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Flap in head and neck surgery part 1
This document provides an overview of flaps used in head and neck surgery. It discusses the history of flap reconstruction from 600 BC to present day. It then covers general concepts in reconstruction including the reconstruction ladder. The rest of the document classifies and describes various types of flaps used in head and neck reconstruction including local, regional, distant, and free flaps. It discusses flap classification based on circulation, contiguity, composition, and contour. It provides details on specific flaps such as forehead, nasolabial, submental island, facial artery myomucosal, temporoparietal fascial, and deltopectoral flaps.
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Flap in head and neck surgery part 1
- 1. Flaps in Headand Neck Surgery 1 Dr Sandeep Shrestha 2nd year Resident ENT
- 2. History • 600 BC: Sushruta – cheek flap for nasal reconstruction • 1920 : Sir Harold Gillies used tubed flap for head and neck reconstruction • 1950 : defects were repaired using a forehead flap or temporal flap combined with split-thickness skin graft • 1959 : Seidenberg described the first revascularized flaps to the head and neck • 1963 : McGregor used forehead flap based on the superficial temporal artery for intraoral reconstruction. • 1965 : Bakamjian first described the deltopectoral flap.
- 3. • 1973: Danieland Taylor reported the first free flap • 1976: Panje and Harashina simultaneously described the use of free flaps to reconstruct defects of the oral cavity. • 1979: Ariyan described the pedicled pectoralis major myocutaneous flap. • late 1980s and early 1990s, the use of osteocutaneous free flaps to reconstruct mandibular defects was advanced.
- 4. General Concepts ofReconstruction • Reconstruction ladder consists of following steps starting from simplest – most complex option 1. Healing by secondary intention 2. Primary intention 3. Delayed primary closure 4. Skin grafts (split or full thickness) 5. Tissue expansion 6. Local tissue transfer 7. Free tissue transfer
- 5. Introduction • A flapis a piece of tissue that has its own blood supply and does not rely on the recipient bed for its survival. • The term "flap" originated in the 16th century from the Dutch word "flappe," meaning something that hung broad and loose, fastened only by one side • Reconstructing defects with poor vascularity • Exposed vital structures and where skin grafts are inappropriate or would lead to poor cosmesis. • Reconstructing defects where post-operative radiotherapy is planned as they are less susceptible than skin grafts to the ill effects of radiotherapy.
- 6. Planning consideration • Anatomyand physiology of the skin including colour, texture, appearance and amount • Local muscle anatomy, vascular supply, nerve supply and lymphatic drainage • Aesthetics of the area • Possible sites for incision placement • Area of local tissue availability in relation to the area to be reconstructed
- 7. COSMETIC SUBUNITS OF THEHEAD AND NECK • The face is divided into multiple cosmetic subunits. • These cosmetic subunits should be taken into account to optimize cosmesis. • Ideally, individual subunits should be reconstructed separately and scars should not cross the subunits if possible. • Graft or flap used to reconstruct one cosmetic subunit and a second graft or flap to reconstruct an adjacent subunit. • If more than 50% of a cosmetic subunit is involved, it may be desirable to excise the entire subunit and reconstruct it to obtain an optimal result.
- 8. • Relaxed skintension lines are those skin tension lines that follow the furrows formed when the skin is relaxed. • They can be found by pinching the skin and observing the furrows and ridges that are then formed. • These relaxed skin tension lines are the same in all people and, where possible, incisions should follow these lines.
- 9. Classification 1. According toCirculation 2. According to Contiguity 3. According to Composition 4. According to Contour
- 10. According to Circulation •Random flaps: supplied by unnamed small vessels usually capillaries • Axial pattern: supplied by a dominant superficial vessel that is oriented along axis the flap.
- 11. According to contiguity •Local flaps: moved from area adjacent to the defect – Random – Axial • Regional flaps: not from the adjacent but same anatomical region as the defect e.g. forehead flap for nasal reconstruction • Distant flaps: from a different part of the body away from the region of the defect • Free Flaps: completely detached from the body and anastomosed to recipient vessels close to the defect
- 12. According to Composition •Cutaneous flap: contain skin only • Myocutaneous flap: contain skin + muscles (pectoralis major/latissimus dorsi) • Fasciocutaneous flap: contain skin + fascia (radial forearm flap)
- 13. According to contour •Advancement flaps: mobilized along a linear axis toward the defect without any rotation or lateral movement • Pivot Flaps move about a fixed pivot point and an arc which is the line of greatest tension of the flap – Transposition flap : flap is moved into an adjacent defect by pivoting around the pivot point, – Rotation flap : where the flap is rotated around the pivot point into the defect
- 14. • Primary defect: A flap is placed • Secondary defect : site from which the flap is raised
- 15. Random Flap • Nonamed specific vascular supply • Most local skin flaps in head & neck • Random not only in blood supply but also in design • In general, height of a flap shouldn’t exceed 1.5 times the length of the base. • Can extend 3-4 times the base in head and neck
- 16. AXIAL FLAPS • Anaxial flap is based on a named arterial pedicle that runs within the skin superficial to the underlying muscle layer, parallel to the overlying skin. • Extremely good blood supply can generally be raised to a much greater length than random flaps
- 17. ROTATION FLAPS • Largearc of semicircle where triangular primary defect represents small arc -1/8th of flap size • Flap elevated & difference in length of 2 sides of defect is made up by suturing with degree of differential tension
- 18. • Larger flap–less differential tension • If Closure – tight- rotation facilitated – back cut • Work well –convex surface • Ideally suited –cheek, submandibular area, upper neck, scalp
- 19. Transposition flaps • Atransposition flap is a flap that is moved into an adjacent defect by pivoting around its fixed point. Types • Z-plasty • Rhomboid flap • Flag or banner flap • Bilobed flap
- 20. Z plasty • Pairof triangular flap in a form of Z • 60 degree • 2 flaps are interposed • Lengthen the area where there is shortage of tissue • To elevate or depress the oral commisure and outer canthus
- 21. Rhomboid flaps • Thedefect is firstly designed as a rhomboid. • Each of the limbs of the defect and the flap being raised need to be of equal length and the angles of the rhomboid need to be 120 degrees and 60 degrees, respectively. • The flap needs to be designed so that the donor site scar lies parallel to the relaxed skin tension lines • Donor defect is closed directly. • A variation of the rhomboid flap is the Dufourmentel flap, which has limbs of equal lengths but angles of 150 degrees and 30 degrees • useful - reconstructing temporal or cheek defects
- 22. Bilobed flap • Esserin 1918 • Consists of 2 transposition flap • First flap is transposed into the primary defect • Second flap is transposed into the secondary defect (the original site of the first flap) • Tertiary defect (the original site of the second flap) is closed directly • Flap should be designed so that the directly closed tertiary defect is parallel to the relaxed skin tension lines
- 23. Flag or bannerflaps • Piece of tissue moved resembles a flag or banner. • These are normally random pattern flaps but can be based on a known artery in some parts of the head or neck. • A glabellar flap is an axial transposition flag flap based on the supratrochlear artery. • This allows the flap length to be three times the base breadth • It is transposed to cover the primary defect and the donor site is closed directly.
- 24. Advancement flaps • Advancementflaps are moved forward into a defect by stretching without any rotation or lateral movement. • Depends on the elasticity of the tissue of the flap(primary movement) and tissue adjacent to the defect(secondary movement) Techniques • Burow’s triangle • V-Y advancement • Panthographic expansion • Advancement Z-plasty
- 25. Burow’s triangles • Singlepedicled rectangular flap –raised & advanced to close defect • Facilitated – excision of Burow’s triangle –either side of base of flap – facilitates movement • Length : breadth ratio 3 : 1 & 4 : 1 • Movement of tissue is facilitated by laxity in surrounding skin
- 26. V-Y advancement • Theflap itself is raised as a triangular (or ‘V’- shaped) flap. • When is it advanced, the secondary defect is closed directly, leaving a ‘Y’-shaped scar.
- 27. Panthographic expansion • Limbsof flap –designed at 120 degree with back cuts at bottom • Looks - Inverted tumbler • Flap is advanced • Donor site closed primarily • Useful –cheek & neck
- 28. Advancement Z -plasty • Problems of skin advancement- once tissue advanced –unless stopped –tends to return • Break up scar with Z- plasty • Useful – defects in lower eye lids – excised as triangle & tissue advanced laterally
- 29. Bipedicled flaps • Receivesa blood supply from both ends as it has two bases. • less prone to necrosis than flaps of similar dimensions which are attached at only one end. • Skin from the upper lid based on both a medial and a lateral attachment is swung down, like a bucket handle, to provide cover for a defect in the lower lid. • To increase the viability of this flap, a strip of the orbicularis oculi muscle can be included, making it a musculocutaneous flap.
- 30.
- 31. Forehead flaps • Axialflap • Provides large areas of skin & subcutaneous tissue • Used –reconstruct defects below level of eyes • Based on ant br of temporal artery -1st flaps – intraoral reconstruction
- 32. • Rarely usednowadays as it gives disfiguring donar site – better alternatives • Most common - Cutaneous axial median forehead flap – supratrochlear artery • Raised & transposed to reconstruct areas in upper medial cheek region & lower half of nose & alar rim • Donor site –close primarily • Cosmetic result excellent
- 33. • Where largerareas of tissue are required, for example in complete nasal resurfacing, larger forehead flaps may be designed (e.g. Millard flying seagull flap), which may be facilitated by prior tissue expansion to ease donor site closure. • Best suited in patients with high foreheads with some lax tissue to facilitate primary closure.
- 36. Nasolabial flap • 1stdocumented –indian Sushruta - 600 BC • True Myocutaneous flap • Workhorse –reconstruction of defects around face & anterior oral cavity • Based on distal br facial artery and its venae commitantes. • Flap designed with a inferior base but can be based superiorly with a more random vascular supply
- 37. • Flap extremelyreliable –based inferiorly • Greatest application intraorally -ant floor of mouth & gingiva • Simple & effective
- 40. Submental island flaps •First described by Martin in 1983 • Axial pattern flap or a free flap for reconstruction of the facial skin or intraoral lining. • Supplied by a branch or branches of the facial artery. • Venous drainage via the facial vein. • Usually designed in the midline, just below the margin of the mandible, with the superior/inferior dimension determined by the ability to close the submental skin. • Dissection is usually initiated on the contralateral side to the planned vessel pedicle.
- 41. • Skin andsubcutaneous tissues are incised down to the level of the investing fascia of the digastric muscle, with the plane of dissection carried in the submental triangle at the level of the mylohyoid muscle. • The ipsilateral anterior belly is usually divided distally and proximally to preserve the blood supply to the flap and the dissection proceeds in a retrograde fashion to the facial artery and vein. • The flap can be tunnelled under the mandible and through the submandibular and submental space for oral reconstruction, or can be rotated or transposed onto the face for soft tissue coverage. • The unique advantage of this flap is its colour match with facial skin and the relative inconspicuous nature of the donor site scar.
- 42. Facial artery myomucosalflaps • First described by Pribaz - 1992. • Composed of oral mucosal and buccinator muscle • Based on branches of the facial artery • Harvested as an inferiorly based flap based on antegrade flow or a superiorly based flap with retrograde flow.
- 43. • The basicharvest technique is to Doppler out the facial artery through the buccal mucosa and map the course of the vessel. • For the inferiorly based flap, dissection begins anterosuperiorly to identify the arterial supply to the upper lip with division of the facial artery at this point and then retrograde dissection, which includes the mucosa, buccinator, facial artery and the tissue and venous plexus that lies between the artery and the muscle. • In the superiorly based flap, the dissection begins inferiorly with visualization and ligation of the facial artery and then a retrograde dissection of the tissues including the buccinator muscle. • A flap of 7–8 cm can be harvested with a thickness of 8–10 mm.
- 45. Temporoparietal fascial flaps •First described by Golovine in the 19th century for orbit reconstruction. • Versatile local rotation or free fascial flap for reconstruction of the head and neck or extremities. • Can be use for microtia repair and auricular reconstruction. • Very thin and pliable flap with minimal donor site morbidity. • The arterial supply - superficial temporal artery
- 46. • The flapis harvested as an elliptical or teardrop shape, above the level of the zygoma. • The inferior limit of the incision is usually the tragus but inferior extensions can be used for extended rotations or if the surgeon wishes to visualize the facial nerve. • The initial incision is started just above the zygoma, extending into the scalp.
- 47. • The planeof dissection is initiated by defining the level of the superficial temporal fascia just below the subcutaneous fat layer in the scalp. • A good landmark is to look for the hair follicles; if they are being transected, the surgeon is elevating the flap too superficially. • Once fully mobilized from the overlying skin, the flap is incised around its periphery and elevated in the plane just above the temporal fascia. • Dissection is carried down to about 2 cm below the arch of the zygoma to ensure an appropriate arc of rotation.
- 48. Clinical applications • Orbitalreconstruction, including the extenteration cavity • Upper and lower eyelids and the eyebrow as a fascio-cutaneous hair bearing flap • Auricular reconstruction, including microtia and traumatic or oncologic deformities • Palate reconstruction • Buccal mucosal reconstruction.
- 49.
- 50. Deltopectoral flap • Bakamjian& Littlewood - 1964 • Fasciocutaneous flap • Axial pattern flap designed on the ant chest wall between line of clavicle & level of ant axillary fold. • Vascular supply – upper 3 or 4 perforating branches – int mammary artery
- 51. Boundaries • Superiorly- clavicle •Laterally – acromium • Inferiorly- line running ant axillary fold to above the nipple • Flap – extend any site in neck & occasionally level – zygoma • It retracts – side to side after – elevated • Elongate slightly over time – particulary patients over 60 yrs
- 52. • Flexibility dueto anomolous pivot point • Territory of perforator vascular system – extend –as far as groove seperating deltoid from the pectoralis major (deltopectoral groove) • Extension beyond this – failure – tip of flap
- 53. • Flap markedout • Elevation – laterally • Pectoral fascia left on flap leaving muscle fibres below absolutely bare • Any br thoracoacromial - encountered- ligated • Monopolar diathermy – judiciously on flap & muscle • Distant site-tube the bridge segment in order to eliminate its raw surface.
- 55. Uses of deltopectoralflap • To allow one stage reconstruction of anterior neck skin • To reconstruct defect by passing as bridge over normal skin. • Once take –occurred -3wks – pedicle is divided & remaining part of flap – returned to donor site or discarded • To reconstruct large defect –lower face & upper neck • Skin cover of an exposed carotid artery • Closure of a pharyngocutaneous fistula
- 56. Contraindications • Internal mammaryartery that has previously been used for coronary artery bypass surgery • Prior trauma or surgery (mastectomy, pacemaker, pectoralis major flap) to the anterior chest wall.
- 57. Advantages • Provides largearea of skin cover • Better colour and texture match compared to free tissue transfer flaps from distant sites • Less bulky than pectoralis major flap • Technical simplicity Disadvantages • Limited arc of rotation • Donor site defect requires skin graft
- 59. Other distal axialflaps • Cervical skin flaps – Used –lower face & cheek • Occipitomastoid based flaps
- 60. Supraclavicular artery islandflaps • First described in 1979 by Lamberty • Local fasciocutaneous flap • Harvested from the skin on the shoulder and supraclavicular area. • Based on a branch of the tranverse cervical artery
- 61. FLAP HARVEST • Thesupraclavicular artery is identified using a hand-held Doppler, usually originating in a triangle bounded anteriorly by the posterior border of the sternocleidomastoid muscle, posteriorly by the external jugular vein and inferiorly by the clavicle. • The vessel is followed out over the clavicle to identify the axis and design of the flap. • The flap is usually designed with a width of 6–7 cm and a length of 20–25 cm from the rotation point.
- 62. • Dissection startsdistally and is carried subfascially over the deltoid until one reaches the anterior border of the trapezius. • The proximal portion of the flap is usually de- epithelialized to allow tunnelling into a facial or intraoral defect.
- 63. CLINICAL APPLICATIONS • TheSAI flap has broad application for external skin defects extending from the base of the neck to the parotid. • Use for reconstruction of oral cavity, oropharynx, hypopharynx • Advantages -Ease of elevation
- 64. Myocutaneous & muscleonly axial distant flaps • Pectoralis major • Latissimus dorsi • Sternomastoid • Trapezius • Platysma Free Flap
- 65.
Editor's Notes
- #4 , the transplant of an autologous skin flap to the lower extremity using the operating microscope.
- #9 They are not visible features of the skin, such as wrinkle lines. The Langer's lines are important from a historical point of view. They represent the skin tension in rigor mortis. The relaxed skin tension lines and Langer's lines do not correspond in many areas of the body
- #11 L:W:1:1 Face L:W:2:1 the dermal and subdermal plexus.
- #12 ). Flaps located near the defect but are not in immediate proximity Deltopectoral Cervical occipitomastoid
- #14 Rotation flaps: pivot around a point at the base of the flap. Transposition flap: mobilized to an adjacent defect over an incomplete bridge of skin. Examples of transposition flaps include rhombic flaps and bilobed flaps. Interposition flaps: mobilized to an adjacent defect over an incomplete bridge of skin whish is also elevated and mobilized. An example of an interposition flap is a Z-plasty. Interpolated flaps: mobilized either over or beneath a complete bridge of intact skin via a pedicle.
- #15 Secondary defect can be closed directly or grafted or another flap is placed.
- #16 Cutaneous flap With in head and neck there is an extensive subdermal vascular plexus.E.g Bilobed flap, rhomboid,Z-palsty flap
- #17 Arterial flap , which is determined not only by their length and breadth ratio, but also by thevascular territory of the vessels that supply them. Because of this, they can generally be raised to a much greater length than random flaps and can therefore be used to move skin over a greater distance
- #18 Large flaps that rotate into the primary defect. The volume of tissue raised in the flap is high when compared to the defect being closed. Normally, the flap is a semicircle and the primary defect is ‘triangulated’ or designed as a triangle, adjacent to the flap. Geometrically, the flap circumference should be at least eight times the width of the defect to allow closure of the donor site; However, in practice, it is best to design the flap as large as possible as the direct closure of the donor site relies on tissue redistribution and tissue elasticity. These flaps are useful for dealing with defects of the scalp or cheek
- #19 Occasionally, the use of a Burow triangle or a back cut may be needed. A back cut releases a rotation flap that is too tight by decreasing the tension at the base of the flap, thus moving its pivot point towards the defect. This decreases the tension of closure at the site of the primary defect. A back cut that is taken too far, however, may significantly decrease the width of the flap, which will increase the chance of devascularizing it.
- #22 Limberg in 1966 Skin pinch Rhomboids –can be designed as double or triple flap (swastika flap) – to close larger defects
- #23 Theoretically, the bilobed flap uses less tissue than any other method of wound closure and because of this minimizes tension at the primary defect. Difficult flap to design Long axis of larger flap is at right angle with the long axis of the smaller flap Length is same where as width is half the larger one Use In the nose or cheek or reconstruction of the auricular defect Use in where there is insufficient soft tissue to close the Excellent result – properly executed Best way to reconstruct nose - with skin of nose
- #24 A number of small transposition flaps can be used around the face and generally the donor site is closed directly.
- #26 These help in allowing the flap to advance, as demonstrated by a Rintala flap being used to cover a defect of the nasal tip.
- #27 An example of one such flap is the nasolabial V–Y advancement flap shown, which is an axial flap based on either the superior labial artery or the angular artery.
- #30 An example of this is the Tripier flap for lower eyelid reconstruction The ideal use of a bilobed flap is where there is tissueavailable locally and where it is important to avoid producingtissue stretch. The bilobed flap is most commonly used to deal with defects at the tip of the nose. Although there is some spare tissue around this area, the nasal tip can become displaced if skin is imported to cover defects here as a local flap.26
- #32 Original form as described by mcgregor The flap includes epidermis, dermis, subcutaneous tissue, frontalis muscle and associated fascia. supratrochlear artery, which exits the orbit 1.7- 2.2cm lateral to the midline at the level of the superior orbital rim Traumatic cause of nasal defect, excision of nonmelanotic cancer The median forehead flap is harvested from the mid forehead and has a wide pedicle based in the center of the forehead, which originally captured both supratrochlear vessels as seen in the image below. The paramedian forehead flap is designed around a narrower pedicle based on the medial brow area over the superior/medial orbital rim. The skin paddle and pedicle are aligned vertically, with the supratrochlear notch in the paramedian position of the forehead as seen in the image above. The resultant donor scar is oriented vertically and aligns with the medial brow. The midline forehead flap is a hybrid of median and paramedian flaps, with the skin paddle harvested from the precise center of the forehead. The associated pedicle runs obliquely and is based on a unilateral supratrochlear vessel and collaterals from the medial brow area
- #35 A is a nasal defect template (from suture package). B is the template transferred to the precise midline of the forehead. Pedicle division is performed safely after 3 weeks as seen in the image below. One must aggressively thin the cephalic border of the flap from above to best match surrounding skin thickness; however, exercise caution to avoid extending the level of undermining beyond 50% of the original skin paddle. The vascular supply to the flap is retrograde from the recipient bed, and excessive undermining can jeopardize viability. The original nasal defect wound is freshened, and the superior portion of the skin paddle trimmed to fit the remaining defect. The pedicle base is amputated, thinned, and then inset back into the medial brow region.
- #37 true myocutaneous flap pedicled on the facial artery, single-stage reconstruction of oral cavity defects or to staged reconstructions of facial defects The redundant skin extending from the medial canthus of the eye to the inferior margin of the mandible (nasolabial sulcus and nasofacial groove) defines the donor site for the nasolabial flap. This area is relatively hairless except for the lower cheek in males, an important consideration in oral cavity reconstruction. The flap itself is comprised of skin, subcutaneous tissue and the underlying musculature. The facial artery is deep to the platysma, risorius, zygomaticus major and minor, levator labii superioris, and levator labii superioris alaeque nasi muscles. The artery is superficial to the mandible, buccinators muscle, and levator anguli oris muscle. The position of the artery deep to the majority of facial mimetic muscles suggests that the nasolabial flap may incorporate this muscle layer and be developed as a true musculocutaneous flap.
- #38 The design usually places the most medial limit of the flap in the nasolabial fold with the superior limit approximating the medial canthus of the eye. The medial to lateral dimension of the flap is determined by the defect to be reconstructed and the ability to primarily close the donor site. Flap elevation is usually initiated distally with a retrograde dissection above the plane of the facial musculature. In the intraoral application a tunnel is placed traversing the facial muscles and buccinators, allowing the inferiorly based flap to enter the oral cavity This flap is extremely reliable when based inferiorly, with a relatively inconspicuous donor site, particularly when bilateral flaps are used. Its greatest application intraorally is for the anterior floor of mouth and gingiva, where its use is both simple and effective. The donor site for this flap is best tolerated in elderly patients with rhytids that mask the donor site. The flap is then tunnelled through the buccal space to repair the intraoral defect,
- #39 A fusiform flap is marked ensuring that the medial border of the flap is on the nasofacial groove (Figures 1, 4, 5). A pencil Doppler probe may be useful to locate and delineate the course of the artery. Average flap dimensions are 2.5cm in width and 6cm in length. The width may be closer to 5cm when the facial skin is very redundant. The superior border of the flap is inferior to the medial canthus along the nasofacial junction. Placement of the inferior border depends on the nature of the defect. For floor of mouth reconstruction, the inferior border of the flap should be at the superior border of the mandible; reconstruction of palatal defects, however, requires the inferior border to be approximately at the level of the oral commissure.
- #40 Tumour excised, flap is outlined famale :nasolabial fold,male laterally.flap is elevated skin,subdermal flap and underlying facial muscle .primary suturing.3 weeks later pedicle is ready for division and insetting of flap.
- #41 that pass either over or through the submandibular gland, traversing medially on the mylohyoid muscle and then deep to the anterior belly of the digastric muscle to provide a perforator- based arterial supply and venous drainage to the submental skin. The flap comprises skin, subcutaneous fat, platysma muscle, submental fat, and lymph nodes; the anterior belly of digastric and mylohyoid muscles may also be included. Axial fasciocutaneous flap that includes skin, subcutaneous tissue, platysma, and fat and is pedicled on the submental artery and veins There can be occasional problems with venous congestion, particularly in the reverse flow design, because of valves in the facial vein
- #42 Used for facial, oral cavity, oro- and hypopharyngeal soft tissue defects.
- #43 The anatomy of this flap is based on the buccinator muscle and its relationship to the facial artery. The buccinator is covered medially by the submucosa and mucosa and laterally by the external lamina of the muscles of facial expression, the masseter, the buccal fat pad, and the facial artery and vein. The flap is about 5mm thick, and comprises buccal mucosa, submucosa and buccinator muscle, with the feeding vessels and vascular plexus. . The facial artery, a branch of the external carotid artery, enters the face by curving around the lower border of the mandible at the anterior edge of the masseter muscle. It then follows a tortuous course, passing superiorly and anteriorly to a position just lateral to the commissure of the mouth. At this point it lies deep to the risorius, zygomaticus major muscle and the superficial lamina of the orbicularis oris muscle. It lies superficial to the buccinator muscle and the lateral edge of the deep lamina of the orbicularis oris muscle. At this point in its course it gives off multiple perforating vessels to the cheek and the superior labial artery. It continues superiorly to the angular artery, which reaches the medial canthus. It has communicating branches with the buccal and infraorbital branches.
- #44 The FAMM flap is ideally suited for reconstruction of small mucosal defects in the oral cavity and in particular the mucosa of the lip. The flap can also be rotated across the alveolus to close small defects of the floor of mouth or tongue, as well as the palate. via the pterygoid plexus and internal maxillary (7*5cm)
- #45 Anterolateral floor of the mouth
- #47 There is some variation in venous anatomy, with a small percentage of patients having venous drainage through the post-auricular vein or occipital veins. The temporoparietal fascia (TPF) lies just under the subcutaneous tissue of the lateral scalp. The fascia has an inner and an outer layer, with the artery and vein entering between the inner and outer layers and then coursing vertically in the outer layer of the fascia. The outer layer of the TPF extends as the superficial muscular aponeurotic system (SMAS) below the zygoma. A thin muscular layer (the superficial auricular muscle) separates two parts of the outer layer of the fascia below the temporal line. The inner layer of the TPF contains a dense vascular network, which originates from the outer layer. Two nerves have an anatomic relation to the flap: the auriculotemporal nerve, a branch of V3, lies within the superficial layer of the TPF and theoretically could provide for a sensate flap; and the frontal branch of the facial nerve traverses over the zygoma in the same plane as the frontal branch of the superficial temporal artery and can be injured if the dissection is carried too far forward in the plane of this vessel. For flap harvest the patient is usually positioned in the supine position, with the drape line along the vertex of the scalp leaving the post-auricular area exposed. The important landmarks :arch of the zygoma, the pinna and the usual landmarks of the facial nerve.The artery usually lies just in front of the pinna and is easily palpated or detected with the Doppler in the this location. The artery ascends vertically to the apex with a frontal branch coming off 1–3 cm above the zygomatic arch. The incision is placed just posterior to the position of the vertical branch and can be either a straight or curvilinear incision into the scalp or ‘Y’ shaped for larger teardrop-shaped flaps.
- #48 The surgeon harvesting this flap for the first time must take great care not to incise too deeply as the pedicle can easily be divided during the incision
- #51 Internal mammary artery emerges from the medial end of the intercostal space.
- #52 Not from end to end
- #53 Extension – flap beyond this – not axial flap
- #54 Monopolar diathermy is used judiciously on the flap and the muscle, as this could damage the flap and any diathermy marks on the muscle may compromise the subsequent take of any skin graft. When raising the flap, retraction is upwards by an assistant using skin hooks; it must not be doubled back on itself as this could lead to buttonholing
- #55 After 3 weeks pedicle is divided, the bridge segment of the flap is being untubed and returned to its original site on the chest,excising enough of the graft to accommodate it.mastoid area,ear,parotid area,cheek,lower lip, chin and the neck within the arc.
- #56 The deltopectoral flap has an anomalous pivot point. There is considerable laxity of the skin on the anterior axillary fold when the arm is abducted. This means that the lower border of the flap is considerably longer than the upper part. The pivot point on the flap is thus at the medial end of the upper limb and not the lower limb. This needs to be taken into account when planning the flap. The donor site is usually covered with a split skin graft.
- #58 Fasciocutaneous pedicle limits the reach of the flap
- #63 The spinal accessory nerve is identified and dissection continues in a subfascial plane. The dissection then turns to elevation of the infraclavicular portion of the flap in the subfascial plane; this dissection in the subfascial plane is maintained until over the clavicle. Once the acromion is reached the dissection is continued with careful dissection, with branch ligation with either bipolar cautery or surgical clips. Skeletonization of pedicle is not usually necessary, unless wider arcs of rotation are required. The distal extension of the transverse cervical artery may restrict rotation and can be ligated if necessary.
- #64 simple and quick procedure, usually done in less than an hour, and is a relatively easy to learn procedure. The flap is highly reliable and since the procedure is shorter than free flap reconstruction and does not require expertise in microsurgery, the supraclavicular flap is beneficial for high risks patients who can’t sustain long operative time The supraclavicular flap is an excellent choice for reconstruction of skin defects in the lower face and neck because of a good texture and color match with the skin of the neck and lower face. It also has great pliability which makes it suitable for reconstruction of areas with high mobility, such as the neck and oral cavity. Also, since the skin in the supraclavicular area is generally hairless, it is an appropriate for mucosal defects. The skin has a thin dermis and little fat, which accounts for the flap's thinness which makes it appropriate for reconstruction of contour sensitive areas such as the anterior neck and for pharyngeal defects in which a bulky flap may impair swallowing. It can easily reach distant sites, such as the oropharynx, due to its long pedicle and broad arc of rotation. It can also be used for large defects, since the flap can reach a considerable size, with maximum dimensions of approximately 10 x 20 cm.