This document discusses various flap techniques used in ENT reconstruction. It begins with a brief history of flaps and then covers principles of mucosal, skin, bony, lip, nasal, and pinna reconstruction. Different types of flaps are described such as local advancement flaps, rotational flaps, transposition flaps, interpolated flaps, myocutaneous flaps, and examples such as forehead, nasolabial, pectoralis major, deltopectoral, and temporoparietal flaps. Design, vascular supply, and advantages of local flaps are also summarized.

1. Flaps in ENT
DR SAFIKA ZAMAN
DEPT OF ENT & HEAD NECK SURGERY
VIMS,RKMSP

2. Introduction
Indication-
 Trauma
 Infection
 Osteonecrosis
 Tumour excision

3. History
 Forehead rhinoplasty flap nasal reconstruction-
Sushruta (600–800BC)
 Pedicled medial arm flap- Gasparo Tagliacozzi (1546
and 1599)
 Porehead flap - Mc Gregr in 1963 for intraoral
reconstruction.
 Delto-pectoral flap by Bakamjian in 1965
 Pectoralis major flap in 1979 by Ariyan.
Sushruta

4. History

5. Mucosal Reconstruction principle
Oral cavity- maintenance of tongue mobility, lingual sulcus,& mouth opening
avoidance of convexities at sites of concavity.
Oropharynx - prevent nasal escape and hypernasality,
maintaining velopharyngeal competence.

6. Skin reconstruction principle
 Orientate scar lines in the lines of election.
 Reconstruction of aesthetic subunits.
 Replace like with like.
 Avoiding bulk where thinness is needed and
vice versa.
 Avoid tension at close line.
 Consider fixing with underlying structure.
Image- Stell & Maran text book

7. Aesthetic subunits of face
Image- Stell & Maran text book

8. Principle of bony reconstruction
 Two main bone - Mandible and Maxilla.
 Principles of reconstruction-
cosmesis,
speech,
swallowing,
chewing and dental occlusion

9. Bony reconstruction
Decision making in bony reconstruction –
 Defect
 Postoperative radiotherapy
 Radio-necrosis
 Donor vessels in the region
 Fitness
 Height of the native mandible
 Presence of teeth
 Availability of donor sites

10. Lip reconstruction
 Principles-
Oral competence
Labial sensation
Lower sulcus
Aperture size
Cummings -ENT book

11. Nasal reconstruction
 Skin
 Skeletal support
 Mucosal lining

12. Pinna reconstruction
 Partial auricular reconstruction
 Total pinna reconstruction-
multistage, costal cartilage use
 Autologous
 prosthetic.

13. Flap
 Flap is a piece of tissue with its own
blood supply and its survival is not
dependent upon the recipient site.

14. Advantage of a local flap
 Reliable blood supply
 Good skin texture and colour match
 Single stage procedure

15. The reconstructive ladder
Image- Scott Brown’s text book

16. Vascular supply
When the perfusion pressure drops below a critical
closing pressure of the arterioles in the subdermal
plexus, nutritional blood flow ceases and flap
ischemia occurs.

17. Composition of a flap
 Cutaneous
 Fascio-cutaneous
 Musculocutaneous
 Osteomusculo-cutaneous
Free fibula graft

18. Myocutaneous flaps
 Pectoralis major
 Temporalis
 Radial forearm free flap
Radial forearm free flap

19. Method of transfer and design

20. Advancement Flaps
 Slide along a linear vector to close a
defect.
 The flap relies on stretching of tissue for
advancement.
 Utilized in areas of good skin elasticity.
 Point of greatest wound tension is at the
distal border of the flap.
 Uni-pedicle, bi-pedicle, and V-Y flaps

21. Bilateral unipedicle advancement flap
OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
LOCAL FLAPS FOR FACIAL RECONSTRUCTION
Shiayin Yang, Carl Truesdale, Jeffrey Moyer

22. V-Y Advancement flap
OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
LOCAL FLAPS FOR FACIAL RECONSTRUCTION
Shiayin Yang, Carl Truesdale, Jeffrey Moyer

23. Rotational flaps
 Versatile flaps
 Flap is designed in a
curvilinear fashion with the
defect forming a portion of
the flap’s arc of rotation
 The point of greatest wound
tension is at the apex of the
flap Image-double
rotational flap

24. Rotation flap
OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY
LOCAL FLAPS FOR FACIAL RECONSTRUCTION
Shiayin Yang, Carl Truesdale, Jeffrey Moyer

25. Transposition flaps
 Designed remotely from the primary
defect.
 Base is contiguous with the defect
 Greatest wound closure tension is at the
closure site of the secondary defect.
 Small and medium-sized defects of the
cheek and nose

26. Note flap
OPEN ACCESS ATLAS OF
OTOLARYNGOLOGY,
HEAD &
NECK OPERATIVE
SURGERY
LOCAL FLAPS FOR
FACIAL
RECONSTRUCTION
Shiayin Yang, Carl
Truesdale, Jeffrey Moyer

27. Bilobed flap
Bilobe flap with 90° axis of
rota-tion. The first lobe is
equal in diameter to the
defect while the second
lobe has a small-er
diameter

28. Bilobed flap

29. Rhomboid flap

30. Rhomboid flap
OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
LOCAL FLAPS FOR FACIAL RECONSTRUCTION
Shiayin Yang, Carl Truesdale, Jeffrey Moyer

31. Interpolated flaps
 Base of the flap is not contiguous with
the defect.
 Pedicle passes over intervening tissue
to close the primary defect.
 Need a 2nd stage procedure.

32. Para-median forehead flap
Nasal reconstruction for
large defect
supratrochlear artery and
with some contributions
from the supraorbital artery

33. Melolabial flap
Melolabial flap is an interpolated flap that
transfers tissue from the cheek to recon-
struct nasal ala defects.

34. Abbe flap
 Labial artery based flap
 Labial artery runs between the
orbicularis oris and lip mucosa.
 When lip defect > 25%.

35. Post auricular flap

36. Glabellar flap
 V-Y advancement flap.
 Mainly in upper nose & medial eye.

37. Nasolabial flap
Nasal Reconstruction: An Overview and
Nuances
November 2008Seminars in Plastic Surgery
22(4):257-68
DOI: 10.1055/s-0028-1095885

38. Pectoralis major myocutaneous flap
 Flap comprises the pectoralis major muscle, with or
without overlying skin.
 Pectoral branch of the thoracoacromial artery.
 Soft tissue defects of the oropharynx, oral cavity,
hypopharynx, and skin of the neck;

39. Delto-pectoral flap
 DP flap is a pedicled axial fasciocutaneous
flap.
 Based on the internal mammary artery
perforator arteries (IMAP)

40. Temporoparietal flap
 Versatile flap
 Repair craniofacial defect.
 For scalp, auricle, facial soft tissue, orbital,
oral cavity nasopharyngeal, and skull base
defects.

41. Submental flap

42. Hadad-bassagasteguy flap
 common local flap used in the
reconstruction of the meninges
 It is a nasoseptal flap (NSF)
vascularized by the
sphenopalatine artery

43. approach to facial reconstruction
Concepts in local flap design
and classification
Krishna G. Patel, MD, PhD,a
Jonathan M. Sykes, MDb
From the aDepartment of
Otolaryngology-Head and Neck
Surgery, Medical University of
South Carolina, Charleston,
South Carolina; and the
bDepartment of
Otolaryngology-Head and Neck
Surgery, University of California,
Davis Medical Center,
Sacramento,
California.

44. THANK YOU
Life-size wax model of the head and
upper torso, constructed for teaching
purposes, illustrating surgical techniques
including forehead and tubed pedicle
flaps. Part of the New Zealand records
returned to Sidcup in 1989 and
subsequently restored at Madame
Tussaud’s.