scope of Pedicled flaps in oral and maxillofacial surgery


Published on

Published in: Health & Medicine, Technology
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

scope of Pedicled flaps in oral and maxillofacial surgery

  1. 1. Pedicled flaps in orofacial defects Presented by: Dr.N.R.K.Anil Kumar, II yr PG
  3. 3. Free flaps Distant flap Regional flap Local flap Skin grafts Primary closure INTRODUCTION “WHEN YOUR ONLY TOOL IS A NAIL, THE WHOLE WORLD LOOKS LIKE A HAMMER”
  4. 4.  A flap is a segment of tissue that contains a network of blood vessels that may be transferred from a donor site to reconstruct a secondary defect.  1440 : Dutch word "flappe" : something that hung broad and loose, fastened only by one side.  Whether or not we use our best flap choice in the first instance, we must always be ready for its failure and have a backup flap in mind which will “dig us out of a hole”. Introduction
  5. 5.  Based on Blood supply  Random Axial  Random-pattern flaps: Have no dominant blood supply.  Axial flaps: Have a dominant feeding vessel.  Reverse-flow flaps (also known as distal pedicle flaps or reverse axial pattern flaps): The proximal blood supply is divided, leaving the flap to survive on the intact distally based vessels.  Peninsular flap / Island flap. CLASSIFICATION
  6. 6. CLASSIFICATION According to the proximity to the defect  Local: The flap shares a side with the defect (e.g., rhomboid flap). Regional: The flap is near, but not immediately adjacent to the defect (e.g., paramedian forehead flap). Distant: The flap is not near the defect (e.g., PMMC flap). Free flap: Free tissue transfer.
  7. 7. Local flaps  Flaps adjacent to the defect requiring reconstruction – Local flaps.
  8. 8. Distant flaps  Flaps which are further away and not contiguous with the defect – Distant flaps.  Distant flaps that remain attached to the body – Pedicled flaps. The base of the flap that contains the blood supply is called the pedicle.  Distant flaps those detached and revascularised by anastomising arteries and veins – Free flaps.
  9. 9. CLASSIFICATION  By method of tranfer from the donor site 1) Advancement flaps 2) Rotation flaps 3) Transposition flaps : Rhombic and Bilobed flaps.
  10. 10. According to the tissue contained a. Cutaneous b. Fasciocutaneous c. Musculocutaneous d. Osteocutaneous e. Osteomusculocutaneous
  11. 11. Selection of flap  Multi-factorial  Size, location, depth and nature of defect.  Size and arc of rotation of flap  Vascularity  Accessibility  Donor site  Function
  12. 12. PEDICLED FLAPS  PMMC Flap  Fore Head flap  Temporalis flap  Lattissmus dorsi flap  Delto pectoral flap  Trapezius flap  Buccal Fat Pad  Sub mental island flap  Platysma flap  FAMM flap
  13. 13.  Composed of fascia, subcutaneous tissue and skin; muscle is not transferred with this flap  Boundaries  Clavicle superiorly  Acromium laterally  A line running through the anterior axillary fold to above the nipple inferiorly  Based medially on the upper chest in the upper 3 or 4 perforating branches of internal mammary A from medial end of intercostal spaces DELTOPECTORAL FALP Bakanjian –1965
  14. 14.  Extends to any site in neck & occasionally up to zygoma  Flexibility of the flap  Retracts from side to side  Anomolous pivot point  Uses  To cover whole anterior neck without any subsequent revision  To reconstruct a defect by passing as a bridge over normal tissues where conventionally the pedicle may be tubed  Repair of pharyngeal fistula but lacks muscle bulk  Reconstruct defects – lower face & upper neck Deltopectoral Falp
  15. 15. Deltopectoral Falp Advantages  Usually not delayed  Unilateral or bilateral  Deltoid portion usually not hair bearing  Excellent blood supply, with dependent venous drainage  Donor site hidden, thus cosmetically acceptable  Outside radiation field Disadvantages  Failure rate is 9 to 18%.  If flap is used to cover the carotid vessels, blow out of the carotid artery is a hazard if the flap fails.  Staged approach.
  16. 16. PECTORALIS MAJOR MYOCUTANEOUS FLAP  Ariyan in 1979  Work horse for H & N  Origins -three portions. Medial third of the clavicle, Sternum Cartilages of the first six ribs.  Insertion : crest of greater tubercle of humerus  Medial rotator and adductor  Thoraco acromial artery.
  17. 17. PECTORALIS MAJOR MYOCUTANEOUS FLAP Can reach till zygoma. Most reliable for neck and Lower part of face.
  18. 18. ADVANTAGES  One stage  Large skin territory  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 easy to elevate PECTORALIS MAJOR MYOCUTANEOUS FLAP
  19. 19.  DISADVANTAGES  Arc of rotation limited for oro maxillary defects  It can be too bulky  There is distortion of symmetry at the donor site  Shoulder function can be impaired  Distal skin of the flap is not reliable PECTORALIS MAJOR MYOCUTANEOUS FLAP
  20. 20. POTENTIAL PITFALLS - PMMC  Incidence of total flap necrosis - reported to be 1- 7%.  Partial flap necrosis- 14%-30%  Pedicle compression  In male patients - excessive hair growth in the oral cavity or pharynx
  21. 21. FORE HEAD FLAP  Median fore head flap – Sushruta samita 700 BC  Mid fore head flap Median Para median  Mid facial reconstruction  Para median flap - supra trochlear artery  Revascularization of cartilage & bone
  22. 22.  Largest area of donor site - matching color & texture to facial skin  Safest flap  85% to 95% success  Long enough to reach any part of the ipsilateral face  Different types due to variation in flap pedicle FORE HEAD FLAP
  23. 23. McGregor Millard Wilson FORE HEAD FLAP Variations of pedicle of forehead flap
  24. 24. TEMPORALIS MUSCLE FLAP  Golovine 1898 - orbital exenteration  Gilles - reanimation of paralyzed face  Fan - shaped muscle, temporal fossa & the superior temporal line  Vascular anatomy allows splitting of muscle into anterior & posterior flap
  25. 25.  Mobilized flap - 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  Absence of vascularity  Facial nerve and deep temporal TEMPORALIS MUSCLE FLAP
  26. 26.  Hemi coronal flap - excellent access  Incision - above 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 TEMPORALIS MUSCLE FLAP
  27. 27. TEMPORALIS MUSCLE FLAP ADVANTAGES  Ease of elevation  Reliable blood supply  Proximity  Camouflage of incision with in hair line  Muscle support graft DISADVANTAGES  Sensory disturbances  Potential facial nerve injury  Temporal hallowing
  28. 28. LATISSIMUS DORSI MYOCUTANEOUS FLAP  First myocutaneous flap – Tanzini 1896  Quillen 1978  Distant flap, provides largest possible skin paddle  Most complex donor site dissection,  arc of rotation extremely versatile  Insertion - inter tubercular groove of the humerus
  29. 29. LATISSIMUS DORSI MYOCUTANEOUS FLAP  10 X 8 cm  40 X 20 cm  Safe as free flap  Position intra - op  Extend, adduct, & medially rotate the arm  Thoraco dorsal artery - sub scapular artery  Perforators , medially along the spine – secondary supply
  30. 30. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP Jinau – 1909 Long strap muscle Muscular origin Branch of spinal accessory nerve Segmental supply – dominant blood supply – occipital artery, STA , thyrocervical trunk inferiorly.  Retain 2 out of 3 vessels.
  31. 31. Indications  Epithelial lining for mucosal reconstruction  Closure of oro cutaneous fistulas  Tongue, floor of the mouth, cheek  Compromised neck  Small defects of pharynx STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
  32. 32.  Superior/ inferior blood supply  Paddle of skin over one end of pedicle  Local advancement/ transposition  6 x 8 cm paddle of skin STERNOCLEDOMASTOID MYOCUTANEOUS FLAP  Disadvantage : - Upper skin muscle flap – poorly viable - Lower third blood supply – unreliable not used for mandible
  33. 33. PLATYSMA FLAP  Extremely thin band like & variable muscle forming superficial boundary of neck.  Anatomy :  Arises from clavicle superiorly continues with the attachment to the mandible  Submental branch of the facial artery  Dermal – subdermal plexus  Flap size Muscle - 10 x 10 cm to 10 x 20 cm Skin paddle - 3 x 6 cm to 6 x 20 cm
  34. 34. PLATYSMA FLAP PROCEDURE : Marking by volunterily activating muscle, skin island. Submandibular incision Platysma incised INDICATIONS : - Tumors involving Buccal mucosa and buccal sulcus. - Cicatricial release of burns. - Resurfacing lower lip & creating deep sulcus.
  35. 35. ADVANTAGES  Proximity & regionality  Thin & delicate  Reliable when vascular criteria adhered  Arc of rotation - 180  No donor site disability  Sensitive skin  Donor site: free of Hair  Primary closure DISADVANTAGES  Lack of bulk  Reliability 85%  Complication like skin loss & fistula, necrosis, delayed wound healing.  In patients with prior surgery and radiation  Paresthesia  No lip splitting incision PLATYSMA FLAP
  36. 36. TRAPEZIUS FLAP  Mutter Flap – Mc Craw s 1842  Originally described as superior based cutaneous flap  Flat & triangular - supero posterior aspect of the neck & shoulder  Transverse cervical artery  Spinal accessory nerve  Rotate the scapula elevate, rotate & adduct upper arm  10 x 20 cm in size
  37. 37.  Lateral positioning of patient to elevate flap  Ideally suited - radical parotidectomy - anterior neck coverage - lateral face, posterior scalp neck  Generous amount of soft tissue & large portion of skin island  90 – 95 % of success TRAPEZIUS FLAP
  38. 38.  ADVANTAGES  Versatile  Regionality of flap  Strong vascular security  Supplies considerable bulk  Arc of rotation 90 – 180 degree  One stage procedure  Minimum deficit at donor area 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
  39. 39. Sub mental island flap  Based on submental artery branch of facial artery.  Consists of skin, subcutaneous tissue, fascia.  Vascular pedicle of 8cm length can be taken.  Used for reconstruction of defects of lower face, preauricular defects, inferior and lateral neck defects.  Skin paddle – 4 x 10 cms with maximum of 14 x 7 cms in lax neck.
  40. 40. Sub mental island flap
  41. 41. Sub mental island flap Procedure:  Marked with neck extended.  Submental area 1-2 cms posterior to mandiblar border.  Subplatysmal dissection  Flap dissected till level of facial artery  Donor site – primary closure.
  42. 42. Sub mental island flap
  43. 43. Floor of Mouth
  44. 44. FAMM flap  The facial artery forms the vascular pedicle.  It consists of buccal mucosa, underlying submucosa, a portion of the buccinator muscle, deeper fibers of the orbicularis oris, and the facial artery with its venous plexus.  The flap is an axial pattern flap designed along and including the length of the facial artery, based either inferiorly or superiorly.  Can be used to cover defects in the hard palate, alveolus, nasal lining, upper lip, and lower orbit, lower lip including the vermilion, alveolus, retromolar area, tonsillar fossa, and the floor of the mouth (Pribaz et al., 1992).
  45. 45. FAMM flap
  46. 46. NASO LABIAL FLAP  Melolabial crease  SMAS layer insertion  Most important facial aesthetic boundaries  Vascularity - Facial artery medial cheek skin superiorly based inferiorly based Sufficient skin available unilaterally / bilaterally closure parallel - melolabial crease
  47. 47.  Color, texture & skin – LIPS & LATERAL NOSE  Pivotal + advancement  Rotation not used  Transposition – most common Limited donor tissue Extremely difficult to use in dentate patient Uses closure of oro-antral fistula small defect of anterior floor of the mouth in edentulous patient Oral submucous fibrosis NASO LABIAL FLAP
  49. 49. BUCCAL FAT PAD  Heister (1727) - “Glandula molaris.”  Bichat (1801) - True nature of the BFP. ‘‘boule de Bichat,’’ sucking pad, sucking cushion, masticatory fat pad, or buccal pad of fat.  Scammon - Anatomy of the BFP .  Egyedi (1977) – BFP as a versatile pedicled graft.  Neder described the use of buccal pad fat as free graft to close oral defects.  Tideman et al. (1986) described its detailed anatomy, vascular supply and operative technique.  Yenwas the first to succeed in covering the buccal defect with a split thickness skin graft in treating a case of OSMF.
  50. 50. The possible functions of the BFP  Sucking in newborns  Separating the masticator muscles from one another and from the adjacent bony structures,  Enhancement of intermuscular motion, (syssacosis)  Protection of neurovascular bundles. Advantages of BFP as a pedicled graft are  Easy harvest  Low morbidity  High success rate  Elimination of donor-site skin scars.
  51. 51. ANATOMY  The buccal fat pad located anterior to the masseter muscle and deep to the buccinator muscle.  Acc to Traditional anatomic descriptions Buccal fat pad has a central body and 4 processes: buccal, pterygoid,pterygopalatine, superficial, and deep temporal.  Recently, Buccal fat pad was described as having 3 lobes anterior, intermediate, posterior. The 4 processes described are from the posterior lobe Atlas Oral Maxillofacial Surg Clin N Am 15 (2007) 23–32
  52. 52. ANATOMY •The main body lies on the anterior border of the masseter muscle and extends deeply to lie on the posterior maxilla and forward along the buccal vestibule. •Buccal process - located deep to the superficial musculoaponeurotic system at the anterior border of the masseter and partially responsible for cheek contour. •Pterygopalatine process - extends into the pterygopalatine fossa encapsulating the pterygopalatine vessels.
  53. 53. ANATOMY •Pterygoid extension - posteriorly extends in to pterygomandibular space. •Temporal extension can be divided further into 2 parts: •Superficial part - between the deep temporal fascia, temporalis muscle, and tendon. •Deep part - behind the lateral orbital wall and frontal process of the zygoma and into the infratemporal space. •Blood supply •Buccal and deep temporal branches of the maxillary artery, Transverse facial branch of the superficial temporal artery, Branches of the facial artery such as the inferior buccinator artery.
  54. 54. LIGAMENTS ATTACHED FROM ATTACHED TO Maxillary ligament (fibrous condensation) Anterior lobe Maxilla Posterior zygomatic ligament Intermediate lobe Zygomatic process Medial and lateral infraorbital ligaments Intermediate lobe (Medial and lateral side) Infraorbital rim Temporalis tendon ligament Posterior lobe Temporalis tendon posteriorly. Buccinator ligament Anterior lobe Buccinator membrane. Each process has its own capsule and is anchored to the surrounding structures by ligaments.
  55. 55.  The buccal and zygomatic branches of the facial nerve and the parotid duct lie lateral to the fat pad and should not be injured during flap mobilization.  The parotid duct courses with the buccal branches of the facial nerve anteriorly (superficial), and on the lateral surface of the BFP, it penetrates the buccinator muscles, entering the oral cavity.
  56. 56. •The buccal extension and main body together constitute 55%- 70% of total weight. •BFP seems to be constant throughout life, usually with no direct relationship to the total body fat present. •The mean volume in males was 10.2 ml (7.8–11.2 ml), and in females it was 8.9 ml (7.2–10.8 ml).The mean thickness was 6 mm, and mean weight of 9.7 g. •Blunt surgical dissection reveals that the fat pad may be estimated between 7 to 9.34 cm with reproducible vascularity as long as the flap is tension-free.
  57. 57. SURGICAL PROCEDURE  The BFP was approached via the posterior- superior margin of the created buccal defect or by placing 2 cm horizontal vestibular incision extending backwards from above the maxillary second molar tooth, and then dissected with an index finger.  Blunt dissection through the buccinator and loose surrounding fascia, allowed the buccal fat pad to herniate into the mouth.  The body and the buccal extension of BFP were gently mobilised by blunt dissection, taking care not to disrupt the delicate capsule.  After the pad had been dissected free from the surrounding tissues, it was grasped with vascular forceps, gently teased out, advanced, and expanded over the defect.  The BFP was teased out gently until a sufficient amount was obtained to cover the defect without tension .
  58. 58.  HEALING OF THE BFP  Clinically, in the typical course, the surface of the orally exposed fat becomes yellowish-white in 3 days and then gradually becomes red within 1 week, which is most likely due to the formation of young granulation tissue. This changes into firmer granulation tissue during the 2nd week, and becomes completely epithelialized with a slight contraction of the wound by 3 weeks after the operation.  The BFP healed in 2 weeks and completely epithelized in 6 weeks.5
  59. 59.  Signs of abnormal perfusion  Arterial compromise Skin – Pale, slow capillary refill; cool. Muscle – Pale; no brisk bleeding; skin graft not adherent; no doppler signal. Fascia – No palpable pulse; skin graft not adherent; no doppler signal.  Venous compromise Skin – patchy; bluish fast capillary refill; warmth. Muscle – Dark; dark red bleeding; skin graft not adherent. Fascia – Dark; greyish, doppler signal may remain normal for a longer period Monitoring of Flaps
  60. 60.  Inflow  Arterial kinking  Inset too tight  Damage to pedicle  Arterial insufficiency  Thrombosis in extremity.  Outflow  Venous occlusion  Tunnel too tight.  Venous thrombosis in major veins.  Kinking of pedicle.  Hematoma under flap Possible causes of impaired perfusion
  61. 61. Conclusion Anatomic structure Flap used for reconstruction Floor of the mouth Deltopectoral flap FAMM flap Forehead flap PMMC flap Lower vertical trapezius Platysma flap Buccal mucosal defects Temporo parietal flap PMMC flap Soft palate defects BFP, FAMM flap, Temporalis muscle flap Hard palate defects and Retromolar trigone FAMM flap Temporalis muscle flap BFP
  62. 62. Flap Anatomic structures reconstructed PMMC flap Oral cavity, oropharynx, Face and neck defects Trapezius flap Lower 2/3rd of face, neck, Temporal fossa defects Sternocledo mastoid flap Resurfacing oral cavity, Protecting pharyngeal reconstruction and greater vessels Platysma flap Intra oral defects, oropharyngeal defects. Lattismus dorsi flap Oral cavity, oropharynx, face and neck defects. Temporalis flap Cheek and orbital defects, Dynamic facial reconstruction.
  63. 63.  Plastic Surgery, McCarthy, Vol 5 , Tumours of Head & Neck  Cancer of Face and the Mouth, Pathology and management for surgeon - Mcgregor.  Basic principles of oral and maxillofacial surgery, Peterson References