentation, and wound healing
research have give...
History
• Sushruta Samshita, circa,700 B.C. first to describe a facial (forehead) flap for the
reconstruction of a nose.
•...
MANUEL LA ROSA-CRAIG, DDS
SOFT TISSUE FLAPS IN ORAL SURGERY
University of Illinois at Chicago
Department of Oral & Maxillo...
Definition
A flap is one which contains within its substance a
network of blood vessels, arterial,venous ,cappilaries
and ...
Alternate wound closure tech. include
1.
2.
3.
4.
5.

Secondary healing-small biopsed lesions
Wound contraction-lesions in...
In Irradiated beds use of flaps brings improved blood
supply to the wound .
When major structures are exposed ex: facial n...
GENERAL CONSIDERATIONS
• Criteria for Choosing a Flap:
•
•
•
•
•
•

Adequate amount of skin or mucosa
Adequate bulk
Good l...
•
•
•
•
•
•
•
•
•
•
•
•

Basic Principles of Flaps

Plan
Design
Cannot violate its blood supply
Should generously fit the ...
CLASSIFICATION

www.indiandentalacademy.com
CLASSIFICATION:
By the tissues they contain
• Skin Flaps:
Donor tissue containing skin and subcutaneous
tissue only. Maint...
By the vascular system on which they are based
Axial
Incorporate an anatomically recognized arterio-venous system running ...
By method of movement from the donor site
• Advancement
• Rotation
• Transposition

www.indiandentalacademy.com
Advancement flaps
• Undermining an area of tissue and advancing it forward to cover a defect.
• Requires pliable and elast...
By distance from donor site
Local Flaps:
• Donor site is in close proximity with the defect.
• Defect requires minimum amo...
Transposition flap
• When a flap moves laterally into the primary defect it is called
transpositional flap.
• It is design...
www.indiandentalacademy.com
www.indiandentalacademy.com
• In designing the flap and before any inscion is made
the pivot point must be clearly defined and the distance
from it fr...
• Clinical role of the transpositional flap is confined to
the situations where a secondary graft is not
contraindicated f...
Advancement flap
• The primary motion of this flap is in a straight line from the
donor site to recipient site with out ro...
www.indiandentalacademy.com
Rotational flap
• Random pattern sliding pivotal flaps with curvilinear design.
• Used to close triangular defects.
• Rais...
www.indiandentalacademy.com
www.indiandentalacademy.com
Interpolated flap
• Here the donor site is separated from recipient site ,
and the pedicle of the flap must pass over or u...
Z-plasty:
• Involves the transposition of two interdigitating triangular flaps.
• Flap transposition fallows naturally fro...
www.indiandentalacademy.com
www.indiandentalacademy.com
Analysis of the defect and planning of reconstruction using local flaps.
• Any defect/deformity in head and neck area pres...
Viability of flap :
Blood flow in the local skin flap is characterized by intrinsic
vascular architecture, the nature of w...
BLOOD SUPPLY:
A.MUSCULOCUTANEOUS ARTERIES
B.SEPTOCUTANEOUS ARTERIES

COMPOSITION:
Cutaneous
Faciocutaneous
Musculocuaneous...
PATHOPHYSIOLOGY OF FLAPS
• Flaps undergo necrosis secondary to lack of nutrient blood inflow rather than lack of
venous ou...
Clinical factors associated with ischemic flap
necrosis:
1.
2.
3.
4.
5.
6.
•
•

Excessive tension from taut sutures
Compre...
Therapeutic innervations for flaps:
1.
2.
3.
4.
5.
6.
7.

Direct vassodilators- phenethylamines,calcium chanal
blockers an...
 Leech therapy:
Hermaphroditic ectoparasites
Hirudo medicinalis
leech saliva-hirudin ( inhibitor of thrombin, vassodilato...
MONITERING OF FLAP CIRCULATION
1.
2.
3.
4.
5.
6.

Lasser doppler flowmetry
Thermocupple probe
Temp probe
Pulseoximetry
Flu...
Pivot point
• This point is the center of the arc around which the
flap is moving in its transfer.
• The distance between ...
LOCAL FLAPS
• Forehead flap
• Temporal flap
• Nasolabial flap
• Labial flap
• Palatal flap
• Tongue flap
REGIONAL MYOCUTAN...
TEMPORALIS FLAP
•
•
•
•
•
•
•
•
•

TEMPORALIS MUSCLE
Origin
Deep: Temporal fossa calvarium
Superficial: Deep temporalis fa...
www.indiandentalacademy.com
www.indiandentalacademy.com
• TEMPORALIS MUSCLE
• Blood supply
• Deep temporal fascia: middle temporal branch (superficial
temporal artery).
• Anterio...
www.indiandentalacademy.com
www.indiandentalacademy.com
•
•
•
•
•
•
•
•
•
•
•

MASSETER FLAP

MASSETER MUSCLE
Origin
Deep: inner surface of ZGM arch
Superficial: ant 2/3 lower bo...
• MASSETER FLAP
• Reconstruction of ablative procedures of parotid gland,
mandible, palate and nasopharynx.
• Treatment & ...
•
•
•
•
•
•
•
•

PLATYSMA MUSCLEPLATYSMA FLAP
Origin
Subcutaneous tissues, caudal to the clavicle and acromion.
Insertion
...
www.indiandentalacademy.com
• Antero superior
– facial, submental, submandibular arteries
• Posteiro superior
– occipital and posterior auricular arte...
PLATYSMA FLAP
• Close proximity to defects.
• Good arch of rotation.(180 degrees)
• Primary closure of the donor site can ...
FOREHEAD SKIN FLAP
Introduction:- one of the first pedicled flap to be described.
Advantages:• reliability of its vascular...
www.indiandentalacademy.com
www.indiandentalacademy.com
Anatomy:• Lateral forehead- zygomatic and ant branches of
superficial temporal artery( branch of external
carotid)
• Middl...
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Operating tech:
• Due to large amount of anastomosis of the contraletral
arteries, flap can be elevated from one malar bon...
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• As the flap is raised , care must be taken not to lift the
periostium from bone, and usage of diathermy should be
minima...
NAS0LABIAL SKIN FLAP
Indications:
Bilateral nasolabial flap:
1. Small tumors of the ant floor of mouth
2. Mucosal defect o...
www.indiandentalacademy.com
www.indiandentalacademy.com
• Anatomy:
• Blood supply: angular.a (branch of ant facial),infraorbital.a ,
transverse facial.a , infra trochelear.a
• Th...
• Operating tech:
• Incision is placed passing upwards from base lateral to angle of
mouth and centered approximately alon...
TONGUE FLAPS IN MAX FACS

www.indiandentalacademy.com
• Tongue – Excellent donor site because of its abundant
vascularity and low morbidity .
• Tongue has been used in reconstr...
RANDOM FLAP DESIGN
Dorsal tongue flap: most commonly used
Posterior based : Soft palate,
Retromolar region,
Post buccal mu...
• Elevation of flap post to the circumvalate papilla is avoided to maximize
flap survival .
• Length of the flap should be...
• Lateral Tongue flap:

Buccal mucosa
Lateral palate
Alveolus

• Incisions are made on the ventral and dorsal surface
of t...
Double Door Tongue flap:
• Large defects of buccal mucosa
extending from the commissure to the
Ant mandibular Ramus.
• Hor...
•
•
•
•
•

Median Transit Tongue flap:
Defects of Sublingual region.
An incision is made in the Sagittal midline of the To...
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Sliding posterior Tongue flap:
• This flap design allows coverage of lateral Tongue defects and
it is the modification of ...
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REHRMAN BUCCAL ADVANCEMENT FLAP
• Commonly used for closure of
oroantral fistulas.

• Trapezoidal in shape, with its base
...
MOCZAIR BUCCAL SLIDING ADV FLAP
• Minimizes the reduction in vestibular
depth.
• Similar to rehrman flap but it is shifted...
Buccal transposition flap
• Flap is taken horizontally, parallel to the buccal sulcus,
and may be pedicled mesially or dis...
BUCCAL FAT PAD

•
First described by Egyedi in 1977.
Anatomy :
•
Consists of a central body and 4 processes. (buccal, pter...
TECH:
• The buccal fat is exposed through a 1 cm vertical incision
placed through the sulcus post to the zygomatic buttres...
Palatal flaps

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PALATAL MUCOPERIOSTEAL FLAP
(ASHLEY’S FLAP)
• This flap is mainly based on the G.P
artery
• Flap is thick and inelastic, s...
PALATAL ISLAND FLAP:
• this procedure dissects out
an island of palatal mucosa
but retains its connection to
the G.P arter...
BRIDGE FLAP:
• Incisions are placed
transversly across the line
of the arch with limited on
the palatal side to preserve
t...
COMPOSITE PALATAL FLAP:
• In this procedure the palatal flap is divided in to an upper
mucosal layer and an underlying con...
ABBE-ESTERLANDER FLAP REPAIR

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www.indiandentalacademy.com
KARPANDZIC FLAP REPAIR

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BERNARD RECONSTRUCTION

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www.indiandentalacademy.com
PECTORALIS MAJOR MYOCUTANEOUS FLAP
PECTORALIS MAJOR MUSCLE
• Fan-shaped,
• clavicular & sternocostal segments
• Boundaries...
AXIAL ARTERY

THORACOACROMIAL.A

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Blood supply
• Thoraco-acromial artery (axillary a.)
• Internal (thoracic) mammary artery
• Lateral thoracic artery (Subcl...
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• Island Type
• Paddle Type
• Gemini Type

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ADVANTAGES
• Non-delayed, one-stage procedure
• Highly reliable
• Primary closure of the donor site
• Maybe used along wit...
TRAPEZIUS MUSCLE FLAP
TRAPEZIUS MUSCLE
• Origin: nuchal line of occipital bone to spinal process of C7.
• Insertion: Later...
www.indiandentalacademy.com
•
•
•
•
•
•
•

TRAPEZIUS FLAP
3 different types: superior, lateral & inferiorly base flaps.
Gives considerable bulk, treat...
DELTOPECTORAL FLAP

• Excellent reliability in head and neck defects, but color match and texture
is less than ideal.
• Do...
www.indiandentalacademy.com
www.indiandentalacademy.com
•
•
•
•
•
•
•
•
•
•
•
•

STERNOCLEIDOMASTOID (SCM) FLAP

SCM MUSCLE
Origin: sternum and medial half of clavicle (2 heads)
...
www.indiandentalacademy.com
•

LATISSIMUS DORSI MYOCUTANEOUS
PEDICLE FLAP
LATISSIMUS DORSI MUSCLE

• Origin: posterior iliac crest, thoracolumbar fasc...
www.indiandentalacademy.com
www.indiandentalacademy.com
LATISSIMUS DORSI FLAP
Good for scalp, forehead & anterior cranial defects.
Can be transferred as a pedicle flap or as a fr...
THANK YOU

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Local & regional flaps /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
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Transcript of "Local & regional flaps /certified fixed orthodontic courses by Indian dental academy "

  1. 1. LOCAL & REGIONAL FLAPS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. INTRODUCTION • The compelling drive of human beings to reconstruct deficient or missing parts and the desire of victims to undergo such reconstruction are best appreciated by recognizing the early development and use of pedicle-flap transfers long before the advent of anesthesia. Imagine, the tolerance a patient must have had to undergo nasal reconstruction using a fore-head pedicle flap without anesthesia. • The seminal work of Sushruta in the pre-christian era must have resulted in meager success; however, the basic principle behind the “Indian flap” is so sound that the procedure is still used in contemporary surgery. www.indiandentalacademy.com
  3. 3. • The later-day developments in anesthesia, antibiotics, hematology, instrumentation, and wound healing research have given surgeons devoted to reconstruction the opportunity to achieve results that would have been considered miraculous only four decades ago. www.indiandentalacademy.com
  4. 4. History • Sushruta Samshita, circa,700 B.C. first to describe a facial (forehead) flap for the reconstruction of a nose. • 695 A.D., Justinian II of the Byzantine Empire had a flap restoration of his mutilated nose. • Gaspar Tagliocozzi (1597), University of Bologna, Italy: Experimented with the fabrication of noses from the tissues of the upper arm. • Gentleman’s Magazine (1794), article by Thomas Cruso and James Findlay, "Indian Flap". • J.D. Carpue (1816) learned this technique and reconstructed two patients in U.K. • Tansini (1896), described the concept of muscle and skin flap (LDMF) • George Monks (1898), Boston Medical and Surgical Journal: First island flap ever designed in the US. • Owens (1952): SCM flap. • Conley (1960): Regional flaps. • Bakamjian (1965): Deltopectoralis flap. • Ariyan & Biller (1977): Pectoralis flap. www.indiandentalacademy.com
  5. 5. MANUEL LA ROSA-CRAIG, DDS SOFT TISSUE FLAPS IN ORAL SURGERY University of Illinois at Chicago Department of Oral & Maxillofacial Surgery FLAPS • • • • Definition (1440) Dutch word "flappe": something broad to strike with, specially a flyswatter. (1522) English: anything that hangs broad and loose, fastened only by one side. (1807) English (surgical context):portion of the skin or flesh, separated from the underlying part, but remaining attached at the base. • • • • Definition Mass of tissue having and maintaining its own blood supply. Describe different tissue transfer techniques Implied that the tissue to be transferred is to be used for reconstruction. www.indiandentalacademy.com
  6. 6. Definition A flap is one which contains within its substance a network of blood vessels, arterial,venous ,cappilaries and it is the effectiveness of the circulation through this network in perfusing the tissues of the flap at each stage of its transfer from donor to recipient site which determines its survival. www.indiandentalacademy.com
  7. 7. Alternate wound closure tech. include 1. 2. 3. 4. 5. Secondary healing-small biopsed lesions Wound contraction-lesions in region of medial canthus Primary closure-where there is minimal tension Skin grafting-open wounds with healthy bed. Many wounds have poor beds and are deeper in nature and skin grafting would result in unacceptable contour deformities. www.indiandentalacademy.com
  8. 8. In Irradiated beds use of flaps brings improved blood supply to the wound . When major structures are exposed ex: facial nerve and carotid artery flap coverage of the wound is needed. www.indiandentalacademy.com
  9. 9. GENERAL CONSIDERATIONS • Criteria for Choosing a Flap: • • • • • • Adequate amount of skin or mucosa Adequate bulk Good location & colour match Predictable blood supply Distance from irradiated sites Low donor morbidity www.indiandentalacademy.com
  10. 10. • • • • • • • • • • • • Basic Principles of Flaps Plan Design Cannot violate its blood supply Should generously fit the wound Ratio length:width (avg) 2:1 Avoid areas of tension Transfer Avoid kinking, compression, tension or severe angulation. Always favor gravity and venous drainage. Positioning Use always two layers of sutures Support www.indiandentalacademy.com
  11. 11. CLASSIFICATION www.indiandentalacademy.com
  12. 12. CLASSIFICATION: By the tissues they contain • Skin Flaps: Donor tissue containing skin and subcutaneous tissue only. Maintains its vascular supply via a pedicle attached to adjacent tissue. • Composite Flaps: Contains more than a single type of tissues including skin, subq., muscle and/or bone. www.indiandentalacademy.com
  13. 13. By the vascular system on which they are based Axial Incorporate an anatomically recognized arterio-venous system running along the long axis of the flap. • Random Does not incorporate a dominant vascular supply, relying on the networks of small diameter vessels. Facial Skin. • By the way o transfer Pedicle Flaps: More than a single layer of tissues, which can include skin + subcutaneous tissue and any combination of muscle, fascia, bone, fat. • Free Flaps: Detached at the donor site from arterial and venous connection and reanastomosed at the recipient site. • • FREE FLAPS Iliac crest flap Radial forearm flap Fibula flap www.indiandentalacademy.com
  14. 14. By method of movement from the donor site • Advancement • Rotation • Transposition www.indiandentalacademy.com
  15. 15. Advancement flaps • Undermining an area of tissue and advancing it forward to cover a defect. • Requires pliable and elastic tissue. Rotational flaps • Rotation of skin around an arch to fill a triangular defect. • Design for non-elastic tissues (scalp, forehead). • Arch of approximately 180 degrees. • Base at least twice the width of the defect. Transposition flaps • Exchange or transposition of tissue to an adjacent site. • Single or multiple, unilobed or multilobed and of an infinite variety of shapes and sizes. www.indiandentalacademy.com
  16. 16. By distance from donor site Local Flaps: • Donor site is in close proximity with the defect. • Defect requires minimum amount of tissue. Regional Flaps: • Amount of soft tissue adjacent to the defect is not adequate. • Donor site is distant to the defect area. www.indiandentalacademy.com
  17. 17. Transposition flap • When a flap moves laterally into the primary defect it is called transpositional flap. • It is designed as a square immediately adjoining to the triangular defect. • Transfer leaves secondary defect which is closed by split skin graft. • Length : breadth ration should be considered for the safe vascularity • Rich perfusion in face & scalp enhances the length: bredth restrictions to be some what relaxed ,allowing the flap to be planned even in absence of an anatomically recognized axial system. www.indiandentalacademy.com
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  20. 20. • In designing the flap and before any inscion is made the pivot point must be clearly defined and the distance from it from each point of the flap compared with its estimated distance to the same point and the transposition is complete. www.indiandentalacademy.com
  21. 21. • Clinical role of the transpositional flap is confined to the situations where a secondary graft is not contraindicated for cosmetic reasons and so it is used mainly out side the face. www.indiandentalacademy.com
  22. 22. Advancement flap • The primary motion of this flap is in a straight line from the donor site to recipient site with out rotation/lateral moment. • 1. single pedicle:a rectangular skin is moved forward by virtue of its elastic properties • 2 Bipedicle: here an incision is made parallel to the defect and the flap is undermined and advanced • 3. V-Y flap: with this flaps a V shape incision in the skin is closed by advancing the sides of the V and closing it in the shape of Y. www.indiandentalacademy.com
  23. 23. www.indiandentalacademy.com
  24. 24. Rotational flap • Random pattern sliding pivotal flaps with curvilinear design. • Used to close triangular defects. • Raised most often on the cheek, extending to a varying degree on a submandibular region. • Inferiorly based • Superiorly based • Pivot point – base line, approximately mid way. • Should be designed so that the distance between pivot and any point on circumference of flap is equal. www.indiandentalacademy.com
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  27. 27. Interpolated flap • Here the donor site is separated from recipient site , and the pedicle of the flap must pass over or under the tissue to reach the recipient area ex; nasolabial flap for nose reconstruction. www.indiandentalacademy.com
  28. 28. Z-plasty: • Involves the transposition of two interdigitating triangular flaps. • Flap transposition fallows naturally from the change in the shape of parallelogram, as do the lengthening and shortening. • Single Z-plasty – achieves 2 cm lengthening and 2cm of shortening in transverse axis. • Multiple Z-plasty, each of foure Z-plasties achieve 0.5cm lengthening with a corresponding 0.5cm of shortening at each transverse axis. • Common usage: treatment of contracted scars management of facial scars. www.indiandentalacademy.com
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  31. 31. Analysis of the defect and planning of reconstruction using local flaps. • Any defect/deformity in head and neck area presents several choices to the surgeon in terms of closure and or reconstruction • Various factors that must be considered: • 1. origin,condition,size, shape ,depth and location of the defect/deformity • 2. the condition of the surrounding tissue and its availability for use n reconstructive procedure • 3. pts desire and expectations • 4. surgeons experience and professiency www.indiandentalacademy.com
  32. 32. Viability of flap : Blood flow in the local skin flap is characterized by intrinsic vascular architecture, the nature of which determines the dimensions of the flap that will survive. Flap creation decreases the cutaneous blood flow and renders it dependent on only a few vessels requiring the fundamental capacity of intrinsic vascular system to reequilibrate. www.indiandentalacademy.com
  33. 33. BLOOD SUPPLY: A.MUSCULOCUTANEOUS ARTERIES B.SEPTOCUTANEOUS ARTERIES COMPOSITION: Cutaneous Faciocutaneous Musculocuaneous Muscle Osteocutaneous www.indiandentalacademy.com
  34. 34. PATHOPHYSIOLOGY OF FLAPS • Flaps undergo necrosis secondary to lack of nutrient blood inflow rather than lack of venous out flow. • The sympathetic nervous system is primarily responsible for determining blood flow to the skin. • Two main ressions: 1)vassoconstriction 2)arteriovenous shunt • cutting the skin causes a release of norepinephrine from the severed sympathetic nerves and the release of thromboxane A from platelets, both of which are potent vassoconstrictors. • Arteriovenous shunting is a lack of nutrient blood flow to the distal part of a flap through pathological AV shunts. • Closure of these shunts either pharmacologically are spontaniously will lead to improvement in the sruvival of the distal portion of the flap. www.indiandentalacademy.com
  35. 35. Clinical factors associated with ischemic flap necrosis: 1. 2. 3. 4. 5. 6. • • Excessive tension from taut sutures Compressive dressings Infection Hematoma Subcutanious epinephrin Smoking Despite fixed length-width ratio rules for flap, widening of the pedicle will not always improve vascularity in the distal parts of the flap. However a thicker flap may improve distal vascularity by including deeper plexus containing larger caliber vessels. www.indiandentalacademy.com
  36. 36. Therapeutic innervations for flaps: 1. 2. 3. 4. 5. 6. 7. Direct vassodilators- phenethylamines,calcium chanal blockers and topical nitroglyerin. Adrenergic blockage-isoflurane Growth factors-topical endothelial cell GF. Hyperbaric O2- 48hrs before or 4hrs after surgery. Decreasing temp Tissue expansion Flap delay www.indiandentalacademy.com
  37. 37.  Leech therapy: Hermaphroditic ectoparasites Hirudo medicinalis leech saliva-hirudin ( inhibitor of thrombin, vassodilators and hyaluronidase) leech can ingest up to 8-10 ml of blood and wound can continue to ooze 50ml of blood thus leech therapy is indicated to relieve venous congestion in failing flap.  skin flap delay: tech to increase vascular teritory of a flap prier to its definitive transfer to recipient site. www.indiandentalacademy.com
  38. 38. MONITERING OF FLAP CIRCULATION 1. 2. 3. 4. 5. 6. Lasser doppler flowmetry Thermocupple probe Temp probe Pulseoximetry Fluorescein dye Doppler ultrasonography www.indiandentalacademy.com
  39. 39. Pivot point • This point is the center of the arc around which the flap is moving in its transfer. • The distance between the pivot point and each point of the flap prior to transfer must be equal or not less than the distance after transfer. www.indiandentalacademy.com
  40. 40. LOCAL FLAPS • Forehead flap • Temporal flap • Nasolabial flap • Labial flap • Palatal flap • Tongue flap REGIONAL MYOCUTANEOUS FLAPS • Pectoralis major flap • Trapezius flap • Deltopectoralis flap • Sternocleidomastoid flap • Latissimus dorsi flap • Temporalis flap • Masseter flap • Platysma flap www.indiandentalacademy.com
  41. 41. TEMPORALIS FLAP • • • • • • • • • TEMPORALIS MUSCLE Origin Deep: Temporal fossa calvarium Superficial: Deep temporalis fascia Insertion Coronoid process & anterior ramus of mandible Innervation Motor: Anterior and deep temporal branches Sensory: Auriculotemporal nerve www.indiandentalacademy.com
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  44. 44. • TEMPORALIS MUSCLE • Blood supply • Deep temporal fascia: middle temporal branch (superficial temporal artery). • Anterior deep temporal artery. • Posterior deep temporal artery. • • • • • • TEMPORALIS FLAP Orbital, skull base and small intraoral defects. Is in close proximity to defect area. Small scar with minimal cosmetic deformity Muscular flap only with a good rotational arch. Facial nerve injury is not uncommon www.indiandentalacademy.com
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  47. 47. • • • • • • • • • • • MASSETER FLAP MASSETER MUSCLE Origin Deep: inner surface of ZGM arch Superficial: ant 2/3 lower border ZGM arch Insertion Deep: lateral surface of the coronoid process Superficial: lower portion of mandibular ramus Innervation Masseteric nerve (CN V3) Blood supply Masseteric artery (internal maxillary artery) www.indiandentalacademy.com
  48. 48. • MASSETER FLAP • Reconstruction of ablative procedures of parotid gland, mandible, palate and nasopharynx. • Treatment & reanimation of paralyzed face. • Does not restore emotional mimetic movement, therefore training is necessary. • Limited arch of rotation, size and amount. www.indiandentalacademy.com
  49. 49. • • • • • • • • PLATYSMA MUSCLEPLATYSMA FLAP Origin Subcutaneous tissues, caudal to the clavicle and acromion. Insertion Just cephalad to inferior border of mandible Innervation Motor: Cervical branches of the facial nerve Sensory: Cervical branches of C2-C4. • Blood supply: (Randomized)   www.indiandentalacademy.com
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  51. 51. • Antero superior – facial, submental, submandibular arteries • Posteiro superior – occipital and posterior auricular arteries • Midportion – superior thyroid artery • Inferiorly – Transverse or superficial cervical arteries – Direct branches of subclavian arteries www.indiandentalacademy.com
  52. 52. PLATYSMA FLAP • Close proximity to defects. • Good arch of rotation.(180 degrees) • Primary closure of the donor site can be easily done. • Thin, delicate, pliable flap. • Vulnerable to radical ablations • Not suitable where bulk is necessary www.indiandentalacademy.com
  53. 53. FOREHEAD SKIN FLAP Introduction:- one of the first pedicled flap to be described. Advantages:• reliability of its vascular supply • Excellent colour match • Proximity to the face • Larger area provided • Pt not confined to bed with limitation of neck movements as in other flaps. Disadvantages:• Secondary defect www.indiandentalacademy.com
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  55. 55. www.indiandentalacademy.com
  56. 56. Anatomy:• Lateral forehead- zygomatic and ant branches of superficial temporal artery( branch of external carotid) • Middle forehead- supplied bilaterally by supra trochlear artery, supraorbital artery (branches of opthalamic artery) • All 4 vessels anastomose and supply forehead as a whole. www.indiandentalacademy.com
  57. 57. www.indiandentalacademy.com
  58. 58. Operating tech: • Due to large amount of anastomosis of the contraletral arteries, flap can be elevated from one malar bone to another • Flap can reach up to 25 cm in length • Pedicle should not be more than 2 cm wide at its base to provide max mobility • Pedicle should of sufficient length to transpose the flap with out tension • First, course of superficial temporal artery is marked. www.indiandentalacademy.com
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  60. 60. • As the flap is raised , care must be taken not to lift the periostium from bone, and usage of diathermy should be minimal. • If these two are not fallowed, delayed healing of applied skin graft will result. • A cosmetic result is achieved by beveling the flap borders by 45 degrees so the marginal step deformity is kept to the minimum. • Upper inscission line should be just below the hair line, lower inscission line just above the eyebrows and at midline it is carried down to the glabellar region of the nose. • Donar site closed with a sheet of skin obtained by a dermotome. www.indiandentalacademy.com
  61. 61. NAS0LABIAL SKIN FLAP Indications: Bilateral nasolabial flap: 1. Small tumors of the ant floor of mouth 2. Mucosal defect of the lip 3. Ventral surface of the tongue 4. Nose Unilateral nasolabial flaps: • Adjoining buccal mucosa,lips ,alveoli,buccal sulci(upper & lower),palate and tonsillar area www.indiandentalacademy.com
  62. 62. www.indiandentalacademy.com
  63. 63. www.indiandentalacademy.com
  64. 64. • Anatomy: • Blood supply: angular.a (branch of ant facial),infraorbital.a , transverse facial.a , infra trochelear.a • These are random flaps because no attempt is usually made to include any specific arterial supply. • Because of the rich anastomosis pof arteries and veins, superior, medial, lateral, inf, pedicles are possible. www.indiandentalacademy.com
  65. 65. • Operating tech: • Incision is placed passing upwards from base lateral to angle of mouth and centered approximately along the line of the nasolabil fold. • Then the flap is raised superficial to the facial muscles and stopped a little short of the canthal area. • Then the tunnel is made through the soft tissue of the cheek near the base of the flap to take the most direct route to the defect. www.indiandentalacademy.com
  66. 66. TONGUE FLAPS IN MAX FACS www.indiandentalacademy.com
  67. 67. • Tongue – Excellent donor site because of its abundant vascularity and low morbidity . • Tongue has been used in reconstruction of oral cavity since from 100 years . • Eiselsberg was first to use pedicled tongue flaps in 1901. • Cadennat etal described the rich submucous vascular plexus found in the Tongue and this allows elevation of thin flaps (3 mm). www.indiandentalacademy.com
  68. 68. RANDOM FLAP DESIGN Dorsal tongue flap: most commonly used Posterior based : Soft palate, Retromolar region, Post buccal mucosa. Anteriorly based: Defects of Hard palate, Ant buccal mucosa, Ant floor of the mouth, Lip reconstruction. www.indiandentalacademy.com
  69. 69. • Elevation of flap post to the circumvalate papilla is avoided to maximize flap survival . • Length of the flap should be sufficient to cover the defect and to allow the mobility of the Tongue, which can make flap more versatile. • Following and adequate healing period of 14 – 21 days, the pedicle is severed. • Reinserting of maximal muscular bulk is strongly recommended to prevent post opp tongue deformity. • Debulking of recipient site should not be performed before 3 months after separation of the pedicle. www.indiandentalacademy.com
  70. 70. • Lateral Tongue flap: Buccal mucosa Lateral palate Alveolus • Incisions are made on the ventral and dorsal surface of the Tongue in a V shaped fashion, which allows primary closure of the donor site. • Pedicle is severed at 14th day. www.indiandentalacademy.com
  71. 71. Double Door Tongue flap: • Large defects of buccal mucosa extending from the commissure to the Ant mandibular Ramus. • Horizontal incision is placed on the lateral border of the Tongue of the same length of the defect. • Flaps are elevated and swung upwards and downwards and sutured to the margin of the buccal mucosa defect . • Flaps are divided after 3 weeks and the donor site is closed primarily. www.indiandentalacademy.com
  72. 72. • • • • • Median Transit Tongue flap: Defects of Sublingual region. An incision is made in the Sagittal midline of the Tongue of the same length as the width of the flap, Tunnel is created to allow the flap to reach the floor of the mouth. The relative avascularity of the median raphe allows easy formation of the tunnel. Pedicle is divided after 2 – 3 weeks. www.indiandentalacademy.com
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  74. 74. Sliding posterior Tongue flap: • This flap design allows coverage of lateral Tongue defects and it is the modification of Hemitongue advancement flap. • Mayomucosal flap is created by releasing the Tongue from the Hyoid bone and maintaining the Dorsolingual branch of Lingual A as feeding vessel. • To allow the complete mobilization the entire ipsilateral base must be freed from vertical septum. Clinical indications: • Repair of oronasal communication, • Repair of oroantral communications, • Lip reconstructions, • Buccal mucosa reconstructions, • Reconstruction of Hypopharynx. www.indiandentalacademy.com
  75. 75. www.indiandentalacademy.com
  76. 76. REHRMAN BUCCAL ADVANCEMENT FLAP • Commonly used for closure of oroantral fistulas. • Trapezoidal in shape, with its base at the buccal sulcus to maintain adequate blood supply. • Small horizontal relieving incisions through periosteum at the base of the flap allows for greater lengthning. • Moajor drawback is reduction in vestibular depth. www.indiandentalacademy.com
  77. 77. MOCZAIR BUCCAL SLIDING ADV FLAP • Minimizes the reduction in vestibular depth. • Similar to rehrman flap but it is shifted one tooth distally to reduce tension on vestibular tissues. • Drawback- when used in dentate patient, bone is exposed on the facial aspect of the adjacent tooth. • So mainly used in edentulous patients. www.indiandentalacademy.com
  78. 78. Buccal transposition flap • Flap is taken horizontally, parallel to the buccal sulcus, and may be pedicled mesially or distally. • After adequate reflection, the flap is rotated 90 degrees to cover the defect. • Drawback – loss of keratinized mucosa and distortion of buccal sulcus. www.indiandentalacademy.com
  79. 79. BUCCAL FAT PAD • First described by Egyedi in 1977. Anatomy : • Consists of a central body and 4 processes. (buccal, pterygoid, superfeecial & temporal extensions. Blood supply: 1. Buccal and deep temporal branches of the maxillary.a 2. Transversefacial branches of the superfecial temporal.a 3. Small branches of facial.a INDICATION-closure of oral defects up to an area of 50x60mm and a thickness of 6mm. www.indiandentalacademy.com
  80. 80. TECH: • The buccal fat is exposed through a 1 cm vertical incision placed through the sulcus post to the zygomatic buttress. • The fat is gently advanced over the defect and secured with sutures. • Epithelialization of the exposed adipose tissue occurs between 2 to 4 weeks post opp. ADVANTAGES: • Little decrease in vestibular depth • Low morbidity • Abundant tissue availability • Expandable tissue www.indiandentalacademy.com
  81. 81. Palatal flaps www.indiandentalacademy.com
  82. 82. PALATAL MUCOPERIOSTEAL FLAP (ASHLEY’S FLAP) • This flap is mainly based on the G.P artery • Flap is thick and inelastic, so it must be made longer than would appear necessary • Rotation posterior to the second molar is not recommended but can be used for the contralateral side. • An incision is made along the mid palatal line just ant to the junction of hard and soft palate and curved laterally toward the affected side, when it has reached the canine and lateral incissor region. www.indiandentalacademy.com
  83. 83. PALATAL ISLAND FLAP: • this procedure dissects out an island of palatal mucosa but retains its connection to the G.P artery. www.indiandentalacademy.com
  84. 84. BRIDGE FLAP: • Incisions are placed transversly across the line of the arch with limited on the palatal side to preserve the blood supply (GPA) but can be extended buccally to reduce tension. www.indiandentalacademy.com
  85. 85. COMPOSITE PALATAL FLAP: • In this procedure the palatal flap is divided in to an upper mucosal layer and an underlying connective tissue layer. • The connective tissue layer is used to cover the defect and the epithelial layer is replaced over the donor site to allow primary closure. COMPOUND FLAP: • This procedure involves mobilization of both buccal and palatal flaps over the defect and suturing them to each other. • Buccal sulcus obliteration is minimised. www.indiandentalacademy.com
  86. 86. ABBE-ESTERLANDER FLAP REPAIR www.indiandentalacademy.com
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  88. 88. KARPANDZIC FLAP REPAIR www.indiandentalacademy.com
  89. 89. BERNARD RECONSTRUCTION www.indiandentalacademy.com
  90. 90. www.indiandentalacademy.com
  91. 91. PECTORALIS MAJOR MYOCUTANEOUS FLAP PECTORALIS MAJOR MUSCLE • Fan-shaped, • clavicular & sternocostal segments • Boundaries • Superior: Clavicle • Medial: Sternum • Lateral: Axillary fold • Fascia connects: serratus anterior & rectus abdominis Origin • Clavicular: Medial aspect of clavicle • Sternocostal: Lateral sternum, 1st - 7th costal cartilages and rectus abdominus muscle Insertion • Bicipital groove humerus www.indiandentalacademy.com
  92. 92. AXIAL ARTERY THORACOACROMIAL.A www.indiandentalacademy.com
  93. 93. Blood supply • Thoraco-acromial artery (axillary a.) • Internal (thoracic) mammary artery • Lateral thoracic artery (Subclavian a.) Innervation • C5, C6 & C7 (lateral pectoral nerve) • C8, T1 (medial pectoral nerve) • Sensation: Intercostal nerves www.indiandentalacademy.com
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  95. 95. • Island Type • Paddle Type • Gemini Type www.indiandentalacademy.com
  96. 96. ADVANTAGES • Non-delayed, one-stage procedure • Highly reliable • Primary closure of the donor site • Maybe used along with other flaps • It may be transposed with an attached rib • Skin coverage, muscle bulk and good blood supply DISADVANTAGES • Excessive bulk and thickness may compromise its blood supply • Hair bearing area • Shoulder disability www.indiandentalacademy.com
  97. 97. TRAPEZIUS MUSCLE FLAP TRAPEZIUS MUSCLE • Origin: nuchal line of occipital bone to spinal process of C7. • Insertion: Lateral third of the clavicle, acromion and scapula. • Function: Elevation, flexion and adduction of the upper arm. Movement of the scapula. • • • • Blood supply: Transverse cervical artery Occipital artery Perforating blood vessels from the intercostal system through its paraspinous portion. • • • • • Venous drainage: subdermal veins and concomitant veins of the paravertebral venous system. Innervation: Motor: Spinal accessory nerve. Sensory: Cervical and intercostal nerves. www.indiandentalacademy.com
  98. 98. www.indiandentalacademy.com
  99. 99. • • • • • • • TRAPEZIUS FLAP 3 different types: superior, lateral & inferiorly base flaps. Gives considerable bulk, treating defects of up to 10x20 cm. Arch of rotation of up to 180 degrees. ADVANTAGES Minimal defect at donor area Moderate shoulder-drop after surgery. • Cannot be easily tubed. www.indiandentalacademy.com
  100. 100. DELTOPECTORAL FLAP • Excellent reliability in head and neck defects, but color match and texture is less than ideal. • Donor site requires STSG. • Horizontal flap design with round tip. • Perfused by intercostal perforating branches of the internal mammary artery. • DELTOPECTORAL FLAP • Outlined along the inferior border of the clavicle, beginning > sternum extending lateral > acromion process. Returning at the level of 5th rib. • Elevation beneath the level of the pec. muscle fascia, lateral to medial. • Base: 2 cm from the lateral sternal border. • Provides only skin, subq tissue & muscular fascia. • If used for oral reconstruction, oral cutaneous fistula will be created and repaired in a second procedure www.indiandentalacademy.com
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  103. 103. • • • • • • • • • • • • STERNOCLEIDOMASTOID (SCM) FLAP SCM MUSCLE Origin: sternum and medial half of clavicle (2 heads) Insertion: lateral surface of mastoid process Blood supply: Superior: branches of occipital artery. Middle: branches of the superior thyroid artery. Inferiorly: branches of the thyrocervical trunk. Innervation: spinal accessory nerve. can be used as muscle flap only, myocutaneous flap or as a composite flap Can be based superiorly or inferiorly. The superior thyroid vessels should be preserved at all times. Limited rotational angle (random-pattern). www.indiandentalacademy.com
  104. 104. www.indiandentalacademy.com
  105. 105. • LATISSIMUS DORSI MYOCUTANEOUS PEDICLE FLAP LATISSIMUS DORSI MUSCLE • Origin: posterior iliac crest, thoracolumbar fascia, external oblique fascia and the lower six vertebrae. • Insertion: Intertubercular groove of the humerus • Blood supply: Circumflex subscapular artery Thoracodorsal artery • Innervation: Thoracodorsal nerve. www.indiandentalacademy.com
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  108. 108. LATISSIMUS DORSI FLAP Good for scalp, forehead & anterior cranial defects. Can be transferred as a pedicle flap or as a free flap. As only muscle or as musculocutaneous flap (bulky). Reliable and provides large amount of soft tissues > massive defects. • Not good for reconstruction of thin, esthetic defects • • • • • www.indiandentalacademy.com
  109. 109. THANK YOU www.indiandentalacademy.com

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