local flaps

1. Reconstruction flaps in oral and
maxillofacial surgery
Presented by
Dr. Padmasree Patowary
MDS III

2. • Introduction
• Historical prospective
• Definition
• Flaps physiology
• Types of flaps
• Analysis of the defect and planning of reconstruction
using flaps
• Various flaps
• Description of local flaps in detail

3. Introduction
• Reconstruction of maxillofacial defects still remains a
challenge, in spite of numerous advances in
regenerative medicine.
• These challenges stem from the complex set of criteria
that needs to be met for a successful substitute to
restore, maintain, and improve tissue function.

4. • There are many causes of tissue loss, including
– Trauma
– Pathologic processes
– Congenital anomalies
• The resulting characteristics such as the size, geometry,
and vascularity of the defects decide the surgical options
available for treatment.

6. Historical prospective
• The history of flap surgery dates as far back as 600
BC, when Sushruta described nasal reconstruction
using a cheek flap.
• The origins of forehead rhinoplasty may be traced
back to approximately 1440 AD in India.

7. • Gaspar Tagliocozzi (1597), 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, described about "Indian
Flap".

8. • Tansini (1896), described the concept of muscle and
skin flap.
• George Monks (1898), Boston Medical and Surgical
Journal: First island flap ever designed in the US.
• Owens (1952): Stenocledomastoid flap.
• Conley (1960): Regional flaps.
• Bakamjian (1965): Deltopectoralis flap.
• Ariyan & Biller (1977): Pectoralis flap.

9. • In the 1980s, the number of different tissue types used
increased significantly with the development
of fasciocutaneous (fascia and skin) flaps, osseous
(bone) flaps, and osseocutaneous (bone and skin)
flaps.
• A further advancement in flap surgery came in the
1990s, with the introduction of perforator flaps.

10. Definition
• Dutch (1440) word "flappe": something broad to
strike with, specially a flyswatter or anything that
hangs broad and loose, fastened only by one side.

11. A flap is one which contains within its substance a
network of blood vessels, arterial, venous, capillaries
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.
Definition
PETERSON'S PRINCIPLES of ORAL and MAXILLOFACIAL SURGERY second edition

12. Flaps physiology
• Microcirculation
Anatomy
Physiology
• Pathophysiology Changes
Anatomic changes
Hemodynamic changes
Metabolic changes

13. • Microcirculation
Anatomy :- The microcirculation is composed by
 Smallest vessels in the circulatory system.
 Microcirculation defines absolute classification.
The microcirculation is composed of vessels
responsible for the exchanges of nutrients as well as
local regulation of blood flow.

14. Physiology:- The regulation of cutaneous blood flow is
predominantly performed by-
• Systemic control
• Local control

16. Pathophysiology Changes – When a skin flap is elevated,
profound changes take place and the fine balance that
had regulated blood flow is completely disrupted.
An understanding of the pathophysiology is centered on
two interrelated clinical phenomena.
1. Observed complication of distal flap necrosis
2. The miraculous benefit that the delay procedure
has on increasing flap survival.
Microcirculation -

17. • Anatomic changes –
 The pathophysiologic events in a flaps, one
consider a flap that is created too large for its
supporting blood supply.
 During flap elevation, cuteneous blood vessels and
sympathetic nerves are severed.
 This results in a dramatic alteration in flow.

18. • Hemodynamic changes –
 During the first 18 hours flow decreases secondary
to lowered perfusion pressure.
 In the distal flap where flow is inadequate during
the first 12 hours, irreversible ischemia will result in
flap necrosis.

19. • Metabolic changes -
 With depletion of sympathetic vasoconstrictors there
is further increase in flow from 12 to 48 hours
postoperatively.
 By 4 to 5 days, in a healthy bed, there are adequate
collateral connections to support the flap without its
original primary blood supply.

21. 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

22. • Transfer
• Avoid kinking, compression, tension or severe
angulations.
• Always favor gravity and venous drainage.
• Positioning
• Use always two layers of sutures
• Support

23. 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

24. Classifications of reconstruction
flaps
 Method of movement
 Blood supply
 Composition
 Mathes and Nahai classification

25. • Method Of Movement
 Local Flaps
Advancement
Rotation
Interpolation
Pedicle
Subcutaneous

26.  Distant Flaps
Direct
Tube
Microvascular

27. • Blood supply
 Musculocutanous arteries
-Random cutaneous
- Myocutaneous
 Septocutanous arteries
-Fasciocutaneous arteries
- Arterial

28. • Composition
Cutaneous flap;
example: Limberg’s
rhomboid flap
Fasicutaneous flap; example
Delto
Myocutaneous flap ;
Pectoralis major

29. Sensory flap; example
Karapandzic flap
Osseocutaneous flap ;
Example- Pectoralis major
With rib

30. Muscles by the types of blood supply -

31. Types of flaps

32. • Local flap - It is composed of tissue adjacent to the
defect
 Local cutaneous flaps of the head and neck can be
classified according to their circulation, contiguity
and contour.
 When designing a local flap in the head and neck the
two most important considerations are appreciation
a) Cosmetic units tension lines
b) Relaxed skin tension lines

33. Relaxed skin tension lines Cosmetic units tension lines

34. • Advancement flaps-
An advancement flaps moves directly forward into a
defect without any lateral movement.
Example of straight advancement flap ( from
Kazanjian and Converse)

35. • Modified advance flap
– Burow’s triangle flap (Converse 1977)
– V-Y flaps
– Y-V flaps
– Bipedicle advance flap

36. • Burow’s triangle flap (Converse 1977)
A. Burow’s triangle flap
B. Counter incision at the base
C. Z plasty at the base.

37. • V-Y flaps- Principle is used in both small flaps such as in
columellar advancement and glabellar flaps.
• Y-V flaps - This flap can be used to interrupt
contractures and gain length.

38. • Bipedicle flap: In this flap
an incision is made parallel
to the defect and the flap
is undermined and
advanced.

39. • Transposition flap –
– When a flap moves laterally into the primary
defect it is called transposition flap.
– It is designed as a square immediately adjoining
to the triangular defect.
– Transfer leaves secondary defect which is closed
by split skin graft.

40. A transposition flap. The rectangular flap is
rotated on a pivot point. The more the flap is
rotated, the flap becomes shorter .

41. • 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.
• Example – Limbarg’s rhomboid flap ( where the
donar defect close directly)

43. Video

44. • Another transposition flap is bilobed flaps which
consists of two transposition flap.
– 1st flap transposed into primary defect
– 2nd flap into the secondary defect
• Ideally use this flap is where there is tissue available
locally and where it is important to avoid producing
tissue stretch
• Commonly used for reconstruction of tip of nose.

46. • Rotational flap –
₋ Large flaps that rotate into the primary defect.
₋ The flap circumference should be at least eight times
the width of the defect.
₋ This flap usually permits direct closure of the donor
site.
₋ Risk of devascularization by decreasing the width of
the base.
₋ Useful for dealing with defects of the scalp or cheek.

47. • Squamous cell carcinoma of the cheek with a cheek
rotation flap drawn
• Closure done with rotational flap

48. VIDEO

49. Analysis of the defect and planning of
reconstruction using flaps

50. 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 proper reconstructive procedure
3. Patients desire and expectations
4. Surgeons experience

51. Various flaps
LOCAL FLAPS
• Forehead flap
• Submental island flap
• Nasolabial flap
• Tongue flap
• Buccal fat pad
• Facial artery musculomucosal flap

52. • REGIONAL FLAPS
• Pectoralis major flap
• Trapezius flap
• Deltopectoralis flap
• Sternocleidomastoid flap
• Latissimus dorsi flap
• Temporalis flap
• Masseter flap
• Platysma flap

53. Forehead flap
• It is one of the oldest flaps in use and the earliest
available description is from the 600BC by Sushruta in
India.
• The forehead flap has been used extensively in the past
to provide lining of the oral cavity after major resections
for tumour.
• It is occasionally used for resurfacing defects of the scalp
and of the cheek. It is the best flap available for total
nasal reconstruction.

54. • Its main disadvantage is the relatively poor cosmetic
defect of its donor site.

55. • Indian Forehead Flap
- Also known as midline forehead
flap.
- Blood supply –
• supratrochlear artery extension
of the angular artery
• Used for nose reconstruction.

56. • Lateral Forehead flap-

57. Submental island flap
• First decribed by Martin et al. in 1983 has great
utility as an axial pattern flap or a free flap for
reconstruction of the facial skin or intraoral lining.

58. • Anatomy –
a) Supplied by a submental facial artery or submental
and submandibular branches of facial artery
b) Either pass over or through the submandibular
gland
c) Then deep to the anterior belly of digastric muscle
to provide a perforated based arterial supply and
venous drainage to the submental skin.

59. • Design - the submental flap is designed across the
midline over the submental area:
– The upper limit is just under the mandibular arch
in the midline;
– The lateral limits are marked below the
mandibular angles, bilaterally.
– The inferior limits depend on the tissue available
to allow primary closure.

60. • The arc of rotation of the submental flap pedicle has
its pivot point at the level of the angle of the
mandible.

62. VIDEO

63. • Advantage –
– Colour match with facial skin
– The relative inconspicuous nature of the donor
site scar.

64. • Disadvantages-
– Care should be taken not to injure the marginal
branch of the mandibular nerve, especially when
the dissection starts by incision of the upper part
of the skin paddle.
– Patients should be aware of intraoral hair.
– Take care during the dissection to include the
ipsilateral anterior belly of the digastric muscle to
improve the blood supply to the contralateral
side.

65. Nasolabial flap
• The nasolabial flap was first documented in the
Indian Susruta of 600BC.
• Traditionally, the nasolabial flap has been used
extensively for alar reconstruction.
• The nasolabial flap is also commonly used in intraoral
reconstruction.

66. • Recently, reconstructive surgeons have expanded the
use of the nasolabial flap to include nasal
reconstruction of the tip and dorsum.
• In addition, the soft triangle and partial alar defects,
without having to reconstruct the entire alar subunit,
can be reconstructed using the nasolabial flap.

67. Anatomy - The Anatomy of the nasolabial region is complex.

68. • Nasolabial crease run obliquely from approximately 1
cm superior to the lateral alar rim to approximately 1
cm lateral to the corner of the mouth.
• Four expression muscles present in this region
including part of
Levator labi superioris
Levator labi superioris alaque nasi
Zygomatic major and minor muscles

69. • Facial artery passes deep to the zygomatic major
muscles but superficial to the buccinator muscle.
• It also gave off a superficial branch to the
zygomaticus major muscle and other small
perforating branches to the overlying skin.

70. • Extensive subdermal vascular plexus in this region
supplies from four arteries; facial , angular,
infraorbital and transverse facial
• The buccal and zygomatic branches of the facial
nerve innervate the expression muscles of the face
from bellow

71. • Flap design-
Superiorly based Inferiorly based

72. Centrally based or bi-winged nasolabial flap

73. Nasolabial skin island flap. De-epithelialized part of the
flap near the pedicle.

74. • It is used for small to moderate
intraoral lesions in buccal,
palatal, floor of the mouth,
tongue and
maxillary/mandibular alveolar
region.
• Donor site often is closed with
direct closure.

75. • Advantages-
 It is highly versatile because blood vessels in subdermal
layer travel in axial direction, so the length/width ratio
can reach near that of the true axial-pattern flaps.
 For facial skin replacement, this flap can be used in the
form of the advancement, rotation or transposition flaps
while for oral cavity reconstruction; only available form is
the transposition flap.

76. • 1–1.5 Cm de-epithelialization of the skin flap near
the base is necessary to prevent iatrogenic dermoid
cyst formation when this flap is passed through
the trans-buccal tunnel to reach the oral cavity
• Reconstruction of the tongue and palate, even in
edentulous patients, nasolabial flap is the better
options.

77. • Hypertrophic scars in susceptible individuals and
wound dehiscence are two possible complications,
when donor site is closed under tension.
• The superiorly based flaps can be longer with
extension of the apex of the flap to mandibular
inferior border, while inferiorly based flaps are more
limited in length.
Disadvantages-

78. Pre-operated Post-operated

79. Tongue Flaps
• The procedure was first described more than 100
years ago, initially by Eiselsberg for intraoral defects
and soon after by Lexer, who described its use for
defects of the retromolar trigone and tonsillar areas.
• Technical difficulties precluded its widespread use
until a number of articles in the 1950s and 1960s
described technical advancements that made this flap
useful.

80. • The tongue flap is an extremely versatile flap that
can be used for the reconstruction of many oral,
pharyngeal defects.
• Depending on the type of tongue flap used,
congenital or traumatic defects of the lip; buccal
mucosa; palate; alveolus; tongue; floor of mouth; or
pharynx can be adequately reconstructed.

82. • Indications
 Cleft palate
 Large oroantral fistula or fail, traditional closure
with mucoperiosteal advancement flaps
 Post-traumatic defects and syndromic hypoplasia
of the upper and lower lips.
 Helps to relieve the scar contracture through
composite replacement of the skin, mucosa and
orbicularis oris muscle

83.  Reconstruct the vermillion border after lip shave
procedures for squamous cell carcinoma and veruccous
carcinoma with excellent esthetic results
 The tongue flap has shown promising results as an
attachment for reconstruction of buccal mucosal limit
secondary to oral submucous fibrosis with similar results
in postoperative mouth opening compared with buccal
fat pad grafts, nasolabial fold flaps, and split-thickness
skin grafts.

84. Disadvantage
 The main disadvantage of the tongue flap for lip and
vermillion reconstruction is the potential for color
mismatch, especially in pigmented lips.

85. Various types of tongue flaps
• Dorsal tongue flap
• Ventral tongue flap
• Lateral tongue flap
• Sliding and island tongue flaps

86. Dorsal Tongue Flap
• The dorsal tongue flap is based on the dorsal lingual
artery and can be either anterior or posterior based,
depending on the location of the defect.
• Three types of dorsal tongue-
– Anterior dorsal tongue flap
–Posterior dorsal tongue flap
–Transverse dorsal tongue flap

87. • Thickness of the flap approximately 8mm.
• The flap is elevated with mucosa and superior lingual
musculature.
• An effort made to maintain a fairly uniform thickness
of the flap.

91. Tongue flaps from lingual tip
• From lingual tip tongue flap divided into two groups
– Perimeter flaps from lingual margin for vermilion
repairs
– Flaps dorsoventrally disposed on the lingual tip
for lining and vermilion replacement

92. • Perimeter flaps- Developed by a vertical incision a
little inside and parallel to the border of the tongue,
the perimeter flaps are narrow flaps that may be
bipedicle or unipedicle.

93. A. The bipedicle varity ,
usable for vermilion
border on either lip may
be same as transverse
dorsal tongue flap.

94. B. Partial replacement of the vermillion border a
unipedicle lateral based tongue flap
C. Beyond the midline or one may extend laterally from
a central base.

95. D. With the incisions on its
ventral side connected the
resulting flap based centrally
on the dorsal side of the
lingual tip.
May be used in
reconstruction of the lower
lip.

96. E. With the incision on
the dorsal side
connected, the
ventrally based variant.
May be used in
reconstruction of the
upper lip.

97. • Dorsoventrally disposed flaps-
This second group of flaps derives from the lingual
tip by a horizontal incision, rather than by a vertical
incision inside and parallel to the edge.

98. A. A flap reflected dorsally on
the posterior base may
supply lining for an upper lip
reconstruction, while the
smooth edge of the tongue
itself provides the vermillion
border.

99. B. Flap reflected ventrally
on an anterior based may
do the same a lower lip
reconstruction.

100. C. This flap is forming double
flaps, which may well be
described as the
fishmouth type.
One component is
reflected dorsally and
other ventrally for lining,
depending on the
requirement of the
particular reconstruction.

101. Sliding and island tongue flaps
• Sliding and island tongue flaps can be used to
reconstruct anterior, middle, and posterior tongue
defects that are approximately 4 to 6 cm in size.
• Posterior tongue defects can be reconstructed using
an anterior-based sliding tongue flap.
• The anterior based sliding tongue flap is raised after
division of the median fibrous septum to the anterior
third of the tongue.

103. • Complications of tongue flap
 Pain, swelling, bleeding, infection, hematoma,
and temporary loss of tongue sensation.
 Speech issues, donor site deformity,
premature flap detachment, and necrosis of
the flap, and these are likely related to poor
technique rather than intrinsic failure of flap.

104. • Heister et al. introduced this flap for the first time in
1732. They believed that the newly introduced
structure was glandular and named it “glandula
molaris”.
• Bichat in 1802 described this anatomic mass and
realized its true nature.
BUCCAL (BICHAT) FAT PAD FLAP

106. - The advantages of this flap are as follows:
Quick, simple, and easy dissection;
There are no visible scars;
Low rate of morbidity;
Very low failure rate;
It can be associated with other pedicled flaps.

107. • The disadvantages are as follows:
 It can cover only small-to-medium defects;
because of its thinness, it is only suitable for
covering, providing no bulk.

108. • The landmarks to identify the buccal fat pad are the
superior buccal sulcus in the molar region and the
anterior border of the mandibular ramus.
• The average weight of each fat pad is 9.3 g, and its
average volume is 9.6 ml.

109. • When properly dissected and mobilized, the buccal
fat pad provides a 643 cm pedicled graft.
• Because much of the buccal pad of fat does not have
a clear pedicle, a clear arc of rotation cannot be
defined, thus maximum care is required during
insetting of a buccal fat pad flap.

110. • There are three different approaches to the buccal fat pad,
the choice depending on the defect that has to be closed:
1. Through a vertical incision slightly lateral to the
anterior border of the mandibular ascending ramus.
2. Through the elevation of a lateral mucoperiosteal
flap in the upper molar region and a lateral incision
of the periosteum at the level of the vestibular sulcus.
3. Through a horizontal mucosal incision along the
superior vestibular sulcus.

112. • Indications
 The flap is capable of covering small to medium
defects 5 cm in diameter.
 Oro-antral fistula.
 Palatal cleft defect.

113.  Covering exposed bony or mucosal defects within the
alveolar crest and maxilla, soft and hard palate,
retromolar region of the mandible, anterior tonsillar
pilar, superior buccal sulcus.

114. • Pitfalls
– Because the blood supply is unstable and there is
no signal pedicle, the arc of rotation of the flap
must be minimized, and the inset must be without
any tension.
– It is very important to preserve the thin capsule
overlying the buccal fat pad so that the small
blood vessels are not damaged.
– Avoid suction on the buccal fat pad .

115. – Minimal trismus is possible due to intraoral
scarring.
– In patients who have undergone neck dissection
or extensive radiation therapy to the head and
neck, take care to assess the blood supply and
viability of the buccal fat pad intraoperatively.
– Cheek contour and aesthetic malar projection
may be altered when using this flap.

116. FACIAL ARTERY MUSCULOMUCOSAL
FLAP
• In 1992, Pribaz described an axial musculomucosal
flap based on the facial artery, combining the
principles of the nasolabial and buccal mucosal flaps.
• He designated this facial artery musculomucosal
(FAMM) flap.

117. • Surgical anatomy-
It consists of
Mucosa
Submucosa
A small part of buccinator
 Deeper plane of orbicularis oris
Facial artery and venous plexus.

118. • The flap can be superiorly or inferiorly(posteriorly)
based depending on its vascularity and the defect
to be covered.
• Superiorly based flap can be used to cover the
defects in the hard palate, alveolus, nasal lining,
upper lip and sometimes even the orbit.

119. • The inferiorly based flap can be used for defects in
the alveolus, floor of mouth, lower lip and vermillion
and tonsillar fossa.

120. • An inferiorly based flap can be used only if the facial
artery and if possible the facial vein have been
preserved in neck dissections.
• In case where the vein has been ligated , venous
drainage can still be ensured by preserving wide soft
tissue at the base.

121. • The flap is centred on the
facial artery, oriented
obliquely extending from the
retro molar trigone to the
upper gingivolabial sulcus at
the alar margin. The
maximum width of the flap
can be 1.5–2 cm, anterior to
the Stenson’s duct.

122. • An incision is first made
distally through the
mucosa and buccinator,
the facial artery is
identified, ligated and cut
according to the base of
the flap.

123. • The rest of the flap is then incised including a part of
the deep layer of the orbicularis oris muscle.
• The base of the flap may then be islanded provided
enough soft tissue is retained for adequate venous
drainage.
• The donor defect can be closed primarily in two
layers, muscle and mucosa, taking care to avoid the
Stenson’s duct opening or may be covered with a
split thickness skin graft

124. VIDEO

125. • Pitfalls
– This flap is an axial flap and must follow the
course of the facial artery.
– Resist the temptation to make the pedicle longer
and inset the FAMM flap without any tension.
– A bite block should be used for 10 days to prevent
injury to the pedicle if it crosses over molar teeth.
– When suturing the donor site, pay attention to
Stenson’s duct.

126. Thank you for your attention…