Flaps for reconstruction

GITAM DENTAL COLLEGE & HOSPITAL
DEPARTMENT OF
ORAL & MAXILLOFACIAL
SURGERY
SEMINAR ON
Flaps for reconstruction
Flaps for maxillofacial reconstruction
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Presented by-
Dr. Sambhav. K.Vora
III M.D.S
Contents
I. Introduction
II. Classification
III. Local flaps
IV. Regional flaps
V. Distant flaps
VI. Composite flaps
VII. Free flaps
VIII. Reconstruction of specific regions
IX. Conclusion
X. References
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Introduction
Surgical practice routinely involves excision of body parts for
treatment of pathologic lesions, producing defects of varying sizes.
Defects may also be caused by other factors such as trauma, burns etc.
Reconstruction of the lost body part is important in many respects. They
include provision for cover, restoration of function and aesthetic
rehabilitation.
A flap is defined as a tissue that is either transferred or transplanted
with intact circulation. When vital structures are exposed in a complex
wound or when reconstruction has significant functional or aesthetic
consequences, a flap is generally required.
Reconstructive ladder
A defect may be managed by a wide variety of methods. The first
objective in analysing a reconstructive problem is a correct diagnosis. The
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extent and type of missing tissue are assessed in order to formulate a plan
for correction and reconstruction. In planning for management of defects
of skin, mucous membrane and underlying structures, it would be prudent
to follow what is known as the ‘reconstructive ladder’.
Small defects produced by burns or ulcerations may be allowed to
epithelise primarily. Another option is closure by direct suturing when the
defect is small enough and is otherwise suitable. When the defect is too
large, the potential methods of reconstruction are the use of a free skin
graft, a local skin flap, a distant skin flap, a composite flap or a free flap.
Planning involves consideration of the simplest alternative followed
progressively by the more complex, advancing up the ladder to the most
complex. Progression from primary closure to skin grafts to local flaps to
distant flaps and finally to microvascular free tissue transfers provides a
set of options that can be applied to any reconstructive situation.
Allow wound to heal by secondary intention
Direct tissue closure
Skin graft
Local tissue transfers
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Distant tissue transfers
Free tissue transfers.
General considerations
A skin flap in its basic form is a tongue of tissue consisting of the
entire thickness of the skin plus a viable amount of the underlying
subcutaneous tissue. It is transferred in order to reconstruct a primary
defect and is inset into this defect. The transfer usually leaves a
secondary defect, which is either closed by direct suture or covered by a
skin graft.
An ideal flap should satisfy the following goals
1. provisions of a suitable colour match to the surrounding skin of the
recipient bed.
2. assurance of a compatible thickness
3. retention, or provision of recovery, of clinically perceptible sensory
innervation
4. attainment of sufficient laxity and tissue ablation such that mobile
margins, as in an eyelid or lip, are spared retraction and deranged
function
5. assurance that the resultant suture lines of either primary or
secondary defects are restricted to anatomic units and fall within
natural skin lines.
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6. assurance that the reservoir from which the flap is mobilized is
sufficiently lax to allow closure of the donor site resultant defect.
The flap may be raised from the tissues immediately adjoining, or
very close to, the primary defect, in which case it is called a
loca l/reg ion al flap ; alternatively it may involve the movement of tissue
at a distance from the primary defect and is then called a distant flap .
When a local flap is transferred, movement takes place in the form
of advancement, rotation, transposition or interpolation. Some flaps, at the
time of transfer, are reattached to the body over their entire area, and the
proximal end of such a flap, where it remains continuous with the adjacent
skin, is referred to as its base .
With other flaps, the distal segment alone of the flap is inserted into
the defect, its central segment and base remaining unattached. The base
is then called the pedicle and the central segment is referred to as the
bridg e segment . These two, pedicle and bridge segment, act as the
carrier and provide the channel for the blood supply of the distal segment.
Once the distal segment establishes at the new site, which usually takes
three weeks, the bridge segment is divided and either returned to its
original site or discarded depending on the local situation. Insetting of the
distal segment is then completed. In order to inset the distal segment, it is
necessary to undercut its margin for a short distance.
While the pedicle of a flap usually consists of skin and
subcutaneous tissue, it is occasionally reduced to its subcutaneous
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component, the distal segment alone, as an islan d flap , retaining skin as
well as subcutaneous tissue.
When a distant flap is transferred, it is raised prior to transfer either
single pedicle d as a relatively long narrow tongue of tissue, or
bipe dic le d as a strap of tissue with a pedicle at each end. Transfer to its
destination is carried out in one of two ways –
a. If the flap is relatively near its ultimate destination, it may be swung
on its pedicle, following division of one pedicle if it was bipedicled, and
waltzed to its destination.
b. If it is at a greater distance from its destination, the flap is attached
instead to a carrier, usually the wrist, on which it is conveyed to its
destination.
Most local flaps have an axis around which they rotate or are
transposed in the process of being transferred, and this is called the ‘pivot
point’ of the flap. When it is at all possible, the bridge segment of any flap
is ‘tubed’ in order to eliminate unnecessary raw surface and to reduce
sepsis.
If it is felt that the blood supply of a flap would not be adequate for
its survival if it were transferred straightaway, the circulation can be
rendered more efficient by surgically outlining the flap. Such outlining is
called ‘delay’. The term is also used for the procedure of surgically
augmenting the blood supply of the flap.
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According to McGregor and Morgan (1973), two distinct types of
flaps can be distinguished according to their vascular characteristics and
behaviour, each with a distinct geometry imposed by its vascular anatomy.
Axial pattern flaps
This type of flaps is constructed around a pre-existing anatomically
recognized arteriovenous system. The vascular system running along its
length makes it possible to construct a flap at least as long as the territory
of its axial artery with minimal regard for consideration of its breadth. This
factor also makes the flap more robust and better able to cope with any
adverse circumstances that may arise.
Random pattern flaps
A random pattern flap has no pre-existing bias in its vascular
pattern, and this lack places stringent limits on its dimensions, particularly
in the ratio between its length and breadth. The degree of stringency
placed on the dimensions of a random flap depends to a considerable
extent on the richness of its subdermal vascular pattern.
Classification
There are a number of methods of classifying cutaneous flaps.
Flaps may be classified by the arrangement of their blood supply (random
vs. axial), by configuration (rhomboid, bilobed, elliptical etc.), location
(local, regional and distant) ands by the method of transferring the flap
(rotation, advancement, transposition etc.)
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Local flaps
The local flap consists of tissue immediately adjoining the defect to
be closed. It consists of skin and subcutaneous tissue. The local tissue
may be dissected into a flap and mobilised to the defect by advancement,
rotation, transposition or interpolation.
Advancement flaps
The advancement principle makes use of a linear configuration flap,
raised and advanced to cover a rectangular primary defect which adjoins
its distal end. Tissue transfer is achieved by moving the flap and its
pedicle in a single vector. Advancement flaps may be categorized as
single-pedicled, bipedicled or V-Y.
Single-pedicle flaps
Single-pedicle flaps are created by parallel incisions, which allow a
sliding movement of the tissue in a single vector towards a defect. The
movement is in one direction, and the flap advances directly on the defect.
The flap is developed adjacent to the defect and one border of the defect
becomes a border of the flap. Repair with an advancement flap involves
both primary and secondary tissue movement. Complete undermining of
the advancement flaps as well as of skin and soft tissue around the
pedicle is important to enhance tissue movement. Bilateral advancement
flaps are frequently combined to close various defects, resulting in ‘H’ or
‘T’ shaped repairs. It may also be used as an ‘island’ advancement flap.
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It is virtually only in the face that the necessary skin laxity exists to
allow advancement flaps to be used successfully. It works well in the
repair of the defects of foreheads, helical rims, upper and lower lips, and
medial cheek. Mucosal advancement flaps are also used for vermilion
reconstruction.
The main drawback of this type of flaps is that a standing cutaneous
deformity is created.
Bipedicle flaps
Bipedicle advancement flaps are used primarily for repair of large
defects of the scalp. The flap is designed adjacent to the defect, and
advanced to the defect at right angles to the linear axis of the flap. This
leaves, apart from the dog-ear deformity, a secondary defect which must
be repaired with a split skin graft. So, these flaps are seldom used now-a-
days in the reconstruction of head and neck.
V-Y advancement flaps
In the case of V-Y advancement flaps, a V-shaped flap is pushed
toward the defect. Thus the flap is moved into the recipient site without
any wound closure tension. The secondary triangular donor defect is then
repaired with wound closure tension by advancing the two edges of the
remaining wound towards each other. Thus the wound closure suture line
assumes a ‘Y’ shape, with the common limb of the ‘Y’ representing the
suture line resulting from closure of the secondary defect.
V-Y advancement is useful when a structure or a region requires
lengthening or release from a contracted state. It is particularly effective in
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lengthening the columella in the repair of cleft lip nasal deformities. It is
also helpful in releasing contracted scars that are distorting adjacent
structures as the eyelid or vermilion.
Pivotal flaps
There are three types of pivotal flaps – rotation, transposition and
interpolation flaps. All pivotal flaps are moved towards the defect by
rotating the base of the flap around a pivotal joint. The greater the degree
of pivot, the shorter the effective length of the flap. This is because the
pivotal point is fixed in position, and the base of the flap is restricted in
pivoting around this point because of the development of redundant tissue
at the base known as ‘standing cutaneous deformity (dog ear). Pivotal
flaps must be designed to account for this reduction in effective length as
they move around their point of pivot.
Rotation flaps
Rotation flaps are pivotal flaps that have a curvilinear configuration.
Since the flap is being rotated to its destination, its ideal form is as the
large arc of a circle of which the triangular primary defect is a small arc,
with the flap and defect together making a half circle. They are designed
immediately adjacent to the defect and are best used to close triangular
defects. They are usually random in their vascularity but depending on the
position of the base of the flap, they may be axial. Because the flap has a
broad base, it vascularity tends to be reliable. Rotation flaps are useful in
repairing medial cheek defects located near the naso-facial sulcus.
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Large rotational flaps are particularly useful for reconstruction of
sizable posterior cheek and upper neck defects. Incisions for the flaps are
placed in a pre-auricular crease, and can extend for some distance along
the anterior border of the trapezius muscle to facilitate rotation of upper
cervical skin toward the area of the posterior cheek. A z-plasty at the base
of the flap facilitates closure of the secondary defect. Chin reconstruction
often can be readily accomplished with rotational flaps. Smaller rotational
flaps may also be used for repair of defects located in the glabellar area.
Scalp defects may be reconstructed with one or more flaps.
Transposition flaps
In contrast to rotation flaps, which have a curvilinear configuration,
the transposition flaps have a straight linear axis. It can be designed in
such a way that one border of the defect is also a border of the flap, or
alternatively, with borders that are removed from the defect with only the
base of the flap contiguous with the defect. In its ‘classic’ form, this flap is
a rectangle, usually near square, which is raised and moved laterally into
the primary defect, previously triangulated in preparation for it. Such a
transfer leaves a secondary triangular defect which is at least equal in
area to the primary defect.
Transposition is the most common method of moving local flaps into
skin defects of the head and neck. They can be elevated in a multitude of
sizes, shapes and orientation and usually are random cutaneous flaps, but
may occasionally be compound. It is a reconstruction option for small and
medium-sized defects. Its main advantage is that the flap can be designed
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some distance away from the defect, and the surgeon can select areas of
skin elasticity and redundancy. The chief drawback is the secondary
cosmetic deformity, but this can be hidden in hear-bearing areas.
Interpolation flaps
The interpolation flap, though it is a pivotal flap with a linear
configuration, differs from transposition flaps in that its base is located at
some distance from the defect. Thus the pedicle must pass over or under
intervening tissue, and must subsequently be detached in a second
procedure. This is the greatest disadvantage of this flap. On occasion, the
pedicle can be de-epithelised or reduced to subcutaneous tissue only and
brought under the intervening skin, to allow a single-stage repair.
A common interpolation flap is the mid-forehead flap, which includes
the median and paramedian flap. They are highly effective in midface
reconstruction because of their excellent vascularity and superb skin
colour and texture match. Apart from nasal defects, defects of the medial
canthal region, upper and lower eyelids, medial cheek, melolabial region
and upper lip may be repaired with mid-forehead flaps. They are thin and
viable flaps and can be easily contoured.
Rhomboid flaps
First described by Limberg (1966) and named after him (Limberg
flap), the distinctive feature of the rhomboid flap is the precision of its
design, which involved both the shape of the defect and the size and
shape of the flap used to fill it. The defect is made in the form of a
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rhombus ( ) in such a way that its shorter diagonal equals the four
sides in length.
The flap is outlined by extending the line of the shorter diagonal, for
a distance equal to its length. From the extremity of this line, again equal
in length to the shorter diagonal, is drawn at an angle 60˚ to it. In this way,
a flap adjoining the defect is enclosed, with a size and shape similar to the
rhomboid of the defect. Both the lines extended from the rhombus for flap
design can be directed in either directions so that the flap can be placed in
one or either side of the defect, with a further possibility of designing two
flaps on each side, making four potential flaps in all. In practice, the side
and direction of the flap are determined by the tissue available to be
included in the flap.
The flap is raised and swung into the defect. This leaves a
secondary defect, which is then closed by direct suture. The area where
the rhomboid flap has its greatest value is the temple, between the
eyebrows and the anterior hairline, and the appropriate direction is along
the ‘crow’s foot’ wrinkle lines lateral to the outer canthus.
Bilobed flaps
In some situations, a defect which, in other respects is suitable for
local flap reconstruction, is somewhat distant from an area of availability
or lies at such an inappropriate angle that a suitable flap cannot be
designed. Zimany in 1953 described a ‘bilobed’ flap for such situations.
The overall outline of the defect plus the flap is a ‘cloverleaf’ – one
of the outer leaves being the defect, other two the bilobed flap, sharing the
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same pedicle. In the transfer, the central lobe of the leaf is rotated into the
primary defect. This leaves a secondary defect which, in turn, is filled by
the remaining cloverleaf. The tertiary defect so left is in an area of tissue
availability, and so may be closed by direct sutures.
Hinged flaps
Cutaneous hinge flaps (trapdoor, turn-in, turn-out flaps) may be
designed in a linear or curvilinear shape with the pedicle based on one
border of the defect. The flap is dissected in the subcutaneous plane and
turned over on to the defect like the page of a book. The epithelial surface
of the flap is turned downward to provide internal lining of a facial defect
that requires both external and internal lining surfaces. The exposed
subcutaneous surface of the hinge flap is covered by a second flap.
The vascular supply of a hinge flap is derived from the soft-tissue
border of the defect. And consequently they have limited and often
restricted vascularity. The dissection should proceed in such a way that
the base is thicker than the distal portion of the flap. Hinge flaps are
commonly used for repair of full-thickness nasal defects and to close
mature sinofacial and salivary fistulae.
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Regional flaps
The regional flaps are local cutaneous flaps which involves transfer
of tissue from areas adjacent to the defect. The commonly used regional
flaps in head and neck include nasolabial flaps, forehead flaps, glabellar
flap, tongue flaps etc.
Nasolabial flap
A nasolabial flap consists of a finger of tissue lying astride the
nasolabial skin crease. It can be based above or below (superiorly or
inferiorly based); and its main use is as a transposed flap to reconstruct
defects of the side of the nose and the upper lip, occasionally the lower lip
and oral cavity.
The nasolabial site is one of the most consistently available areas
of lax skin. The area of skin which is used as the flap and its extension
upwards and downwards varies considerably depending on the site, size
and shape of the defect it is designed to cover. The flap is raised as a
finger of tissue with its width made to correspond to that of the defect.
Within limits, the length of the flap is not significant in vascular terms. The
secondary defect is normally closed by direct suture.
The distribution of hair on the face and whether hair on the flap is
desirable or undesirable will determine the ultimate the ultimate details of
placing the flap. Used for defects of the nose, the superior pedicle is
almost invariable. The lip and intra-oral defects may be repaired by either
superiorly or inferiorly based flaps.
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A nasolabial island flap may be designed, which bridges intact skin
to reach the side of the nose. This is used to reconstruct the lower half of
the side of the nose, occasionally the alar base and the margin, and rarely
the adjoining upper lip.
P er i- alar r ot at ion- adv anc ement f lap
This technique, described by Webster (1955), addresses the
problem of asymmetry of the upper lip caused by direct closure of elliptical
defects of alar bases. It involves excision of a crescent of the skin and
subcutaneous tissue immediately lateral to the ala of the nose and
mobilisation of the skin of the adjacent nasolabial area from the underlying
cheek and lip musculature. The crescentic defect is then closed directly
and the effect is to rotate and advance nasolabial skin into the lip defect to
be closed without creating asymmetry.
Forehead flaps
The forehead flaps transfer the skin area from the forehead, most
often to cover a defect of the middle third of the face. The tissue
transferred can vary from a relatively small area to virtually the entire
forehead. The pedicles generally make axial use of the superficial
temporal, supraorbital and supratrochlear vessels, entering from the
margins of the forehead. The secondary defect of a forehead flap is closed
by direct suture when it is small enough; where it is too extensive, it is
split-skin grafted.
Flaps raised from forehead are based either laterally on the
temporal region, or inferiorly on the supraorbital region. The flap based
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laterally uses part or all of the breadth of skin between the ear and the
outer end of the eyebrow. The flaps raised with an inferior pedicle vary
considerably in design, but there are two basic designs – a straight
relatively narrow finger like flap passing upwards from the glabellar region,
and a ‘sickle’ shaped flap which rises in upward direction but curves down
on the scalp to run vertically downwards on the opposite side of the
forehead.
The temporal island flap, parented by the laterally based forehead
flap, is occasionally used in the resurfacing of the malar region and also in
reconstruction of the eyebrows.
Forehead flaps generally provide excellent contour and texture
matches in the sites to which they are usually transferred.
Glabellar flap
The glabellar flap acts by transferring the skin from the glabellar
region to cover defects of the side of the nose where it adjoins the medial
canthus and the cheek immediately below the canthus. It is constructed on
the hairless area between the eyebrows and the adjacent forehead,
pivoting around the region of the superior orbital foramen on the opposite
side from the defect, and incorporating a significant portion of the
supraorbital and supratrochlear arteriovenous systems. The flap itself is
triangular in outline with the apex pointing upwards on to the forehead.
When it is rotated into the defect, it leaves a triangular secondary defect in
the centre of the forehead, and this is closed by direct suture.
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A glabellar island flap may be used to reconstruct the canthal area
or the adjoining side of the nose and the cheek. Its parent flap is the finger
variant of the supraorbital flap, rather than the classical glabellar flap. The
subcutaneous pedicle pass from the island downwards towards the
glabellar region.
Median glabellar f lap
This rectangular flap (Rintala and Asko-Selvaara, 1969), long in
relation to its width, is placed vertically in the glabellar region. With its
base approximately 1 cm above the medial end of the eyebrows, its
rectangle extends down over the bridge of the nose. It uses the principle
of straight advancement to redeploy the glabellar area of skin availability,
and can be used to cover square shaped defects of the upper third of the
nasal skin in the midline. This method can be used only if the gap
between the eyebrows is wide enough to allow a reasonably broad flap to
be constructed.
Tongue flaps
Eiselberg used tongue flaps to repair oral defects in 1901. However,
he gave credit to Gersuny at the end of the 19
th
century for the first use of
a tongue flap to restore oral defects. Klopp and Schurter (1956),
Bakamjian (1963) and Conley (1982) repopularised its use in the modern
era.
The tongue flaps offer the advantage of adjacent and similar tissue
for repair of intra-oral defects. An excellent axial and collateral circulation
provides for flap viability. The lingual artery is the main vessel supplying
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the tongue. Anastomotic connections between the terminal lingual artery,
the facial artery and the tonsillar branches of palatine artery are present.
The branches that directly supply the tongue are the suprahyoid artery, the
dorsalis lingual artery, the sublingual artery and the deep lingual artery.
There are vascular arcades, which often perforate the midline of the
tongue.
Dorsal based tongue flaps get most of their blood supply from an
intact lingual artery. The rich collateral circulation of the tongue prevents
tongue flap death as long as the base of the flap and its design allow for
collateral circulation to develop.
A wide variety of tongue flap designs are possible, the common
ones being anterior or posterior dorsal based lateral or midline flaps,
posterior based lateral flap (Vaughn, 1983), posterior based bilateral
lateral flaps, anterior based ventral flaps etc.
The common indications for tongue flaps include
1. reconstruction of intra-oral structures following cancer excision,
2. resurfacing of oral defects and
3. closure of palatal fistulae in cleft palate and acquired OAF.
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Distant flaps
Deltopectoral flap
The deltopectoral flap is an axial pattern flap, first described by
Bakamjian in 1965. It is composed of fascia, subcutaneous tissue and
skin, and can be used for soft tissue reconstruction of mandible and
maxilla.
The flap design is horizontal and rectangular with a rounded end
over the shoulder. Based medially on the anterior chest wall, the flap on
its upper border follows the clavicle and along the lower border, it runs just
above the male nipple and not lower than the anterior axillary fold. In
females, the base of the flap should include the first five ribs. The base of
the medial portion of the flap must be 2 cm from the lateral sternal border
to preserve the perforating vessels from the internal mammary artery,
which supply blood to the flap. The perforators enter the flap through the
first four intercostals spaces.
The fascia overlying the deltoid and pectoralis major muscles
should be elevated with the flap by sharp dissection. Several branches of
thoracoacromion artery will have to be ligated when elevating this flap.
After appropriate planning and marking, the skin, subcutaneous tissue and
the muscle fascia are sharply divided. The flap is elevated with skin hooks,
and sharply dissected from the underlying muscles. It is then passed on to
the defect and sutured in place.
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The deltopectoral flap cannot be used for intra-oral reconstruction
without creating an oral fistula. This is a controlled fistula and is
necessary to preserve the blood supply to the flap. After the flap is sewn
in place, it usually needs to be tubed.
The flap is divided 3 weeks later and the fistula closed. Waiting 6
weeks before dividing the pedicle ensures better survival of the flap. If the
flap as designed is not long enough to fill the defect, it may be delayed to
gain additional length.
The deltopectoral flap is useful for most reconstructive problems of
head and neck, especially when a large amount of skin is required for
coverage. It has been used in the repair of defects in the cervical
oesophagus, hypopharynx, oropharynx, base of the tongue, mandible,
maxilla and skin of cheek, chin and neck. In situations where both mucosal
defects and skin defects are to be corrected, the combination of an
appropriate myocutaneous flap for mucosal replacement, and the
deltopectoral flap for external skin replacement works well. This flap may
be used in most cases without having to reposition the patient.
The main disadvantage of this flap is the need to form an oral fistula
and close it at a second operation. The donor defect is also a cosmetic
problem. Another potential hazard is the rare occurrence of distal flap
necrosis.
Cervical skin flaps
Flaps of varying size, shape, site and direction have been designed
which make use if neck skin for reconstructive purposes. It is possible in
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theory to raise a flap from virtually any site on the neck and transpose it
upwards to cover a defect of lower face or oral cavity. Being random in
type, such flaps are restricted in their useful length.
Side of the neck
The flaps making use of the side of the neck are generally
horizontally designed, based anteriorly or posteriorly. Because of their
limited application, they are rarely used and have not been systematised
in design.
Occipito-mastoid based flaps
From a base which extends form the midline and even beyond the
occiput and event o the angle of the mandible, these flaps pass in a
generally downward direction curving slightly laterally. Based on the
downward extension, they may be ‘nape-of-the-neck’ flaps or
sternocleidomastoid flaps.
‘N ape- of - t he- neck ’ f laps
This random pattern skin flap was first described by Mutter (1842).
It makes use of the neck skin lying above the trapezius muscle. The flap
can be raised pedicled on the occiput and extended downward as required
to the approximate level of the spine of the scapula. Swung on the upper
pedicle, such a flap can be used as a transposed flap to reconstruct the
lower face and the submandibular region.
It is not generally considered safe to raise the ‘nape-of-the-neck’
flap and transfer it immediately because of the high incidence of necrosis.
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Prior delay is advisable and this makes it suitable for the already existing
defect rather than the fresh post-excisional one.
S t er noc leidomas t oid f laps
This is a single-pedicled random pattern flap (Bakamjian and
Littlewood, 1964), based on the skin overlying the upper insertion of the
sternomastoid and running downwards along the line of the muscle.
Pedicled above, it can be swung forward to be used both intra-orally and
extra-orally.
Used as a skin flap, it has a bad reputation for necrosis (about
20%). Because of its vascular vulnerability, it is sometimes delayed before
transfer. The incidence of necrosis can be greatly reduced by
incorporating the underlying muscle as part of the transfer, thus making it
a myocutaneous flap.
Apron flap
Described by Zovickian in 1958, this is a superiorly based flap
which consists of skin from the submental region and front of the neck
between the line of the carotids on either side. It is hinged along a line
parallel to and just below the lower border of the mandible and is designed
to be turned upwards along the inner side of the mandible to replace the
mucosa of the anterior floor of the mouth and anterior part of lower
alveolus. Problems resulting from the presence of beard skin led to its use
as an island flap. This, combined with the compromise on vascularity
following neck dissection, has made this flap unpopular.
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Composite flaps
The composite flaps contain, apart from skin and subcutaneous
tissue, underlying supportive tissue such as muscle, fascia or bone.
Myocutaneous flaps with their excellent blood supply have proved to be
very reliable in reconstruction following ablative surgery. In some
instances, the underlying bone is pedicled on the muscle, thus making it
an osteomyocutaneous flap
Muscle / myocutaneous flaps
Pectoralis Major Myocutaneous flap
The pectoralis major myocutaneous flap is the most useful flap for
soft tissue reconstruction of bone and soft tissue defects of the mandible
and maxilla secondary to cancer surgery. This flap was first described by
Heuston and McConchie, who used it to reconstruct a chest wall defect in
1968. Ariyan (1979) demonstrated the vascular arrangement of the flap.
The pectoralis major muscle is a fan-shaped muscle on the anterior
chest wall. It is bounded by the clavicle superiorly and the sternum
medially. The lateral border forms the axillary fold. The superior fibres run
parallel to the clavicle, and the inferior fibres run from the inferior border
of the deltoid to the 5
th
and 6
th
ribs and lower sternum. The clavicular head
of the muscle originates from the upper three ribs and the clavicle and
inserts into the inter-tubercular groove of the humerus.
The pectoralis major muscle has two separate blood supplies. The
thoracoacromial artery arises from the second portion of the axillary
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artery, and passes along the medial border of the pectoralis minor muscle
and penetrates the clavipectoral fascia. It has 4 branches at this level. The
pectoral branch is the largest, supplying the standard pectoralis major
myocutaneous flap. The other blood supply to the muscle comes from the
perforating branches of the internal mammary artery, which penetrates the
muscle next to the sternum. The motor nerve to the upper half of the
muscle is the lateral pectoral nerve, and that to the lower half is the medial
pectoral nerve. Sensation is by the intercostals nerves.
The technique for flap elevation depends on the location of the
defect. Most commonly defects of the head and neck require skin for lining
the oral and maxillary cavity and bulk for filling bone and soft tissue
defects. Currently two specific PMMC flaps are commonly used. These
are the PMMC island flap and the PMMC paddle flap.
For raising an island flap, measurement is from clavicle to the
inferior margin of the skin island, the measuring tape rotated to the defect
to arrive at the appropriate length of the flap. The skin island may be
placed on any part of the muscle as needed. The skin incision is carried
down to the fascia of the pectoralis major muscle. Sutures are used to
secure the skin island to the fascia. Then the entire muscle may be
elevated, or it may be divided lateral to the island, leaving the lateral
portion intact. The muscle is elevated primarily by blunt dissection off the
ribs, care being taken not to enter the chest cavity. Medial to the island,
the muscle is divided 2 cm lateral to the sternum to avoid injuring the
internal mammary artery. The muscle is divided medially up to the clavicle.
26

Laterally it is necessary to divide the humerus attachment. After the flap is
elevated, the skin between the upper portion of the chest and neck is
elevated and the flap passed under the skin to the defect. The neck
incision is closed over the muscle, and the chest skin is mobilised and
closed primarily in most of the cases.
In cases where the island flap is not long enough to cover the
defect, a paddle flap may be useful. Another variant is the bilobular or
‘Gemini’ PMMC flap, in which two separate skin islands are raised with the
muscle for simultaneous replacement of oral mucosa and overlying skin.
The pectoralis major myocutaneous flap and its variants are the
flaps of choice for most defects in mandible and maxilla. It has also been
used for the reconstruction of pharngoeophageal area, the base of the
tongue, the anterior skull base, midface, total nose and orbital defects.
The PMMC flaps are very reliable in their survival chances. Very
good functional and cosmetic results have been obtained using PMMC
flaps along with dynamic fixation of the remaining mandible after partial
resections. The disadvantages of this flap are also mainly cosmetic, the
loss of muscle being very noticeable especially in thin patients. With 18
other muscles assisting shoulder motion, functional problems are rare.
Forehead flap
The forehead flap in its most reliable configuration is a
myocutaneous flap, composed of the frontalis muscle extending from the
hairline to the eyebrows with the overlying skin and subcutaneous tissue.
It was introduced by Carpue in 1816. Blair (1941), Moore and Byars and
27

McGregor (1963, 1964) have used this flap for lesions of the gingival
mucosa, buccal mucosa and lateral pharyngeal wall. It may also be used
to reconstruct defects of hard and soft palate.
The flap may be designed with a dual or single blood supply. It
makes use of the superficial temporal artery and the posterior auricular
artery, branches of external carotid artery. It may be used as a hemi-
forehead flap or a total forehead flap depending on the size and location of
the defect. The total forehead flap should include both the vessels.
The base of the total forehead flap extends from the lateral canthus
of the eye to a point 2 cm posterior to the ear, to include the posterior
auricular artery. The distal extremity is a transverse line at the level of the
opposite lateral canthus. The base of the hemi-forehead flap extends from
the lateral canthus at the eyebrow to the root of the superior helix of the
ear and distally, it ends in the midline. The width of both types depends on
the distance between the eyebrows and hairline.
Both the hemi-forehead and the forehead flaps are elevated at the
level of the pericranium. The donor defect is covered with a split skin graft.
Various methods have been used for placing the flap into the
oropharynx.
1. McGregor (1963) – the flap is rotated 180˚ laterally and entrance is
gained into the oral cavity through a separate transverse incision.
2. Hoopes and Edgerton (1966) – the flap is rotated 180˚ medially and
placed through a tunnel created at the base of the forehead pedicle
that lies between the flap and the zygomatic arch.
28

3. Terz and Lawrence (1969) – the temporal fascia is incised and the
flap folded medial to the zygoma to be transferred into the oral
cavity.
4. The flap is hinged downwards and inserted into the oral cavity
through the posterior part of the submandibular component of the
neck dissection incision.
The advantages of forehead flaps are its close proximity to the
orofacial regions, excellent blood supply and firmness of tissue. The main
disadvantages are noticeable the donor site defect, the need to divide the
pedicle to close the oral fistula art a second operation, and the frequent
complication of bleeding. Flap necrosis, both major and minor, is an
occasional problem.
Temporalis flap
The temporalis flap was introduced in 1898 by Golovine. The flap is
useful
a. to obliterate skull base, maxillofacial and orbital defects.
b. to close cerebrospinal fluid leaks, to cover dural tears secondary
to trauma or cancer operations
c. to reconstruct patients requiring midface augmentation for
hypoplasia secondary to trauma, operation or congenital
anomalies.
d. to reanimate the face after injury or resection of the facial nerve.
e. to reconstruct small intra-oral defects. The flap extends across
the midline of the soft palate for repair of velum defects.
29

The temporalis muscle is a broad, fan-shaped bipennate muscle
with two origins – deep one from the temporal fossa extending from the
superior temporal line to infratemporal crest, and the superficial one from
the deep temporal fascia. The insertion is onto the coronoid process and
anterior ramus of the mandible. The deep temporal fascia invests the outer
aspect of the mandible. The superficial temporal fascia lies on top of the
deep fascia.
The blood supply of the deep temporal fascia is by the middle
temporal vessel, a branch of superficial temporal artery. The temporalis
muscle has a dual blood supply from the anterior and posterior deep
temporal arteries. These vessels arise from the second portion of the
internal maxillary artery.
The available length of the arc of rotation is estimated pre-
operatively by palpating the superior extent of the muscle while the patient
clenches his teeth. The incision is started in a skin crease anterior to the
ear, and is extended superiorly toward the vertex, ending above the
superior temporal line. The incision is carried down to the deep temporal
fascia, and anterior and posterior flaps are developed above the deep
fascia, until the entire muscle is exposed. Then the fascia is incised
around the border of the muscle down to the calvarium. Elevation of the
muscle is done in a subperiosteal plane.
The zygomatic arch may have to be divided to facilitate placement
of the flap into the mouth. Additional mobility is gained by sectioning the
coronoid process. A tunnel is created into the oral cavity by blunt
30

dissection, and the flap is passed to the defect with the aid of traction
sutures. Split skin grafts may be applied, but is not necessary.
The main advantage of the temporalis flap is its proximity to defects
high in the oral cavity or on the face. Problem from loss of muscle function
are minimal. It can support skin grafts, has a good arc of rotation, may be
turned in different directions and is thin, providing for less bulky
reconstruction.
The main disadvantage is the cosmetic deformity, though minimal,
caused at the donor site. This may be corrected with autogenous or
alloplastic materials, or camouflaged by hairstyle.
Platysma flap
The platysma flap was first used by Gersuny (1887) for
reconstruction of a through-and-through cheek defect. In 1951, Edgerton
described a lateral cervical island flap based on the platysma muscle for
reconstruction of intra-oral defects. DesPrez and Kiehn (1959) reported
the modified apron flap, which included the platysma muscle. In 1978,
Futrell and colleagues reported the use of the platysma muscle as a true
myocutaneous flap.
The platysma muscle lies deep to the subcutaneous tissue overlying
the anterior and lateral aspect of the neck. Superficial cervical fascia
separates it from sternocleidomastoid muscle, the great vessels of the
neck and other underlying structures. The origin of the muscle is in the
subcutaneous tissue just caudal to the clavicle and the acromion. Its
insertion is just cephalad to the inferior border of the mandible. Laterally,
31

it extends over part of the posterior triangle and sternocleidomastoid
muscle. In the midline, it may merge at any point from the chin to the
thyroid cartilage. Its function is to depress the lower lip.
The blood supply of the muscle and overlying skin was described by
Hurwitz et al (1983) and Rabson et al (1985). The cervical skin is supplied
by a random anastomosing network located superficial to the platysma.
The principal vascular supply to the muscle is from branches of the facial
artery. But it also receives rich blood supply from other vessels such as
occipital, posterior auricular and superior thyroid arteries.
The flap may be raised on either a superiorly or inferiorly based
pedicle. For use in the facial region, it must be raised as a superiorly
based flap. If t is to be used in conjunction with neck dissection, it is
elevated before the neck dissection is done. A skin island is designed on
the inferior aspect of the muscle. Following an incision outlined to the
platysma muscle, a supra-platysmal dissection is carried superiorly to the
point of rotation. The incision through the inferior base of the skin island is
carried deep to the platysma muscle and including the superficial cervical
fascia. It is preferable to preserve as many blood vessels in the vicinity as
possible.
The muscle is flipped 180˚ and brought through a tunnel into the
mouth or is rotated and taken through a subcutaneous tunnel for coverage
of extra-oral defects. The neck is closed primarily.
The primary use of this flap is in the reconstruction of intra-oral
defects of the palate, buccal mucosa, tongue, floor of the mouth and
32

pharynx; and extra-oral defects in the cheek and lower lip region.
Advantages of this flap include its close proximity, and a minimal donor
site defect which can be closed primarily. This thin, pliable flap causes
negligible impairment of functions like deglutition, speech or prosthetic
appliance use. It can be used for mild facial augmentation and reamination
following facial nerve injury.
The greatest disadvantage of the platysma flap is that it is not
reliable because of its unpredictable blood supply, which can cause flap
loss. Another problem is the folding of the muscle which causes a bulge in
the neck. Also, it cannot be used in regions where tissue bulk is required.
Sternocleidomastoid flaps
The sternocleidomastoid flap was introduced in 1909 by Jinau for
facial reanimation. In 1949, Owens described a compound neck flap that
included the muscle. This flap can be used as a muscle, myocutaneous or
a myo-osseous flap.
The sternocleidomastoid muscle has two heads which at the origin
attach to the manubrium sterni and the medial third of the clavicle. The
insertion is to the mastoid process and lateral third of the superior nuchal
line of the occipital bone. It divided the neck into anatomical anterior and
posterior triangles.
The blood supply to the muscle is through three arteries. Superiorly
a branch of the occipital artery enters the muscle below the mastoid tip.
The middle branch is from the superior thyroid artery. The inferior third is
33

supplied by a branch from the thyrocervical trunk. The dominant vessel is
the occipital artery.
The incision is determined by the proposed use of the muscle. If a
muscle flap is to be used alone, a vertical incision over the midportion of
the muscle extending from its origin to insertion may be used. As an
alternative, two horizontal incisions can be placed. The flap can then be
elevated by tunneling through these incisions. A myocutaneous flap can be
developed by basing it either superiorly or inferiorly with a skin island or
skin pedicle attached to the muscle. In cases of simultaneous neck
dissection, the McFee or hockey stick incisions can be modified to
accommodate its elevation.
For superiorly based flaps, the flap is developed by elevating the
skin and platysma from the underlying sternocleidomastoid muscle. The
sternal and clavicular head are transected and the muscle is elevated by
dissection between its deep surface and the deep cervical fascia. The
lower branches of the vascular supply may be ligated without affecting the
survival of the flap, according to Ariyan (1979). But Sasaki (1980) and
Marx & McDonald (1985) recommend maintaining two of the supplying
branches, by dissecting the middle branch (superior thyroid) back to its
parent vessel.
The muscle is separated from the fascia, taking care to preserve the
spinal accessory nerve. Arc of rotation may be restricted by the superior
thyroid artery or the spinal accessory nerve. The muscle is then
34

transposed and sutured in position, and the incision closed in layers over
suction drains.
When a skin island is being taken, the incisions are carried down to
the muscle fascia, the skin sutured to the underlying fascia, and the
dissection proceeded as for the standard muscle flap. After the flap is
rotated into position, the muscle is sutured to the subcutaneous tissues,
and the skin island to the mucosa or skin as required. Because of
variability in the axial blood flow, fluorescein may be used intra-operatively
to determine the amount of viable skin. 1000 to 2000 mg of fluorescein is
injected intravenously and the flaps are observed.
Extra-orally, the sternocleidomastoid flap can be used form the
cheek to the neck area, and intra-orally, from the palatal region to the
larynx. Other uses of the flap are to provide soft tissue augmentation after
parotidectomy, for facial reanimation in 7
th
nerve injuries, to obliterate the
dead space around a bone graft and to provide a vascularised muscle bed
in patients with poor recipient tissues.
Advantages of the flap are the close proximity to recipient site,
good colour match, adequate bulk and minimal donor site morbidity. The
disadvantages include flat neck deformity, disruption of cutaneous nerve
supply of the neck and unreliability of vascular supply of the flap. Potential
limitations include the need to resect the muscle as part of neck dissection
and obese people with short necks. Complications include muscle atrophy
and flap necrosis.
35

Trapezius flaps
Flaps from the shoulder and back have a long history. Mutter
described the trapezius flap in 1842, which was named after him.
Zovickian popularised these flaps in 1957. Several designs of the
trapezius myocutaneous flaps have been used because of its triple blood
supply.
The trapezius is a flat and triangular muscle that covers the superior
posterior part of the neck and shoulder. It originates from the nuchal line
of the occipital bone and the spinous processes of C-7 through T-12. It
courses laterally to insert on the lateral third of the clavicle, the acromion
and the spine of the scapula. It overlies the semispinalis and splenius
capitis in the neck, and both rhomboid muscles in the back.
The main blood supply of the trapezius muscle is by a branch of the
thyrocervical trunk, the transverse cervical artery. At the border of the
muscle, the vessel divides into an ascending and a descending branch,
which permits separate flaps based on the lateral and vertical portions of
the muscle. The upper portion of the muscle in the neck is supplied by the
occipital artery. So this part of the muscle can be used as a separate
myocutaneous flap. The muscle is also supplied by numerous deep
perforating vessels from the intercostal system.
Three flap designs have been described – the upper trapezius flap,
the lateral trapezius flap and the lower trapezius flap. The upper flap is the
myocutaneous version of the standard nape-of-the-neck flap in which a
strip of underlying trapezius is raised along with the skin (McCraw et al-
36

1979). The flap in the form of an island can be rotated to allow a skin
paddle to replace a mucosal defect.
The lateral trepezius flap (Bertotti, 1980, Guillamondegui & Larson,
1981) is based on the transverse cervical arterio-venous system and is
raised from more or less the same skin area as the upper trepezius island
myocutaneous flap. Its anterior border corresponds to approximately to the
anterior margin of trepezius and from there it extends backwards and
downwards in general the direction of the spine of the scapula. In order to
be certain of including the vessels in the flap both the muscle element and
the skin should extend above the point at which the transverse cervical
vessels disappear deep to trepezius. The pivot point of the transfer is the
medial end of its feeding arterio-venous system. The first step is to dissect
the pedicle at its medial end. The island of skin with the underlying muscle
is raised from levator scapulae. The flap can be used in conjunction either
with a radical or a functional neck dissection.
The lower trapezius myocutaneous flap may be used as an island
flap or as a solid flap. The vessels must be identified in the neck and
traced to the anterior border of the muscle. The anterior incision for the
skin island extends along the anterior border of the trapezius. The muscle
and its blood supply are elevated from the underlying structures. An
appropriate skin island is cut and the underlying muscle is incised with
care. The pedicle is then isolated and traced to its origin at the
thyrocervical trunk. The island, now attached only by its pedicle, is rotated
into the defect and sutured into place.
37

The transverse cervical trapezius myocutaneous flap is useful for
repairing defects within the oral cavity, hypopharynx or skin of the lower
cheek and chin. For it to be considered, the blood supply must be
preserved during the neck dissection. The horizontal (shoulder)
fasciocutaneous flap is useful for coverage of neck.
The flap is a ready source of supple skin of uniform thickness
without excessive muscle bulk, which lends itself to more contouring
during reconstruction. The donor area is usually hairless and may be
closed primarily in most cases. Scars in this area are not obvious.
The main disadvantages are the short pedicle available, limited arc
of rotation and need for patient repositioning to use the flap. This flap
cannot be used with a McFee incision. Injury or resection of the spinal
accessory nerve causes significant and painful shoulder problems. Failure
to heal donor defects is a dreaded complication.
Latissimus dorsi flap
The latissimus dorsi myocutaneous flap is one of the most useful
and most reliable flaps that have been described. This flap was used by
Tansini (1896) to cover a mastectomy defect. The use of this flap for
reconstruction of head and neck defects was first described by Quillen et
al in 1978.
The latissimus dorsi muscle extends from the tip of the scapula to
the midline of the back posteriorly, and to the iliac crest inferiorly. The
anterior border extends on an oblique line from the axilla to the midpoint of
the iliac crest. The muscle is triangular and originates from the spinous
38

processes of the lower six thoracic vertebrae, the spines of the lumbar and
sacral vertebrae, posterior iliac crest, inferior angle of scapula and the last
four ribs. The upper an anterolateral borders are free. The insertion is into
the humerus in the intertubercular groove.
The thoracodorsal artery, the terminal branch of subscapular artery
(which arises from the axillary artery), is the dominant vascular supply. Its
vascular arrangement allows the muscle to be split into medial and lateral
flaps. The secondary vascular source is from a few perforators from the
posterior intercostals and lumbar vessels.
To reach defects in the head and neck region, the skin island must
be placed on the anterolateral margin of the inferior half of the muscle.
This area has the least number of perforating vessels. The size of the
island conforms to the size of the defect, and the location of muscle
paddle is distal enough to reach the defect by rotating the flap.
The initial incision is along the anterolateral border of the muscle.
The skin island is outlined and the incision carried to the muscle. Then a
skin incision is made connecting the island with the axilla along the
proximal border of the muscle. Lateral and medial skin flaps are raised as
needed to expose the muscle. The muscle is separated from the
underlying bones. As the dissection proceeds upwards, the thoracodorsal
pedicle is identified in the undersurface of the muscle.
Several different routes to the head and neck are available
depending on the location of the defect. The flap may be tunneled over the
pectoralis major and clavicle but under the overlying skin; or under the
39

pectoralis major but over the clavicle. Care should be taken to protect the
artery and the skin island. The flap is delivered to the defect and sutured
in place. The skin defect on the back may be closed primarily or split-skin
grafted. Drainage catheters are used under the back flap and also in the
neck region.
The latissimus dorsi myocutaneous flap has been used to repair
defects of the entire cheek, hemiface, oropharynx, mandible, segments of
cervical oesophagus, posterior scalp, pharynx, etc. Its major advantage is
the large amount of available skin and the wide arc of rotation. The blood
supply is reliable, the muscle thick and the skin hairless. The main
disadvantage is the need to reposition the patient during the operation.
The donor site skin grafts occasionally fail to take.
Prior surgery in the axilla or radiation to the axilla makes the use of
this flap unwise. Also, patients who have undergone thoracotomy with
latissimus dorsi transection, are not candidates for this flap.
Osteomyocutaneous flaps
The osteomyocutaneous flaps consist of a segment of underlying
bone pedicled on myocutaneous flaps, and are used for simultaneous soft
and hard tissue reconstruction.
Sternocleidomastoid with clavicle/sternum
This flap was first described by Conley in 1972. He used all or part
of clavicle and a part of sternum with sternocleidomastoid muscle. The
main indications are for defects secondary to traumatic mandibular
40

fractures, mandibular osteoradionecrosis and mandibular defects following
cancer ablation.
The technique involves raising the contralateral flap with clavicle or
sternum or both to reconstruct the mandible. The flap is raised preserving
the occipital, posterior auricular and superior thyroid artery.
The main advantages are the provision for one stage reconstruction,
and the rapid and technical ease of elevation of the flap. The
disadvantages include loss of protection of great vessels, and the minimal
donor site morbidity. The obvious limitation for its use is the presence of
contralateral positive neck nodes in malignancy, in which case the
sternocleidomastoid muscle will have to be excised.
Pectoralis major with rib
This flap was first developed by Ariyan et al in 1980. It is based on
success with pectoralis myocutaneous flap and good periosteal supply to
ribs form the pectoralis muscle.
The pectoralis muscle has three heads of origin the clavicular head
from anteromedial clavicle, sternocostal head from anterior sternum and
six upper ribs and abdominal head is variable from the external oblique
muscle. It is inserted into the lateral lip of the humerus and deep fascia of
the arm.
Vascularised upper six ribs based on the periosteal blood supply
can be harvested along with pectoralis flap for maxillary and mandibular
reconstruction. Usually 5
th
or 6
th
ribs are harvested with the muscle flap.
41

This flap combines the advantages of the versatile and durable
myocutaneous flap and the presence of osseous tissue for bone
reconstruction. Large skin island with soft tissue bulk is available for oral
and facial reconstruction. Its long pedicle allows it to be mobilised to
greater distance.
The disadvantages include poor bone stock for mandibular
reconstruction, limited vascular supply to the bone, chance of
pneumothorax, poor contour stability and limited dental restoration
potential and the significant donor site cosmetic defect.
Trapezius with spine of scapula
Trapezius osteomyocutaneous flap for mandibular reconstruction
was first described by Panje and Cutting in 1980. Here, the spine of
scapula is harvested along with trapezius muscle for oromandibular
reconstruction.
It has the advantages of a versatile and durable myocutaneous
pedicle in the muscular part, with a dependable vascular supply. Other
advantages are the location of the flap close to the operating site, low
morbidity of donor site bone defects less than 12 cm, provision for large
skin island and improved bone stack in comparison to rib with pectoralis
flap.
Disadvantages include the requirement for repositioning during the
procedure for flap harvest, inadequate bone stock for defects larger than
12 cm, limited manipulation of bone relative to soft tissues and the
42

frequent complication of shoulder morbidity due to acromion damage and
denervation.
Latissimus dorsi with rib / iliac crest
Maruyama et al (1985) described the use of this flap with rib for
reconstruction of a complete hemimandibulactomy defect secondary to
osteoradionecrosis. The vascular supply of the rib graft comprised of
perforating branches from the posterior intercostal artery and the
periosteal supply from the thoracodorsal artery. Follow-up bone graft
biopsy at 3 months revealed viable bone.
An innovative latissimus dorsi myocutaneous–iliac crest bone flap
was described by Magi et al (1986). A segment of iliac crest was
transplanted beneath the muscle 2 months before raising the flap. The
composite flap was then used for mandibular reconstruction. The results
were disappointing in their two patients.
Temporalis with calvarium
As early as 1890, Konig and Muller reported the clinical applications
of calvarial bone transfers with osteocutaneous flaps. Watson-Jones in
1933 transferred calvarial bone on periosteal pedicles to repair depressed
skull fractures. Conley (1972) designed an osteomuscular flap consisting
of temporalis muscle and clavarial bone. The bone-muscle-fascial-
periosteal flap was developed by McCarthy and Zide in 1984.
The temporalis flap has an excellent arc of rotation about the
coronoid process. It can be rotated to reconstruct the defects of orbit, oral
cavity and also of face.
43

The advantages of this flap include minimal morbidity of the donor
site and large volume of bone with a curvature. It is claimed that the
viability of the membranous bone is superior to the endochondral bone.
The flap’s weaknesses include its bulkiness, anterior mobilisation
requirements, donor site volume defect and possible limitation of jaw
movement. Choung et al (1991) introduced a bone–fascial–periosteal flap
to overcome these limitations.
44

Free flaps
Microvascular techniques for anastomosis of small vessels allow the
transfer of skin flaps from distant sites. Free vascularised tissue transfer
is a major advance in maxillofacial reconstruction by providing tissue with
inherent ability to heal. These flaps are particularly useful in cases where
adequate tissue for reconstruction is not available in the vicinity of the
defect, and where the recipient bed is not vascular enough to facilitate the
take of an ordinary flap.
An artery and vein of adequate size and in proximity to the defect
should be chosen for microvascular anastomosis. It is usually possible to
choose vessels with adequate pedicle length for donor vessels to reach.
Delicate handling of the vessels is essential to prevent damage to the
intima. The recipient vessels may be sutured end-to-end or end-to-side to
the donor vessels. Branches of the external carotid artery and internal
jugular vein may be used as recipient vessels.
Jejunum
The small intestine has been used for reconstruction of cervical
esophagus to provide a reconstructive pharyngeal conduit following
pharyngolaryngectomy and for resurfacing the oral cavity defects.
A segment of proximal jejunum is harvested along with mesenteric
vasculature, which is capable of providing a single arterial and venous
pedicle suitable for anastomosis. After the harvest of jejunum the
continuity of the intestine is restored.
45

The advantages of this flap for intra-oral reconstruction is that the
transferred tissue has a mucosal surface which secrete mucous and that
the vascular pedicle is of adequate caliber for anastomosis.
The disadvantages of this flap are that it requires abdominal
operation and the operating period is prolonged.
Groin flap
This was the first free tissue transfer performed with micro-vascular
technique. First described by Wood in 1863 and reevaluated by McGregor
and Morgan in 1973 as an axial pattern flap. The skin overlying the Iliac
crest and ilium are perfused by arteries which anastomose in the vicinity of
the anterior superior iliac spine, the superficial and deep circumflex
arteries and the superior gluteal artery.
The standard groin flap is based on the superficial circumflex iliac
artery, usually a branch of femoral artery. Venous drainage is by a
superficial and deep system of veins. Large area of tissue meassauring up
to 24 by 16 cm can be successfully transferred. The donor defect is
minimal. It can also be used as a de-epithelised flat flap for repair of soft
tissue defects.
The disadvantages are a variable pattern of vascularity, short
vascular pedicle and the excess bulk of the groin.
Lateral arm
The lateral arm provides a free flap based on the posterior radial
collateral artery, which is a direct continuation of the profunda branchii.
The flap is thin and pliable and consists of fascia and skin. The posterior
46

cutaneous nerve of the arm accompanies the artery and can be transferred
with the flap.
Several branches from the artery provide a periosteal blood supply
to the humerus and can allow harvesting of a small segment of
vascularised bone.
Latissimus dorsi
Described by Maxwell (1978), the flap consists of latissimus dorsi
muscle and its overlying skin paddle. The dominant vascular pedicle is the
thoracodorsal artery, arising from the subscapular artery (branch of
axillary artery). The subscapular artery and its branches offer a variety of
flaps suited for free tissue transfer. Venous drainage is by venae
comitantes, which accompany the thoracodorsal and axillary arteries.
The flap offers a large amount of tissue with a good quality skin
element, thus making it useful to fill large and full thickness head and neck
defects. It is very reliable and is easy to use. The disadvantages are the
bulk, risk of seroma formation and functional incapacitation in certain
occupation groups (athletes and tennis players). The muscle bulk settles
slowly over time as the denervated muscle shrinks.
Rectus abdominis
The rectus abdominis muscle can be transferred either as a muscle
flap or as a myocutaneous flap. The muscle is supplied by the superior
and inferior epigastric vessels. The larger pedicle is the inferior epigastric,
which forms the basis of the rectus abdominis free flap.
47

This flap is very useful in cases where an extensive area of soft
tissue cover is required. Alternatively, it is possible to take a small amount
of muscle that contains two or three perforators, which supply a large area
of skin. It has a consistent, reliable, long vascular pedicle with vessels
that are easily dissected.
The removal of the muscle causes some abdominal weakness, and
ventral herniation is frequent. The flap is often too bulky.
Dorsalis pedis
First described by O’Brics and Shanmughan in 1973, this
fasciocutaneous flap transfers skin, superficial fascia from the dorsum of
the foot using as its vascular basis the dorsalis pedis artery and the
superficial veins, which pass proximally into the long saphenous system.
The vascular pedicle of this flap can be dissected from the leg to a length
of at least 10 to 15 cm. If additional venous drainage is required, the
saphenous vein may be included in the flap.
It has been used both to provide skin cover and an intra-oral lining.
Second metatarsal bone can be harvested along with the flap for
mandibular and temporomandibular reconstruction.
Iliac crest – composite groin flap
The iliac bone along with its overlying skin paddle can be harvested
as a free flap based on either the superficial or deep circumflex iliac
arteries. This flap was first described for mandibular reconstruction by
Daniel (1978). Taylor et al (1983) showed the superiority of the deep
circumflex iliac arteries. The segmental nature of the vessels supplying the
48

iliac crest allows maintenance of viability with multiple osteotomies. The
deep circumflex iliac artery arises from the external iliac artery just above
the inguinal ligament. The venous drainage of the flap consists of two
venae comitantes which may unite to form a single trunk.
The flap provides an abundance of well-vascularised iliac bone
(corticocancellous), which can be used to adequately reconstruct large
mandibular defects including hemimandibular or even total mandibular
defects if bilateral flaps are used. The donor defect is minimal.
The chief disadvantages are the risks of necrosis of the skin
segment and abdominal wall herniation. The dissection is tedious.
Radial fore-arm flap
The radial forearm free flap, described by Soutar (1983), is a
fasciocutaneous flap based on the radial artery. The venous drainage is
dual; the paired venae comitantes accompanying the radial artery and the
subcutaneous veins. These two systems communicate and either can be
used to provide adequate venous drainage.
The entire fascia and skin of the volar aspect of the forearm can be
used for microvascular transfer. The periosteum of the radius is supplied
by a rich network of vessels from the radial artery, and a vascularised
segment of radius lying between the insertion of the pronator teres and the
radial styloid may be transferred with the flap.
The flap is extremely reliable, has a constant anatomy, and has
large diameter vessels. A large amount of thin, pliable skin may be
harvested. The blood supply to the bone and skin arises from a different
49

system of perforators, thus permitting multiple osteotomies without
compromising skin viability. Furthermore, the segmental blood supply
preserves vascularity of all segments. This flap is most useful in mucosal
defects of the floor of the mouth and anterior mandibular defects in
combination with floor of the mouth defects.
The main disadvantage is the need to interrupt the radial artery and
the resultant compromise to vascularity of the hand. The amount of bone
available for use is limited to 10 or 11 cm in length. This limits its use to
small defects.
Scapular / parascapular flap
The scapular and parascapular free flaps are based on transverse
and descending branches, respectively, of the circumflex scapular artery,
which is the largest branch of axillary artery. Each artery is usually
accompanied by two venae comitantes.
The flaps are of fasciocutaneous type, though variable amounts of
bone or muscle (serratus anterior) can be included in selected cases.
Large cutaneous paddles based on either of the arteries may be raised.
The descending branch provides multiple segmental vessels to the
periosteum of the lateral border of scapula, allowing a vascularised
segment of bone to be harvested.
The flap is relatively thin, the anatomy reliable, and a large area is
available for transfer. It also allows a second large myocutaneous area
based on thoracodorsal vessels to be harvested. The donor site can be
closed primarily and the flap hidden in clothing.
50

The chief disadvantage is the need to reposition the patient. The
dermis of the back is thick, and the scar tends to widen in course of time.
Fibula free flap
Introduced in 1975 by Taylor et al, the free fibula flap was one of
the earliest osseous free flaps with extensive application in long bone
reconstruction. In 1983, Chen and Yan described the vascular supply of
free fibular osteocutaneous flap. Hidalgo (1992) reported the first
application in mandibular reconstruction. Hayden (1992) described the
nerve supply to the cutaneous paddle and advocated a neurosensory
potential. He also demonstrated successful primary osseointegration with
titanium implants in the fibula.
A long segment of fibula can be harvested as a free flap based on
the peroneal artery. The blood supply is rich, consisting of both medullary
and periosteal vessels, which allows osteotomies without jeopardising
viability. The branches of the common peroneal nerve, the lateral
cutaneous nerve of the calf or the sural communicating nerve may be
harvested with the flap to provide a neurosensitised skin paddle.
The dissection is straightforward and provides vessels of moderate
size. The bone is strong and can even be folded on itself to provide a
double strut. Donor site morbidity is unusual as long as the distal 5 to 6
cm of fibula is left for ankle support.
51

Reconstruction of specific regions
The different techniques used in reconstruction of head and neck
are broadly classified as follows: -
Intra-oral reconstruction techniques
Reconstruction of tongue
1. S uper f ic ial t umors of t ongue
a. Primary closure
b. STSG
c. Healing by secondary intention
2. P ar t ial gloss ect omy w it hout mandibulec t omy
a. Primary closure
b. Local flaps eg. Nasolabial flap
c. Regional flaps eg. Masseter flap
d. Distant flap eg. Pectoralis major flap
e. Free flap eg. Radial fore arm flap, Dorsalis pedis
flap.
3. P ar t ial gloss ect omy w it h ant er ior mandibulec t omy
a. Free Osseocutaneous flap eg. Osseocutaneous
medial forearm flap
4. P ar t ial gloss ect omy w it h pos t er ior mandibulec t omy
a. Regional flap and mandibular swing
b. Distant flap and mandibular swing
c. Distant flap with reconstruction plate
5. T ot al glos s ec t omy + lar y ngec t omy or lary ngoplas ty
a. Regional myocutaneous flap eg. Pectoralis major
flap.
b. Free myocutaneous flap eg. Rectus abdominis flap,
Latissmus Dorsi flap
Reconstruction of the floor of the mouth
1. Reconstruction of the anterior floor of the mouth
52

2. Reconstruction of the posterior floor of the mouth
Reconstruction of the buccal cavity
1. Using temporalis myofascial pedicled flap
2. Using buccal fat pad.
53

Closure of oro-antral fistula
Management of ac ut e or o- ant r al c ommunic at ion
1. Socket edge reduction and suturing
2. Use of supportive packs or protective plate
Management of chr onic / es t ablis hed f is t ulas or Lar ge OA C
1. Local flaps
a) Buccal flaps
(i) Advancement flap (Welty, Von Rehrmann & Berger).
(ii) Modified advancement (Laskin & Robinson)
(iii) Sliding flap (Moczair)
b) Palatal flaps
(i) Straight advancement
(ii) Rotational advancement
(iii) Hinging and Island flaps
(iv) Palatal submucosal connective tissue flap.
c) Bridge flap
d) Combined local flaps
(i) Double flap
2. Distant flaps
a) Tongue flaps
(i) Anteriorly based
(ii) Posteriorly based
(iii) Laterally based
b) Temporalis muscle flap
c) Buccal fat pad flap
d) Osteoperiosteal flap
3. Grafts
54

a) Autogenous bone grafts
b) Allografts
(i) Gold foil.
(ii) Tantulum foil
(iii) Gold plate
(iv) Poly methyl methacrylate
(v) Hydroxy apatite blocks.
(vi) Fibrin glue.
Extra-oral reconstruction techniques
Reconstruction of midfacial defects
C las s if ic at ion of mid- f ac ial def ec ts
Type I Loss of midfacial skin only; buttress of the maxilla, orbital floor and
palate intact
Type II Partial maxillectomy with intact palate and orbital floor
Type III Partial maxillectomy with resection of a portion of palate; orbital floor and
Lockwood’s ligament remain intact
Type IV Total maxillectomy and palatectomy; orbital support remains intact
Type V Total maxillectomy and palatectomy with loss of orbital support or eye.
Midface defects produce significant functional and aesthetic
consequences. Feeding and speech can be a problem. Oro-antral fistula
and velopharyngeal incompetence can develop. Resection of Lockwood’s
ligament may result in enophthalmos and orbital dystopia.
T y pe I def ec t s
Patients with type I defects suffer from variable loss of soft tissues
of cheek and lips. Bony framework is not affected. Palate and orbital floor
remain intact.
55

If the defect is small and the surrounding tissue lax, primary closure
may be possible. Small rhomboid flaps or subcutaneous pedicled flaps are
used for superficial midface defects. Tissue expansion has been used
successfully for superficial defects of cheek. This technique affords
excellent colour and texture match with least amount of scar tissue
formed.
For larger defects, regional or distant flaps like pectoralis major,
deltopectoral, latissimus dorsi, temporalis and forehead flaps have been
used with success.
T y pe I I & I I I def ec t s
The traditional method of reconstructing these defects is by skin-
grafting the internal cavity and the placement of a maxillofacial prosthesis.
The prosthesis usually serves as a denture and a palatal obturator, closing
the oro-antral fistula and providing projection of midface. An adequate
residual palatal arch and surrounding soft tissues are required to support
the prosthesis. As the size of the defect increases, problems with stability
often are exacerbated especially if the prosthesis must function as a
support for orbital structures or reconstruct a missing cutaneous segment.
Some limited maxillectomy defects may be reconstructed using
autogenous tissue. Choung et al described the use of ipsilateral or
bilateral temporalis muscle flaps. Calvarial bone may be included in the
flap, making it a myo-osseous flap. The zygomatic arch may be cut
anteriorly and posteriorly so that the muscle is mobilised to its insertion on
56

the coronoid process. The composite flap is passed into the oral cavity
and sutured to the remaining septum or palate.
T y pe IV def ec ts
Individuals with extensive defects are best served by reconstruction
with regional or distant flaps to obturate palatal defects, to provide
complete soft tissue coverage and to aid in retention of a prosthesis. The
reconstuctive goal is to provide a healed wound, separation of oral and
nasal cavities, support for intracranial contents and obliteration of
maxillectomy defects.
A variety of pedicled regional flaps have been advocated for
midface resurfacing. They include the deltopectoral flap, pectoralis major
myocutaneous flap, forehead flap etc.
Free tissue transfers advocated to repair midface defects include
the free omental flap combined with non-vascularised bone grafts, the free
latissimus dorsi flap, the rectus abdominis flap, the free scapular
fasciocutaneous flap and the free fibular osseocutaneous flap.
Each donor site has its own advantages and disadvantages. The
rectus abdominis flap allows a two-team approach, thus reducing
operating time. Both the latissimus dorsi and scapular flaps require a
change in the patient position, but they provide long vascular pedicles and
large volumes of tissue. By de-epithelising intervening segments of dermis
between cutaneous paddles, the palatal, maxillary and orbital components
of the defects may be simultaneously reconstructed.
57

Isolated soft tissue repair without bony reconstruction tends to lose
midfacial projection and result in sagging. Coleman and Sandham noted
that by preserving the angular artery to the tip of scapula, vascularised
bone could be harvested along with the scapular flaps. This helps in
closure of massive midface defects. The muscular component helps in the
closure of dead space of maxillary sinus. The cutaneous portion is used to
resurface face and palate.
T y pe V def ec ts
When orbital floor and Lockwood’s suspensory ligament are
resected, reconstruction should obliterate the orbital cavity and restore
facial contour.
Ilankovan and Jackson described the split thickness vascularised
calvarial bone either pedicled on the temporalis muscle or with a free flap
based on superficial temporal artery, to reconstruct the floor of the orbit.
The temporoparietal fascial flaps have been used for orbital and
eyelid reconstruction. The free vascularised forearm flaps have been used
to reconstruct the orbital floor and provide overlying soft tissue.
In extensive maxillectomy defects, soft and hard tissue
requirements are massive, and free tissue transfer is preferred. It offers
the advantage of one-stage reconstruction without the constraint of fixed
point of rotation observed in regional flaps.
58

Reconstruction of the lip
The successful reconstruction of the lower lip must meet some
criteria.
1. The reconstructed lip should be sensate.
2. Retain sphincter or muscle function.
3. Oppose vermilion to vermilion of the upper lip in a
watertight continent seal.
4. Allow sufficient space for food, dentures and so on.
5. Acceptable aesthetic appearance.
Defect of up to one third of the lip can be closed primarily. Larger
defects require tissue transfer, and the preferred donor site is adjacent
cheek or upper lip.
D ef ec t of 30% t o 50%: -
In moderate-sized defects, reconstructive techniques that use lip
tissue will yield an excellent result. Transfer of upper lip tissue (lip switch)
pedicled on the labial artery (Abbè technique), preserving the oral
commissure, or rotated around the commissure by the Estlander method
can be accomplished.
Another method is Karapandzic technique of advancement rotation
of segments of skin, orbicularis and mucosa – after division of other
supporting muscles. This procedure redistributes remaining lip, yet
preserves the motor and sensory function. The principal disadvantage has
been the relative microstomia and the necessity of extensive circumoral
incision and dissection.
59

D ef ec t s of 65% t o 80%: -
A widely used technique is the advancement of the cheek tissue by
the Webster- Bernard approach. Initial results are good; the continued
chronic tension of the closure has culminated in a tight lower lip that
functioned poorly.
A more satisfactory procedure for defects of this magnitude has
been the Karapandzic lip rotation, although a microstomia is inevitable.
Denture construction should be modified here.
The Karapandzic approach essentially is dissection of the remaining
lower lip segment, modiolus (bilateral) and lateral upper lip tissue in the
neurovascular pedicles and advancement of these components to
reconstruct the lower lip deficiency. The method requires incisions
extended laterally and transversely in adjacent cheek tissue, curving
upward into the nasolabial folds and into the lateral upper lip toward the
alar base. Once skin incisions are made, the residual depressions and
elevations are divided, beneath which lie both the facial nerve and artery
branches to be preserved. Similar incisions need to be made in the
mucosa at the labial sulcus, extending into the labial mucosa.
After mobilization of the segments, closure of donor site defect in
the cheek is done in a V to Y fashion. Microstomia produced can be
corrected later with a lip-switch procedure.
T ot al r es ec t ion of t he lip: - ( K ar apandz ic appr oac h)
A massive resection of the lip, chin and mandible must be
reconstructed with distant flaps and requires reconstruction of the lower lip
60

as a separate unit. The transfer of composite flaps of skin and bone
revascularised and the result allows for institution of radiotherapy in the
early post postoperative period.
Reconstruction of the lip and chin as a single unit can be
accomplished with a radial forearm flap, incorporating a plantaris tendon
as a vascularised unit to provide support. The tendon is sutured into either
modiolus (if still present). The provision of sensation to the reconstruction
by suturing the antebrachial cutaneous nerve of the flap into the stump of
the mental nerve has been included.
To effectively reconstruct the lower lip, one must provide not only
skin and mucosa, but also functioning mimetic muscle. Dissection of a
platysma myocutaneous flap with an extended muscle pedicle to include
the cervical branches of the facial nerve would empower the muscle
component. Bilateral flaps would also provide sufficient tissue for mucosa
reconstruction.
Another use of a full thickness inferiorly based nasolabial flap or
bilateral flaps as needed for lower lip reconstruction.
Conclusions
Defects of the head and neck region resulting from severe trauma
and ablative procedures for neoplasms, and those associated with
congenital deformities, can be functionally and aesthetically debilitating.
The primary objective of the reconstructive surgeon is to restore a level of
61

form and function that provides the closest approximation of the patient’s
pre-disease state.
Reconstructive options for patients with large defects have
significantly progressed over the last century. The early primary closure
techniques with their poor aesthetic results have now been replaced by
improved surgical techniques, including composite tissue transfer. Free
tissue transfer has now enabled the surgeon to reliably reconstruct the
defects in areas of inadequate tissue availability and regions of vascular
compromised. Different types of flaps, if used judiciously and carefully,
allows reliable aesthetic and functional reconstruction in specific
situations.
62

References
1. Head and neck microsurgery. William M Swartz & Joseph C Banis.
Williams & Wilkins. 1992.
2. Fundamental techniques of Plastic Surgery and their surgical
applications. 9
th
edition. IA McGregor & AD McGregor. Churchill
Livingstone 1995.
3. Use of flaps in reconstructive surgery of the head and neck. DM
Morris, G Unhold. In Basic Principles of Oral and Maxillofacial
Surgery. (eds.) Peterson, Marciani, Indresano. 1997.
4. Cancer of the Face and the Mouth: Pathology and Management for
Surgeons. IA McGregor & FM McGregor. Churchill Livingstone 1986.
5. Use of local flaps for intra-oral reconstructive surgery. MS Block. In
Basic Principles of Oral and Maxillofacial Surgery. (eds.) Peterson,
Marciani, Indresano. 1997.
6. Grabb and Smith’s Plastic Surgery. 5
th
edition. SJ Aston, RW
Beasley, CHM Thorne. Lippincott-Raven. 1991.
7. Design of local skin flaps. WF Larrabee Jr. In Facial Plastic
Surgery. Otolaryngology Clinics of North America. Oct 1990. 23:5.
8. Soft tissue augmentation and replacement in head and neck.
Otolaryngology Clinics of North America. Feb 1994. 27:1.
9. Reconstruction of the mandible and oropharynx. Otolaryngology
Clinics of North America. Dec 1994. 27:6.
63

10.Pedicled Osseous Flaps. AG Lane, CS Johnson, PD Constantino. In
Augmentation Craniofacial Skeletal Augmentation and Replacement.
Otolaryngology Clinics of North America. Oct 1994. 27:5.
64

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