basic dental surgical procedure

1. BASIC SURGICAL
PROCEDURES III
FLAPS
OUTLINE
INTRODUCTION
INDICATIONS FOR FLAPS
QUALITIES OF IDEAL FLAP
CLINICAL CONSIDERATIONS FOR
FLAP SURGERY
CLASSIFICATION
COMPLICATIONS

2. INTRODUCTION
• Loss of soft or hard tissues in the oral and
maxillofacial region could constitute
functional and aesthetic challenges to the
patient and surgeon.
• Functions of mastication,
occlusion, deglutition and speech and the
maintenance of facial contour (aesthetics).
• Functions and the specialised nature of
tissues in the region could require several
steps to be able to achieve full

3. Intro contd
• Basic principle of reconstruction is that lost
anatomical structures are rebuilt with
tissue as similar as possible.
• Inadequate or lack of reconstruction of
facial defects could reduce post-surgical
quality of life.
• Flaps are tissues with their attached
vasculature used in reconstructive surgery
to transfer tissues from a donor site to a
recipient site.

4. INDICATIONS
To cover defects of:
• 1. Congenital origin such as clefts of
lip and palate, microtia.
• 2. Resection of benign and malignant
tumours.
• 3. Traumatic loss such as electrical,
chemical burns, physical defects
• 4. Infectious origin such as cancrum
oris, gangrene.
• 5. Vascular or cystic lesions

5. QUALITIES OF AN IDEAL
FLAP
• 1. Thin or as bulky as appropriate
• 2. Reliable
• 3. GOod colour match. with the surrounding
tissues.
• 4. Easy to dissect.
• 5. Have long arc of rotation
• 6. Minimum donor site morbidity after raising
• 7. Give consistent results
• 8. Technically not very demanding to utilise
• 9. Have short operating time.

6. VASCULAR SUPPLY OF
FLAPS
- The vascular anatomy of skin flaps is based on the
blood supply to that part of the body. the supply to
the bone, muscle and fascia give rise to
the subnormal vasculature that perfuses the skin.
Good supply to the skin consists of the
segmental vasculature which are branches of
the aorta such as the superficial temporal, facial
arteries which supply the perforating vessels.
these perforators connect to the third group, the
cutaneous vasculature.
The vasculature has two major subgroups: the
musculocutaneous perforators, which supply
blood to the skin of most parts of the body, and the

7. Vascular supply contd
• It is the direct cutaneous vessels
that give the arterial pattern found
in axial flaps.
• The musculocutaneous
perforators are arranged
perpendicularly and supply a
limited territory of overlying skin,
the direct cuataneous vessels run

8. SKIN ANGIOSOMES

9. CLINICAL CONSIDERATIONS
IN FLAP SURGERY
• Patients for flap surgery need to be properly
evaluated to determine suitability, appropriate
type of flap and other factors such as:
• 1. Site, size, shape and functional
consequence of the defect.
• 2. Type of tissue required for function and
appearance.
• 3. Associated physical condition of the patient-
age, sex, expectations of oral competence,
tongue mobility, speech, appearance,
swallowing.
• 4. Medical history of the patient- debility,

10. CLASSIFICATION OF FLAPS
• Various classification systems have been utilised in describing
flaps. these include:
• A. Based on vascular anatomy
• 1. Random pattern (cutaneous) flap. Has no specific
arterial-venous system. it has limitations in length and width.
Example is the buccal flap.
•

11. Classification contd
• 2. Axial pattern (arterial) flap. Has a defined anatomic
arterial-venous system.
– specific direct cutaneous artery in its long, longitudinal axis
running within the subcutaneous tissue superficial to the
muscle.
– can be raised at least to the length of the arterial-venous
supply.
– examples are buccinator, nasolabial, median forehead
flaps.

12. CLASSIFICATION BASED ON
ANATOMIC BLOOD SUPPLY

13. CLASSIFICATION BASED ON
MOVEMENT PATTERN
• Local or Distant.
• Local flaps are transferred from
an area adjacent the defect. They
may share a side with the defect.
• They are divided into those
that move around a fixed point
and those advanced into the
defect.

14. MOVEMENT AROUND A FIXED
POINT
• a. Rotation- move in an arc around a
fixed point, primarily in one lane in a
semicircle.
• b. Transposition- rotate on a pivotal
point but the more it is rotated, the
shorter the flap effectively becomes.
Example is the rhomboid flap.
• c. Interposition- the donor site is
separated from the recipient site by
tissue that has to be crossed over or

15. TYPES OF FLAPS
ROTATION TRANSPOSITION

16. TYPES OF FLAPS CONT’D
INTERPOLATION ADVANCEMENT

17. PROXIMITY TO DEFECT
 Local - close to defect
 Regional- a regional flap is near but not
immediately adjacent to the defect or
outside the anatomical region of the
defect. Example median forehead
(glabellar) flap used to repair the nose.
 Distant- a distant flap is not near the
defect. A distant flap could be paddled as
in the deltopectoral, pectorals major flaps
or microvascular free-tissue transfer as in

18. Classification based on tissue
composition
• a. Cutaneous -full thickness of skin
and superficial fascia
• b. Mucocutaneous - mucosa and
cutaneous tissue.
• c. Fasciocutaneous- deep fascia
and cutaneous tissue
• d. Myocutaneous- muscle and
cuatenoues tissue
• e. Osteocutaneous - bone and cutaneous
tissue

19. SKIN

20. CLASSIFICATION AS
PEDICLED/FREE
Types of vascular pedicles supplying muscles
(Mathes and Nahai classification)
- Type I - single vascular pedicle eg tensor fascia
lata, gastrocnemius.
- Type II- dominant pedicle and othe minor pedicle
eg trapezius, gracilis
- Type III- two dominant pedicles each arising
from a separate regional artery or opposite
side e.g. rectus abdominis, pectoralis minor
- Type IV- multiple segmental pedicles eg
sartorius, tibialis anterior (rarely used)
- Type V- one dominant pedicle with several
segmental pedicles e.g. latissimus

21. TYPES OF VASCULAR
PEDICLES

22. MICROVASCULAR FREE
FLAPS
• Large resections, irradiated surrounding
tissues and post-operative adjuvant
radiation therapy necessitate the use of
microvascular free flaps with an effective
soft tissue paddle to achieve functional
and aesthetic outcomes. Examples of free
flaps are radial forearm, anterolateral
thigh, latissimus dorsi flaps.
• Some of these can be taken with bone.

23. BUCCAL
FLAP
The buccal flap
with a thin layer of
buccinator was
described by
Axhausen in 1930
for closure of an
or-antral defect.

24. MEDIAN FOREHEAD
(Glabellar) FLAP
Based on the proximal
suprotrachlear artery.
The base of the
pedicle is often
around 1.2cm, no
more than 1.5cm.
Provides optimal
colour and texture
match for the nose.
Reconstruction is
aesthetically inconspic
uous and restores
function.
Donor site is similarly
acceptable.

25. DELTOPECTOR
AL
(BAKAMJIAN)
FLAP
Described by
Bakamjian in 1965 for
head and neck
reconstruction.
Pedicled, axial
fasciocutaneous flap
based on the
perforators arising
from the internal
mammary arteries.
Flap is raised based
on associated
angiosomes.
Can be used to repair

26. FOREARM
FREE
MICROVASCUL
AR FLAP
-China, developed in 1978 as a
fasciocutaneous flap.
-Most frequently used free flap
in the head and neck
reconstruction.
- Is thin, pliable and ideal for
restoration of oral mucosal
defects.
- Characteristic, long pedicle
(about 20cm) makes it easy to
harvest.
- Comprise the entire skin on
the volar aspect of the forearm.
- Can be harvested with some
of the radius bone.
- Commonly used for tongue,

27. COMPLICATIONS OF FLAP
SURGERY
• 1. Flap failure - extrinsic factors are
obvious, potentially controllable like wound
infection, systemic hypotension,
compression, kinking or tension of the flap,
haematoma accumulation, cigarette
smoking. Intrinsic factors such as
inadequate arterial inflow/venous
drainage. often due to poor planning by
the surgeon.
• 2. Scarring/hypertrophic scar/keloid.
• 3. Pain.
• 4. Psychological problems.
• 5. General surgical risks like deep venous