Micro vascular Free Flaps
Used in Head and Neck
Reconstruction.
INDIAN DENTAL ACADEMY

Leader in continuing dental educati...
Outline
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Radial Forearm Flaps
Lateral Arm Flaps
Lateral Thigh Flap
Anterolateral Thigh Fla...
Radial Forearm Flap
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1981 (China), 1985 (pharyngeal recon)
Oral cavity, base of tongue, pharynx, soft pal...
Neurovascular pedicle
► Up to 20 cm long

► Vessel caliber 2 – 2.5 mm
► Radial artery

► Venae comitantes / cephalic

vein...
Technical considerations
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Tourniquet

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Flap designed with skin paddle
centered over the radial artery
Dissection in su...
Technical considerations
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Osteocutaneous flap
 Monocortical
 Cuff of flexor pollicis longus
 10 – 12 cm of radius
 U...
Radial Forearm Flap

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Radial Forearm Flap

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Radial Forearm Flap

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Radial Forearm Flap
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Morbidity
 Hand ischemia
 Fistula rates - 42% to 67% in early series
► Subsequent series - 15% an...
Radial Forearm Flap
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Preoperative considerations
 Allen test
► Tests viability of palmar
arch system
 No IVs / blood d...
Lateral Arm Flap
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Described by Song in 1982
Moderately thin fasciocutaneous flap
Donor site skin 6-8 cm (1/3
...
Neurovascular pedicle
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Terminal branch of profunda brachii artery
and posterior radial collateral artery
Vena...
Technical considerations
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No tourniquet.
Central axis of flap design based on
intermuscular septum
 Lateral ...
Lateral Arm Flap
► Morbidity

 Radial nerve damage
►Palsy 2/2 constrictive

dressings or tight wound
closure.

 Primary ...
Lateral Arm Flap
► Preoperative Considerations

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Easy scar camouflage
Male patients may have less hair in
this region ...
Lateral Thigh Flap
► Described by Baek in 1983
► Large surface area
► Expendable tissue

► Flap size up to 25 x 14 cm

► F...
Neurovascular pedicle
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Third perforator of profunda
femoris
Travels w/in intermuscular
septum
Pedicle 8 – 12 cm
...
Lateral Thigh Flap

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Lateral Thigh Flap

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Technical considerations
Centered over lateral intermuscular septum
 Separates vastus lateralis and iliotibial
tract (fas...
Lateral Thigh Flap
► Morbidity

 Atherosclerosis of profunda femoris and its
branches
 Avoid in pts with h/o PVD
 Sciat...
Lateral Thigh Flap
► Preoperative

► Postoperative

Considerations

management

 Assess for PVD
(palpate peripheral
pulse...
Anterolateral thigh flap
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First reported by Song et al
Subcutaneous, fasciocutaneous,
myocutaneous, adipofasci...
Neurovascular pedicle
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Descending branch of lateral
circumflex femoral artery
 Septocutaneous
► Traverse the ...
Neurovascular pedicle
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Musculocutaneous variations
 Vertical musculocutaneous perforators (descending lateral
circum...
Anterolateral thigh flap

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Anterolateral thigh flap

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Technical considerations
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Draw line from ASIS to lateral patellar border
Cutaneous perforator exit po...
Anterolateral thigh flap

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Anterolateral thigh flap
► Morbidity

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Possible STSG
Depends on extent of injury to vastus lateralis
Thinned flaps w...
Anterolateral thigh flap
► Preoperative Considerations

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Reduced donor site morbidity compared to RFF
Can be as thin...
Rectus abdominis
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Easy to harvest
Long pedicle
Skin from abdomen and lower chest
Myocutaneous fl...
Neurovascular pedicle
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Two dominant pedicles

 Deep superior epigastric artery/vein
 Deep inferior epigastric artery a...
Technical considerations
Cutaneous blood supply
 Harvest anterior rectus sheath in paraumbilical
region (dominant perfora...
Technical considerations
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Dissect superiorly first
Dissect down to underlying muscle
...
Rectus abdominis

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Rectus abdominis

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Rectus abdominis

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Rectus abdominis
► Morbidity

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Abdominal weakness
Hernia

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Rectus abdominis
► Preoperative

Considerations

► Postoperative

 Prior abdominal surgery
 Prior inguinal
herniorrhapy ...
Latissimus dorsi
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Pedicle or free flap
Free flaps
 Better flap positioning
 Cutaneous portion can be...
Neurovascular pedicle
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Thoracodorsal artery
Arise from subscapular vessels off
of third portion of axillary art...
Technical considerations
Lateral decubitis position
 If at 15 degrees, flap may be
harvested simultaneously with
primary ...
Latissimus dorsi

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Latissimus dorsi
► Morbidity

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Marginal flap necrosis
Pedicled flaps pass b/w pec major and minor
►Changes in arm posi...
Latissimus dorsi
► Preoperative

► Postoperative

Considerations

management

 Relative
contraindications - prior
axillar...
Gracilis flap
► 1976
► Thin muscle flap
► Dynamic facial

reanimation
► Muscle revasularized
and reinnervated
► Long vascu...
Neurovascular pedicle
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Terminal branch of adductor artery from
profunda femoris
Runs b/w adductor longus (...
Technical considerations
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Muscle can be split into at least
two functional muscular units
Single neuromuscular unit ...
Gracilis flap

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Temperoparietal Fascia Flap
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More commonly transferred as a
pedicled flap but can be used as a
free flap when...
Neurovascular pedicle
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5 layers – scalp
Temperoparietal fascia (TPF) deep
to skin and subcutaneous tissue.
Super...
Temperoparietal Fascia Flap

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Technical considerations
► Vertical incision over root of helix to superior

temporal line
► V-shaped extension at superio...
Temperoparietal Fascia Flap

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Temperoparietal Fascia Flap
► Morbidity

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Frontal branch weakness (travels in TPF)
Secondary alopecia – damage to hair...
Temperoparietal Fascia Flap
► Preoperative Considerations

 Relative contraindications - prior XRT, neck
surgery, bicoron...
Fibular osteocutaneous flap
► 1975
► Hidalgo – mandibular recon

1989
► Longest possible segment of
revasularized bone (25...
Neurovascular pedicle
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Peroneal artery and vein
Sensate restoration with lateral sural
cutaneous nerve
Peroneal c...
Technical considerations
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Choose leg based on ease of
insetting
 Intraoral skin paddle
► Harvest flap from
c...
Fibular osteocutaneous flap

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Fibular osteocutaneous flap

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Fibular osteocutaneous flap

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Fibular osteocutaneous flap
► Morbidity

 Donor site complications
►Edema

►Weakness in dorsiflexion of great toe

 Skin...
Fibular osteocutaneous flap
► Preoperative

► Postoperative

Considerations

management

Angiography
MRA
h/o distal lower
...
Iliac crest flaps
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Osteocutaneous, osteomusculocutaneous
Segmental mandibular defects
Up to 16 cm bone
O...
Neurovascular pedicle
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Deep circumflex iliac artery from lateral
aspect of external iliac artery
 1 – 2 cm cephalic to ...
Iliac crest flaps

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Technical considerations
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Skin paddle centered on axis
from ASIS to inferior tip of
scapula
Cutaneous perforators

 ...
Iliac crest flaps

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Iliac crest flaps

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Iliac crest flaps
► Morbidity

 Hernia
► Need to approximate cut edge of iliacus muscle to transversus

abdominis
► Can b...
Iliac crest flaps
► Preoperative Considerations

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

www...
Scapular flaps
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Fasciocutaneous, osteofasciocutaneous,
cutaneous flap, parascapular cutaneous
flap, latissimus dors...
Neurovascular pedicle
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Subscapular artery and vein

 Circumflex scapular artery and vein emerge from
triangular space (...
Scapular flaps

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Technical considerations
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Decubitis positioning
 15 degree angle
 Separate axillary incision helpful
in dissecting ...
Scapular flaps

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Scapular flaps
► Morbidity

 Brachial plexus injury 2/2 lateral decubitis
positioning
►Use axillary roll

 Stay 1 cm inf...
Scapular flaps
► Preoperative

Considerations
 Prior axillary node
dissection –
contraindication

► Postoperative

manage...
Rib flap
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First vascularized bone to be used
in mandibular reconstruction.
(osteocutaneous)
Blood supply to the ...
Neurovascular pedicle

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Metatarsus flap
► Osteocutaneous flap

based on the first
dorsal metatarsal
artery
► Thin sensate skin
with the second
met...
Neurovascular pedicle

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Jejunal flap
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1959
Circumferential pharyngoesophageal
defects
Patch graft
Diameter of jejunum – good match t...
Neurovascular pedicle
► Mesenteric

arcade vessels
 Usually 2nd arcade
is best for
pharyngeal
reconstruction

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Technical considerations
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Harvest distal to Ligament of Treitz
Up to 20 cm
Laparoscopic harvest has been
re...
Jejunal flap

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Jejunal flap
► Morbidity

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Most susceptible to primary ischemia
Fistula formation – 18%
11% rate of anastomotic stri...
Jejunal flap
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Preoperative
Considerations

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 Absolute contraindications
► Disease extension into

proximal thoracic
e...
Gastroomental flap

1961, 1979
► Greater omentum – double layer of
peritoneum
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 Hangs from greater curvature of stomach...
Neurovascular pedicle
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Right gastroepiploic artery
 Caliber – 1.5 to 3.0 mm

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Gastroomental flap
► Morbidity

 Intraabdominal complications
► Gastric leak
► Peritonitis

► Intraabdominal abscess
► Vo...
Gastroomental flap

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Bibliography
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Chepeha, DB, Teknos, TN. Microvascular Free Flaps in Head and Neck
Reconstruction....
Thank you
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Leader in continuing dental education

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Micro vascular free flaps used in head and neck reconstruction /certified fixed orthodontic courses by Indian dental academy

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Micro vascular free flaps used in head and neck reconstruction /certified fixed orthodontic courses by Indian dental academy

  1. 1. Micro vascular Free Flaps Used in Head and Neck Reconstruction. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Outline ► ► ► ► ► ► ► ► ► ► ► ► ► ► ► ► Radial Forearm Flaps Lateral Arm Flaps Lateral Thigh Flap Anterolateral Thigh Flap Rectus Abdominis Flaps Latissimus Dorsi Flap Gracilis Flap Temperoparietal Fascial Flap Fibular Osteocutanous Flap Iliac Crest Flaps Scapular Flaps Metatarsal Flap Rib Flaps Jejunum Omentum Gastroomentum www.indiandentalacademy.com
  3. 3. Radial Forearm Flap ► ► ► ► ► ► ► 1981 (China), 1985 (pharyngeal recon) Oral cavity, base of tongue, pharynx, soft palate, cutaneous defects, base of skull, small volume bone and soft tissue defects of face Thin, pliable skin  Reconstitution of contours, sulci, vestibules  Tongue mobility Fasciocutaneous flaps are highly tolerant of radiation therapy Composite flap with bone, tendon, brachioradialis muscle and vascularized nerve.  Sensory recovery reported in patients even when a neural anastomosis is not performed. ► Fasciocutaneous flaps > musculocutaneous flaps ► Incomplete and unpredictable Skin from entire forearm 2 team approach www.indiandentalacademy.com
  4. 4. Neurovascular pedicle ► Up to 20 cm long ► Vessel caliber 2 – 2.5 mm ► Radial artery ► Venae comitantes / cephalic vein ► Lateral antebrachial cutaneous nerve (sensory)  Anastomose to lingual nerve  Increased two point discrimination after inset www.indiandentalacademy.com
  5. 5. Technical considerations ► Tourniquet ► Flap designed with skin paddle centered over the radial artery Dissection in subfascial level as the pedicle is approached. Pedicle identified b/w medial head of the brachioradialis, and the flexor carpi radialis Radial artery is dissected to its origin  Divided distal to the radial recurrent artery ► ► ► External skin monitor can be incorporated into the flap (proximal segment) ► A -plasty - reduces the potential for stricture ► www.indiandentalacademy.com
  6. 6. Technical considerations ► Osteocutaneous flap  Monocortical  Cuff of flexor pollicis longus  10 – 12 cm of radius  Up to 40% circumference  Limited by amount of available bone and risk for pathologic fracture. ► Pollicis longus tendon  Suspending flap laterally in palatal and total lower lip recon www.indiandentalacademy.com
  7. 7. Radial Forearm Flap www.indiandentalacademy.com
  8. 8. Radial Forearm Flap www.indiandentalacademy.com
  9. 9. Radial Forearm Flap www.indiandentalacademy.com
  10. 10. Radial Forearm Flap ► Morbidity  Hand ischemia  Fistula rates - 42% to 67% in early series ► Subsequent series - 15% and 38%. ► Creation of a controlled fistula or use of a salivary bypass stent can protect the suture line from salivary soilage and decrease the potential for fistulization.    Stricture formation - 9% to 50%. Radial nerve injury Variable anesthesia over dorsum of hand. www.indiandentalacademy.com
  11. 11. Radial Forearm Flap ► Preoperative considerations  Allen test ► Tests viability of palmar arch system  No IVs / blood draws in donor arm.  Skin graft (must preserve paratenon layer)  Osteocutaneous flaps ► Radius fracture ► Weakened supination, wrist flexion, grip strength and pinch strength.  Should not be used defect extends below the thoracic inlet ► Postoperative management  Forearm and wrist immobilization w/volar splint  7-10 days  Oral intake can generally begin within 7 to 10 days www.indiandentalacademy.com ► 2 weeks is best if the patient has been previously irradiated.
  12. 12. Lateral Arm Flap ► ► ► ► ► ► Described by Song in 1982 Moderately thin fasciocutaneous flap Donor site skin 6-8 cm (1/3 circumference of arm) Fascial flap  Augmentation of subcutaneous defects from lateral temporal bone resection or total parotid Portion of humerus can be taken. Oropharyngeal reconstruction  Incorporates thin skin from the proximal forearm. ► Pharyngeal wall  Thick skin from the upper arm ► Tongue base www.indiandentalacademy.com
  13. 13. Neurovascular pedicle ► ► ► ► ► ► Terminal branch of profunda brachii artery and posterior radial collateral artery Venae comitantes Travel with radial nerve in spiral groove of humerus  Travels in the lateral intermuscular septum ► Posterior - Triceps ► Anterior - Brachialis and Brachioradialis Artery caliber 1.55 mm diameter (1.25 to 1.75 mm) @ deltoid insertion Skin blood supply – 4 to 5 septocutaneous perforaters Sensory nerves (from proximal radial nerve)  Posterior cutaneous nerve of the arm (lower lateral brachial cutaneous nerve)  Posterior cutaneous nerve of the forearm (post antebrachial cut nerve) www.indiandentalacademy.com
  14. 14. Technical considerations ► ► ► ► ► ► No tourniquet. Central axis of flap design based on intermuscular septum  Lateral intermuscular septum - 1 cm posterior to line drawn from insertion of deltoid and lateral epicondyle  Can be extended distally over the upper forearm Radial nerve identified along the anterior aspect of the pedicle Radial nerve and pedicle are followed into the spiral groove Must identify and preserve muscular branches from radial nerve Osteocutaneous flap  Humerus segment ► 10 cm in length ► 20% of the circumference www.indiandentalacademy.com
  15. 15. Lateral Arm Flap ► Morbidity  Radial nerve damage ►Palsy 2/2 constrictive dressings or tight wound closure.  Primary closure if less than 1/3 of arm ►Use STSG if closure under too much tension. www.indiandentalacademy.com
  16. 16. Lateral Arm Flap ► Preoperative Considerations   Easy scar camouflage Male patients may have less hair in this region when compared to forearm ►Consider for intraoral reconstruction  Flap becomes thinner more distally www.indiandentalacademy.com
  17. 17. Lateral Thigh Flap ► Described by Baek in 1983 ► Large surface area ► Expendable tissue ► Flap size up to 25 x 14 cm ► Fasciocutaneous flap – thin to moderately thick ► Intraoral and pharyngeal reconstruction ► Reinnervated via lateral femoral cutaneous nerve www.indiandentalacademy.com
  18. 18. Neurovascular pedicle ► ► ► ► ► Third perforator of profunda femoris Travels w/in intermuscular septum Pedicle 8 – 12 cm Vessel caliber 2 – 4 mm Lateral femoral cutaneous nerve of the thigh  Anterosuperior entry into flap  Does not travel with vascular pedicle ► Terminal cutaneous branch of second or fourth perforators are the dominant arterial supply (rare)  4th perforator usually included in dissection to account for variations  When 2nd perforator dominant – pedicle length limited by muscular branch vessels to preserve femoral blood supply. www.indiandentalacademy.com
  19. 19. Lateral Thigh Flap www.indiandentalacademy.com
  20. 20. Lateral Thigh Flap www.indiandentalacademy.com
  21. 21. Technical considerations Centered over lateral intermuscular septum  Separates vastus lateralis and iliotibial tract (fascia lata) anteriorly from the biceps femoris posteriorly ► Septum located by line b/w greater trochanter and lateral epicondyle of femur ► 3rd perforator at midpoint of line ►  Terminates in the intermuscular septum between the long head of the biceps femoris and the vastus lateralis Lateral femoral cutaneous nerve provides sensation to the skin of the lateral thigh and may be incorporated into the flap ► Dominant perforator identified in subcutaneous plane and then traced through the biceps femoris to the main pedicle ► Release of the adductor magnus from the linea aspera facilitates dissection of the main pedicle ► www.indiandentalacademy.com
  22. 22. Lateral Thigh Flap ► Morbidity  Atherosclerosis of profunda femoris and its branches  Avoid in pts with h/o PVD  Sciatic nerve injury www.indiandentalacademy.com
  23. 23. Lateral Thigh Flap ► Preoperative ► Postoperative Considerations management  Assess for PVD (palpate peripheral pulses)  Not advised for use in obese individuals or in those with previous surgery or trauma to the thigh  Primary closure of donor site  Early walking www.indiandentalacademy.com
  24. 24. Anterolateral thigh flap ► ► ► ► ► ► First reported by Song et al Subcutaneous, fasciocutaneous, myocutaneous, adipofascial Laryngopharynx, oral cavity, oropharynx, external skin and maxilla Flap may be thinned or suprafascial flaps taken for thinner flaps Popular in Asia Less popular in Europe and America  Difficult perforator dissection (bountiful subcutaneous tissue)  Variation in vascular anatomy www.indiandentalacademy.com
  25. 25. Neurovascular pedicle ► ► ► ► ► Descending branch of lateral circumflex femoral artery  Septocutaneous ► Traverse the fascia lata  Musculocutaneous perforators ► Traverse the vastus lateralis muscle and the deep fascia Venae comitantes Descending branch travels inferiorly in intramuscular space b/w rectus femoris and vastus lateralis Caliber – 2.1 mm artery, 2.6 mm vein Vascular pedicle up to 16 cm ► Lateral femoral cutaneous nerve – sensory nerve  Branch of lumbar plexus  Enters thigh deep to lateral aspect of inguinal ligament near ASIS  Runs with deep circumflex iliac artery and vein  Runs anterior, posterior or through sartorius, continuing through fascia lata www.indiandentalacademy.com
  26. 26. Neurovascular pedicle ► ► Musculocutaneous variations  Vertical musculocutaneous perforators (descending lateral circumflex femoral artery) ► Pass through vastus lateralis perpendicularly into fascia lata  Horizontal musculocutaneous perforators (transverse branch of lateral circumflex femoral artery) ► Pass through vastus lateralis horizontally Skin blood supply  Septocutaneous perforators – 10.7%  Musculocutaneous perforators from descending branch – 89%  Musculocutaneous perforator from transverse branch – 3.5% www.indiandentalacademy.com
  27. 27. Anterolateral thigh flap www.indiandentalacademy.com
  28. 28. Anterolateral thigh flap www.indiandentalacademy.com
  29. 29. Technical considerations ► ► ► ► ► ► ► ► ► Draw line from ASIS to lateral patellar border Cutaneous perforator exit point from intermuscular septum or from vastus lateralis  2 cm lateral to and 2 cm inferior to midpoint of line from ASIS and lateral border of patella Use Doppler to mark perforators Dissect (medial to lateral) to intermuscular septum b/w rectus femoris and vastus lateralis. Retract rectus femoris medially exposing perforators  Leave muscle cuff around myocutaneous perforators Fasciocutaneous flap, suprafascial flap, cutaneous flap (up 5 mm thickness), adipofascial flap May include lateral cutaneous nerve of thigh Max size – horizontal line from greater trochanter down to a parallel line 3 cm above patella  25 x 18 cm  20 x 26 cm Close donor site primarily if less than 8 cm wide www.indiandentalacademy.com
  30. 30. Anterolateral thigh flap www.indiandentalacademy.com
  31. 31. Anterolateral thigh flap ► Morbidity    Possible STSG Depends on extent of injury to vastus lateralis Thinned flaps with more complications in intraoral defects www.indiandentalacademy.com
  32. 32. Anterolateral thigh flap ► Preoperative Considerations    Reduced donor site morbidity compared to RFF Can be as thin as RFF Contraindicated in pts with prior upper thigh surgery, vascular procedures, big eaters… www.indiandentalacademy.com
  33. 33. Rectus abdominis ► ► ► ► ► ► ► ► ► ► ► ► ► Easy to harvest Long pedicle Skin from abdomen and lower chest Myocutaneous flap or muscle only flap Not used for functional motor reconstruction Can include entire muscle or only small portion in paraumbilical region Plentiful people – thinner flap created by skin grafting the muscle Skinny people  Flap used for moderately volume defects Poor color match Tends to become ptotic Skull base defects  Muscular component used to seal subarachnoid space Able to fill large tissue deficits Total glossectomy defects www.indiandentalacademy.com
  34. 34. Neurovascular pedicle ► Two dominant pedicles  Deep superior epigastric artery/vein  Deep inferior epigastric artery and vein ► ► ► ► Based on inferior epigastrics when used for h/n recon because of larger pedicle size Inferior epigastric diameter – 3 to 4 mm Reinnervated with any of the lower six intercostal nerves. Pedicle may travel along lateral aspect of muscle before taking intramuscular route www.indiandentalacademy.com
  35. 35. Technical considerations Cutaneous blood supply  Harvest anterior rectus sheath in paraumbilical region (dominant perforators located here)  Skin paddle designed with epicenter above the umbilicus ► Primary closure ► Hernia prevention depends on restoring abdominal wall. ► Arcuate line (level of ASIS)  Superior – posterior sheath with transversalis fascia, internal oblique and transversus abdominis ► Closure of posterior sheath prevents herniation  Inferior – only transversalis fascia posterior to muscle ► Must close anterior sheath to prevent herniation ► www.indiandentalacademy.com
  36. 36. Technical considerations 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Dissect superiorly first Dissect down to underlying muscle Split fascia to the costal margin Lateral and inferior portions of skin paddle incised next Small cuff of anterior rectus fascia preserved medially and laterally, to preserve cutaneous perforators Split fascia vertically down to the public region Divide rectus superiorly and free from posterior rectus sheath Dissection below the arcuate line Vascular pedicle identified below arcuate line along the lateral deep aspect of the muscle. Divide rectus inferiorly Pedicle dissected inferiorly to origin off the external iliac system www.indiandentalacademy.com
  37. 37. Rectus abdominis www.indiandentalacademy.com
  38. 38. Rectus abdominis www.indiandentalacademy.com
  39. 39. Rectus abdominis www.indiandentalacademy.com
  40. 40. Rectus abdominis ► Morbidity   Abdominal weakness Hernia www.indiandentalacademy.com
  41. 41. Rectus abdominis ► Preoperative Considerations ► Postoperative  Prior abdominal surgery  Prior inguinal herniorrhapy may compromise pedicle dissection 2/2 scarring  Hernia  Diastasis recti management  Ileus  Avoid abdominal strain for 6 weeks. www.indiandentalacademy.com
  42. 42. Latissimus dorsi ► ► ► ► ► ► ► ► ► Pedicle or free flap Free flaps  Better flap positioning  Cutaneous portion can be centered over pedicle  Less risk of pedicle kinking Musculocutaneous  Large volume defects of large cutaneous neck defects Muscle-only flap  Broad and thin  Atrophies to about 4 mm  Ideal for scalp reconstruction  Poor for large volume defects Massive scalp defects STSG for final resurfacing Non sensate Motor reconstruction possible Useful after total glossectomy www.indiandentalacademy.com
  43. 43. Neurovascular pedicle ► ► ► ► ► Thoracodorsal artery Arise from subscapular vessels off of third portion of axillary artery and vein Vessel diameter at origin – 2.7 mm(1.5 to 4.0) Vein diameter – 3.4 mm (1.5 to 4.5) Pedicle length 9.3 cm (6 to 16.5)  Can be lengthened by sacrificing branch to serratus anterior ► Numerous variations  Most common: independent origin of thoracodorsal vein/artery www.indiandentalacademy.com
  44. 44. Technical considerations Lateral decubitis position  If at 15 degrees, flap may be harvested simultaneously with primary lesion resection  Anterior muscle border along line b/w midpoint of axilla and point midway b/w ASIS and PSIS ► Vessels enter undersurface of muscle 8 to 10 cm below midpoint of axilla ► Serratus vessels ligated during harvest ► Can design two paddle flap based on medial and lateral branches of thoracodorsal vessels ► ► Total glossectomy insetting.  Muscle inset as a sling on undersurface of mandible  Sutured to pterygoid, masseter, or superior constrictor...  Thoracodorsal nerve anastomosed to a hypoglossal nerve www.indiandentalacademy.com ► Gives reconstructed tongue the ability to elevate superiorly toward the palate
  45. 45. Latissimus dorsi www.indiandentalacademy.com
  46. 46. Latissimus dorsi ► Morbidity   Marginal flap necrosis Pedicled flaps pass b/w pec major and minor ►Changes in arm position may occlude pedicle ►Should immobilize arm in flexed position www.indiandentalacademy.com
  47. 47. Latissimus dorsi ► Preoperative ► Postoperative Considerations management  Relative contraindications - prior axillary LN dissection  Preop angiography advocated to assess vessel patency  Suction drains  High incidence of seroma www.indiandentalacademy.com
  48. 48. Gracilis flap ► 1976 ► Thin muscle flap ► Dynamic facial reanimation ► Muscle revasularized and reinnervated ► Long vascular pedicle ► Easy dissection www.indiandentalacademy.com
  49. 49. Neurovascular pedicle ► ► ► ► ► ► ► Terminal branch of adductor artery from profunda femoris Runs b/w adductor longus (anterior) and adductor brevis and magnus (posterior)  Enters gracilis at junction of upper third and lower two thirds  8 – 10 cm inferior to pubic tubercle 2 venae comitantes – drain into profunda femoris Artery caliber – 2 mm Vein caliber 1.5 – 2.5 mm Motor innervation – anterior branch of obturator nerve  2 – 3 cm cephalic to vascular pedicle. Blood supply to skin variable  Skin supplied mostly by septocutaneous perforators www.indiandentalacademy.com
  50. 50. Technical considerations ► ► ► Muscle can be split into at least two functional muscular units Single neuromuscular unit can be transferred to decrease bulk Orient skin paddle longitudinally  Must be centered over dominant musculocutaneous perforator ► For synchronous mimetic movement when proximal facial nerve not available.  2 stage procedure with cross face sural nerve graft  Tinel sign used to monitor axonal growth across the face – 9-12 months  After adequate axonal regrowth – muscle transferred www.indiandentalacademy.com
  51. 51. Gracilis flap www.indiandentalacademy.com
  52. 52. Temperoparietal Fascia Flap ► ► ► ► ► ► More commonly transferred as a pedicled flap but can be used as a free flap when arc of rotation is inadequate Ultra thin – 2 to 4 mm thick Highly vascular, pliable and durable Fascial, fasciocutaneous Up to 17 x 14 cm with extensive scalp undermining Oral cavity, hemilaryngectomy defects, middle and upper regions of face w/split calvarial bone graft www.indiandentalacademy.com
  53. 53. Neurovascular pedicle ► ► ► ► ► 5 layers – scalp Temperoparietal fascia (TPF) deep to skin and subcutaneous tissue. Superficial to temporalis muscular fascia Above superior temporal line it’s continuous with galea aponeurotica Base centered over helix ► Superficial temporal artery and vein – travel in TPF layer  3 cm superior to root of helix  Vessels branch into frontal and temporal divisions  Most commonly based on parietal branch  Ligation of frontal artery 3 – 4 cm distal to branching point to avoid frontal nerve injury  Venous pedicle may course with arteries or 2 to 3 cm posteriorly Middle temporal artery – proximal superficial temporal artery at zygomatic arch (supplies temporalis muscular fascia) ► Including middle temporal artery enables a two-layered fascial flap on a single pedicle. ► www.indiandentalacademy.com
  54. 54. Temperoparietal Fascia Flap www.indiandentalacademy.com
  55. 55. Technical considerations ► Vertical incision over root of helix to superior temporal line ► V-shaped extension at superior limit of incision ► Scalp elevation ant and post ► Dissect deep to flap ► Loose areolar tissue deep to flap www.indiandentalacademy.com
  56. 56. Temperoparietal Fascia Flap www.indiandentalacademy.com
  57. 57. Temperoparietal Fascia Flap ► Morbidity   Frontal branch weakness (travels in TPF) Secondary alopecia – damage to hair follicles due to superficial dissection www.indiandentalacademy.com
  58. 58. Temperoparietal Fascia Flap ► Preoperative Considerations  Relative contraindications - prior XRT, neck surgery, bicoronal incision or external carotid embolization.  Doppler assessment of pedicle www.indiandentalacademy.com
  59. 59. Fibular osteocutaneous flap ► 1975 ► Hidalgo – mandibular recon 1989 ► Longest possible segment of revasularized bone (25 cm) ► Ideal for osseointegrated implant placement ► Mandible reconstruction (near total), maxillary reconstruction www.indiandentalacademy.com
  60. 60. Neurovascular pedicle ► ► ► ► Peroneal artery and vein Sensate restoration with lateral sural cutaneous nerve Peroneal communicating branch vascularized nerve graft for lower lip sensation Skin perforators  Posterior intermuscular septum (septocutaneous or musculocutaneous through flexor hallucis longus and soleus)  Should always include cuff of flexor hallucis longus and soleus in flap harvest  5-10% of cases blood supply to skin paddle is inadequate www.indiandentalacademy.com
  61. 61. Technical considerations ► ► ► ► ► Choose leg based on ease of insetting  Intraoral skin paddle ► Harvest flap from contralateral side of recipient vessels 8 cm segment preserved proximally and distally to protect common peroneal verve and ensure ankle stability Center flap over posterior intermuscular septum  Anterior to soleus and posterior to peroneus Doppler cutaneous perforators Greatest number of perforators present in the 15 to 25 cm range Distal skin paddle increases pedicle length ► Thigh tourniquet to 350 mm Hg ► Vascularity to skin running through the septocutaneous perforators may be enhanced by harvesting a segment of soleus to capture additional musculocutaneous perforators ► www.indiandentalacademy.com
  62. 62. Fibular osteocutaneous flap www.indiandentalacademy.com
  63. 63. Fibular osteocutaneous flap www.indiandentalacademy.com
  64. 64. Fibular osteocutaneous flap www.indiandentalacademy.com
  65. 65. Fibular osteocutaneous flap ► Morbidity  Donor site complications ►Edema ►Weakness in dorsiflexion of great toe  Skin loss in 5 – 10% of flaps ►reliability of the skin is questionable, and both the surgeon and the patient should be prepared for the possible need for a second soft tissue flap, either free or pedicled, when reconstructing composite defects with a fibular osteocutaneous flap  May need STSG over donor site closure www.indiandentalacademy.com
  66. 66. Fibular osteocutaneous flap ► Preoperative ► Postoperative Considerations management Angiography MRA h/o distal lower extremity fracture  Look for varicose veins, edema     Distal pulses monitored  Posterior splint for 10 days www.indiandentalacademy.com
  67. 67. Iliac crest flaps ► ► ► ► ► ► ► ► Osteocutaneous, osteomusculocutaneous Segmental mandibular defects Up to 16 cm bone Oromandibular reconstruction No motor or sensate reconstruction Only vascularized bone used extensively with simultaneous or delayed endosteal dental implant placement Skin paddle was not ideal for relining the oral cavity  Too thick for accurate restoration of the 3D anatomy Inclusion of internal oblique flap  Denervated muscle undergoes atrophy that leaves a thin, fixed, soft tissue coverage over the bone. www.indiandentalacademy.com
  68. 68. Neurovascular pedicle ► Deep circumflex iliac artery from lateral aspect of external iliac artery  1 – 2 cm cephalic to inguinal ligament ► ► Ascending branch of deep circumflex iliac artery supplies internal oblique muscle Deep circumflex iliac vein – 2 venae comitantes  Can pass either superficial to deep to artery ► ► ► Artery caliber – 2 to 3 mm Vein caliber – 3 to 5 mm Pedicle to internal oblique can arise separately from deep circumflex iliac artery www.indiandentalacademy.com
  69. 69. Iliac crest flaps www.indiandentalacademy.com
  70. 70. Technical considerations ► ► Skin paddle centered on axis from ASIS to inferior tip of scapula Cutaneous perforators  9 cm posterior to ASIS and 2.5 cm medial to iliac crest ► Generous cuff of external oblique, internal oblique and transversus abdominis layers must be preserved to maintain cutaneous perforators  Internal oblique muscle ► ► ► axial-pattern blood supply Skin paddle bulky and immobile Do not rotate skin in order to prevent sheer injury www.indiandentalacademy.com
  71. 71. Iliac crest flaps www.indiandentalacademy.com
  72. 72. Iliac crest flaps www.indiandentalacademy.com
  73. 73. Iliac crest flaps ► Morbidity  Hernia ► Need to approximate cut edge of iliacus muscle to transversus abdominis ► Can be reinforced by drilling holes into cut edge of iliac bone ► Approximate external obliques and aponeurosis to tensor fascia lata and gluteus muscles ► Keep inferior oblique inferior and anterior to ASIS   Skin loss from perforator sheer injury poor color match www.indiandentalacademy.com
  74. 74. Iliac crest flaps ► Preoperative Considerations    h/o hernias, prior iliac bypass graft Severe PVD, Preop angio www.indiandentalacademy.com
  75. 75. Scapular flaps ► ► ► Fasciocutaneous, osteofasciocutaneous, cutaneous flap, parascapular cutaneous flap, latissimus dorsi myocutaneous flap, and serratus anterior flap Thin, hairless skin Two cutaneous flaps may be harvested  Horizontally oriented flap – transverse cutaneous branch  Vertically oriented flap parascapular flap – descending cutaneous branch ► ► ► ► ► ► Long pedicle length Large surface area Complex composite midfacial or oromandibular defects Up to 10 cm bone Osseointegrated implants possible Single team approach www.indiandentalacademy.com
  76. 76. Neurovascular pedicle ► Subscapular artery and vein  Circumflex scapular artery and vein emerge from triangular space (teres major, teres minor and long head of triceps)  Paired venae comitantes  Artery caliber – 4 mm at takeoff from subscapular ► Subscapular caliber – 6 mm at takeoff from axillary artery  Pedicle length – 7 to 10 cm, 11 to 14 cm (from axillary artery)  Preservation of thoracodorsal vessels allows simultaneous transfer of latissimus and portion of serratus flap ► Largest amount of tissue available for transfer Thoracodorsal artery and circumflex scapular artery can have separate origins from axillary artery. ► Non-sensate flaps ► Scapular vessels - very rarely affected by atherosclerosis ► www.indiandentalacademy.com
  77. 77. Scapular flaps www.indiandentalacademy.com
  78. 78. Technical considerations ► ► Decubitis positioning  15 degree angle  Separate axillary incision helpful in dissecting pedicle to axillary artery and vein  Bone harvest ► Teres major, subscapularis and latissimus dorsi need to be reattached to scapula Flap harvest opposite side of modified or radical neck dissection www.indiandentalacademy.com
  79. 79. Scapular flaps www.indiandentalacademy.com
  80. 80. Scapular flaps ► Morbidity  Brachial plexus injury 2/2 lateral decubitis positioning ►Use axillary roll  Stay 1 cm inferior to glenoid fossa  Detach teres major and minor to harvest bone ►Can cause shoulder weakness and limit range of motion. www.indiandentalacademy.com
  81. 81. Scapular flaps ► Preoperative Considerations  Prior axillary node dissection – contraindication ► Postoperative management  Immobilize for 3 to 4 days  Early ambulation  5 days for bone harvest  PT www.indiandentalacademy.com
  82. 82. Rib flap ► ► ► ► First vascularized bone to be used in mandibular reconstruction. (osteocutaneous) Blood supply to the rib  Internal mammary artery  Posteriorly or posterolaterally on the posterior intercostal vessels  Transferred with the pectoralis major, serratus anterior, or latissimus dorsi muscle Poor bone stock except for condylar reconstruction Not commonly used www.indiandentalacademy.com
  83. 83. Neurovascular pedicle www.indiandentalacademy.com
  84. 84. Metatarsus flap ► Osteocutaneous flap based on the first dorsal metatarsal artery ► Thin sensate skin with the second metatarsal. ► Limited bone volume ► Not commonly used www.indiandentalacademy.com
  85. 85. Neurovascular pedicle www.indiandentalacademy.com
  86. 86. Jejunal flap ► ► ► ► ► ► ► 1959 Circumferential pharyngoesophageal defects Patch graft Diameter of jejunum – good match to cervical esophagus Ideal mucosal surface Two team approach Advantages  Better superior positioning ► Disadvantage  Inferior positioning limited by thoracic inlet  3 anastomoses www.indiandentalacademy.com
  87. 87. Neurovascular pedicle ► Mesenteric arcade vessels  Usually 2nd arcade is best for pharyngeal reconstruction www.indiandentalacademy.com
  88. 88. Technical considerations ► ► ► ► ► ► ► Harvest distal to Ligament of Treitz Up to 20 cm Laparoscopic harvest has been reported Mark proximal graft with suture – isoperistaltic placement Proximal end divided along antimesenteric border to facilitate tongue base closure Distal end – end to end anastomosis  Lock and key closure Exteriorize a monitoring segment www.indiandentalacademy.com
  89. 89. Jejunal flap www.indiandentalacademy.com
  90. 90. Jejunal flap ► Morbidity    Most susceptible to primary ischemia Fistula formation – 18% 11% rate of anastomotic stricture ►Higher rate if cervical anastomosis stapled     Wet voice (TEP) Functional obstruction 2/2 peristalsis Dysgeusia Harvest site complications www.indiandentalacademy.com
  91. 91. Jejunal flap ► Preoperative Considerations ►  Absolute contraindications ► Disease extension into proximal thoracic esophagus ► Ascites ► Crohn’s disease Postoperative management  Remove monitoring segment pod 7.  Jejunostomy tube  Relative contraindications ► Chronic intestinal diseases ► h/o abdominal surgery  Consider angio ► Intraperitoneal sepsis  Do not use in laryngeal sparing procedures www.indiandentalacademy.com
  92. 92. Gastroomental flap 1961, 1979 ► Greater omentum – double layer of peritoneum ►  Hangs from greater curvature of stomach and transverse colon ► Omentum - thin and well vascularized    Excellent coverage for great vessels Plasticity allows for variable placement Form adhesions to inflamed, ischemic, or necrotic tissues ► Separates them from surrounding tissues  Promotes healing in previously radiated fields ► ► ► ► ► Large scalp defects, Extensive midfacial defects w/coverage of split rib or calvarial grafts Facial contouring Management of osteoradionecrosis or osteomyelitis in head and neck Pharyngoesophageal reconstruction www.indiandentalacademy.com
  93. 93. Neurovascular pedicle ► Right gastroepiploic artery  Caliber – 1.5 to 3.0 mm www.indiandentalacademy.com
  94. 94. Gastroomental flap ► Morbidity  Intraabdominal complications ► Gastric leak ► Peritonitis ► Intraabdominal abscess ► Volvulus ► Gastric outlet obstruction  If mucosal flap too large or if placed too close to pylorus  Fistula ► Preoperative Considerations  h/o GOO  h/o PUD www.indiandentalacademy.com
  95. 95. Gastroomental flap www.indiandentalacademy.com
  96. 96. Bibliography 1. 2. 3. 4. 5. 6. 7. Chepeha, DB, Teknos, TN. Microvascular Free Flaps in Head and Neck Reconstruction. In: Head and Neck Surgery—Otolaryngology, 3rd ed., Bailey, BJ Ed. Philadelphia, Lippincott-Raven Publishers, 2001; 2045 – 2065. Urken, ML, Buchbinder, D, Genden, EM. Reconstruction of the Mandible and Maxilla. In Otolaryngology Head and Neck Surgery, 4th Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1618 – 1635. Chang, KE, Gender, EM, Funk, G. Reconstruction of the Hypopharynx and Esophagus. In Otolaryngology Head and Neck Surgery, 4th Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1945. Taylor, SM, Haughey, BH. Reconstruction of the Oropharynx. In Otolaryngology Head and Neck Surgery, 4th Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1758. Lee, KJ. Essentials of Otolaryngology. 891. Lin, DT, Coppit, GL, Burkey, B. Use of the Anterolateral Thigh Flap in Reconstruction of the Head and Neck. Curr Opin Otolaryngol Head Neck Surg. 12: 300-304. 2004. Lippincott Williams and Wilkins. Genden, E, Haughey, BH. Mandibular Reconstruction by Vascularized Free Flap Tissue Transfer. Am Journ Otolaryngol. 1996; 17 (4): 219 – 227. www.indiandentalacademy.com
  97. 97. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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