Nsw speech path talk flapvs grafts

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Nsw speech path talk flapvs grafts

  1. 1. Flaps and Grafts
  2. 2. “….the application ofanatomical knowledge to restore form and function…”
  3. 3. Graft VS FlapWhat is the difference?
  4. 4. What is a Flap?• 16th century Dutch word “flappe” – ….something that hangs broad and loose , fastened only by one side..”
  5. 5. What is a Flap?• A flap is a unit of tissue that may be transferred from a donor to a recipient site while maintaining its blood supply. – Flaps can be characterized by their component parts • cutaneous, musculocutaneous, osseocutaneous – Their relationship to the defect • local, regional, or distant – Nature of the blood supply • random versus axial – The movement placed on the flap • advancement, pivot, transposition, free, pedicled
  6. 6. • Rung 1: Healing by secondary intention• Rung 2: Primary closure• Rung 3: Delayed primary closure• Rung 4: Split thickness graft• Rung 5: FTSG• Rung 6: tissue expansion• Rung 7: Random flap• Rung 8: Axial flap• Rung 9: Free Flap

  7. 7. Reconstructive Elevator• Get off at the right level
  8. 8. Composition of a flap• Skin – Muscle – Bone – Omentum – Composite
  9. 9. Composition of a flap – Skin• Muscle – Bone – Omentum – Composite
  10. 10. Composition of a flap – Skin – Muscle• Bone – Omentum – Composite
  11. 11. Composition of a flap – Skin – Muscle – Bone• Omentum – Composite
  12. 12. Composition of a flap – Skin – Muscle – Bone• Omentum / viscera – Composite
  13. 13. Composition of a flap – Skin +/- fascia – Muscle (+/- innervation) – Bone – Omentum / viscera• Composite
  14. 14. Which flap when?
  15. 15. Goals of reconstruction• Separating the physiological cavities – Eg brain, orbit, mouth, neck• Protecting the neck vessels• Obtaining a healed wound• Restore function• Restore swallowing• No leaks• Aesthetics
  16. 16. • Flaps reduce complications by: – Obliterating dead space – Recruiting healthy well-vascularized tissue into the region, which has commonly been irradiated and contaminated – Tension free closure – Interposing flap skin between irradiated wound edges
  17. 17. Pharyngeal defects• Partial defects – Pectoralis major flap with muscle and skin – Radial forearm free flap• Circumferential defects – Tubed radial forearm flap or ALT flap – Jejunum
  18. 18. Goals of reconstruction:• A single stage, reliable reconstruction• Prompt discharge from hospital• Return of swallowing and speech function• No salivary fistulas
  19. 19. Literature Review• Nelligan (J PlastReconstrAesthet Surg. 2008) reported a fistula rate of: – 13% for all fasciocutaneous flaps • ALT flap 16.4% • radial forearm free flap 14.4%. – Jejunum 9.4%• Charing Cross Study (Moradi et al) – fistula rate: 2/43 (4.7%) – stricture rate: 6/43 (14%)
  20. 20. Murray D, Novak C, Neligan P. Fasciocutaneous free flaps in pharyngolarngo- oesophageal reconstruction: A critical review of literature. J PlastReconstrAesthet Surg. 2008
  21. 21. Voice Restoration (Charing Cross series)• 22 of 42 received a primary (TEP)• 14 of 42 received a secondary TEP• 36/42 (85%) received either a primary or secondary TEP• Voice was reported as: – Good in 17 of 39 – Fair in 11 of 39. – 28 of 39 (72%) used their tracheoesophageal puncture as their primary mode of communication
  22. 22. When to eat?• No scientific evidence on the timing of oral intake• Err on the side of caution if previous radiotherapy• Day 10
  23. 23. Mandible reconstruction• Osteoradionecrosis (ORN) is a condition of non-vital bone in a site of radiation injury• Characterised by: – hypovascularity – hypocellularity – hypoxia• ORN occurs when, in the process of otherwise normal turnover of bone, the degradative function exceeds new bone production• Can be either spontaneous or the result of an insult
  24. 24. Facial reanimation• Goal of treatment – Rest symmetry – Facial function – Voluntary function – Spontaneous movement – Absence of synkinesis
  25. 25. Facial reanimation• Static vs dynamic• Static: Divide face into 1/3rds – Upper: – Middle: – Lower:
  26. 26. Dynamic: free gracilis
  27. 27. Static: slings
  28. 28. Tongue reconstruction• Depending on extent of defect and the status of the floor of mouth• Generally use: – Radial forearm free flap – Ulnar forearm free flap – ALT
  29. 29. Radial forearm free flap
  30. 30. Ulnar forearm free flap
  31. 31. Ulnar forearm free flap
  32. 32. Ulnar forearm free flap

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