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Flaps in Head and Neck powerpointpresentation.pptx
- 1. Flaps in Head and Neck Presenter-Maj Arun Moderator- Maj Sunil NP
- 2. Introduction • Definition: A flap is a unit of tissue that is transferred from donor site to recipient site while maintaining its own blood supply. • Term ‘Flap’: Originated from the 16th century Dutch word ‘FLAPPE’ which means anything that hung broad and loose fastened only by one side.
- 3. Problem • In India->30% of all cancers are head and neck cancers • In head and neck cancers upper aerodigestive tract is most common site with oral cavity being most common followed by oropharynx followed by larynx • 90% of all aerodigestive tract cancers are SCC.
- 4. Things to consider for best functional and aesthetic result • Skin quality- Color, texture, hair bearing etc. • Middle lamella- Muscles of facial expression, muscles of mastication • Deeper tissue- Bone(contour) and soft tissue • Mucosal lining.
- 5. Goals for reconstruction • Integrity (must) • Function • Form
- 6. Why Integrity is must? • Continence (feeding) • Protects vital structures from blow outs • Separation from intracranial structures in skull base ( to prevent infection in/ leak out) • Prevent aspiration • So—> Must for survival
- 7. Function • Minimal goal when patient is fit • So—> better quality of life.
- 8. Approach to reconstruction Pre operative planning:- • Nature of defect • Clinical stage and prognosis • Patient factors • Available flap donor sites • Compliance, expectations and psychological needs • Clinical experience and skill of surgeon
- 9. Timing of reconstruction • Optimally performed in one stage • Optimal conditions present on resection • Defect is widely exposed • Tissue requirement accurately assessed • Potential recipient vessel for anastomosis dissected out • Surgical Margins cleared out by frozen section • Delayed reconstruction secondary procedure
- 10. Reconstruction ladder Free tissue transfer Distant tissue transfer Local tissue transfer Skin graft Direct tissue closure Allow wound to heal by secondary intension
- 11. Flaps: Classification • Blood supply • Axial • Random • Free • Location • Local • Regional • Distant
- 12. Flaps: Classification • Type of tissue • Mucosal • Fasciocutaneous • Myocutaneous • Osteocutaneous • Visceral
- 13. Flaps in head and Neck Reconstruction • Local flaps:- • Effective reconstructive alternatives for small and medium sized defects • Use determined by • Size and location of defect • Properties of available tissue • Vascular supply • Advantages:- • Best match of colour and texture • Less Morbidity
- 14. • Local Flaps: Types • Mucosal flaps- • Palatal • Tongue • Buccal • Skin and Mucosal flaps • Forehead flap • Nasolabial flap • Temporal flap/Temporoparietal flap
- 15. Local Flaps:- • Nasolabial flap- • Upto 25 sq cms is provided for oral lining • Vascular supply- Labial artery • One/ Two stage. • Uses:- • Anterior oral defects • Floor of mouth defect • Coverage of exposed mandible • Advantages: • Minimal donor site morbidity • Excellent cosmesis
- 16. Local Flaps • Temporal flap:- • Vascular supply: Deep Temporal artery • Uses:- • Tissue defects of orbit and lateral face • Palatal defects • Reanimation of unilateral facial paralysis • Complications:- • Injury to Temporal branch of VII nerve • Fibrosis of TMJ • Distortion of facial contour
- 17. Local Flaps • Temporoparietal flap:- • Pedicled or free fascial flap • Vascular supply- Post branch of supf temporal artery and vein • Uses:- • Resurfacing the orbit, lateral oral defects, mid face defects • Auricular reconstruction • Composite flap for reconstruction of orbit and zygoma
- 18. • Temporoparietal flap • Advantages- • Well hidden donor site • Minimal morbidity • Disadvantages- • Risk of injury to temporal branch of VII nerve • Auriculotemporal nerve is sacrificed causing temporal numbness • Alopecia
- 19. Regional Flaps • Pedicled flaps • Classification:- • Fasciocutaneous • Myocutaneous • Muscle • Selection:- • Location and size of defect • Intrinsic Properties of flaps
- 20. Deltopectoral flap • Bekamjian- 1965 • Fasciocutaneous flap • Axial pattern • Vascular supply- 2nd and 3rd perforating branches of internal mammary artery • Use:- • Resurfacing cutaneous neck defects • Facial- oral, pharyngeal defects
- 21. Deltopectoral flap • Advantages:- • Technically easy • Low morbidity • Disadvantages:- • Unreliable distal random portion • Lack of bulk • Skin graft for donor site • Two stage procedure
- 22. Pectoralis Major Flap • Ariyan- 1979 • Work horse flap • Vascular supply: • Pectoral branch of thoracoacromial artery • Skin island- Perforators • Modifications: • Bipaddled • Osteomyocutaneous
- 23. Pectoralis Major Flap • Uses:- • Oral cavity and pharyngeal defects • Mandibular defects • Cutaneous defects of neck • Protection of great vessels • Obliteration of dead space after mediastinal dissection • Reconstruction of pharynx after pharyngectomy
- 24. Pectoralis Major Flap • Advantages:- • Good vascular supply • Large skin paddle • Versatile • Easy to harvest • Single stage • Supine postion • Primary closure of donor site • Low incidence of complications
- 25. Pectoralis Major Flap • Disadvantages:- • Less reliable for cephalic defects • Effect of gravity • Excessive bulk • Transposition of hair • Complications • Flap necrosis- Total/Partial • Donor site complications • Hematoma • Wound dehiscence
- 26. Trapezius Flap • Conley- 1972 • Vascular supply: Perforating branches of posterior intercostal arteries • Use: Ipsilateral skin and pharyngeal defect • Advantages: • Simple dissection • Not prone to wound separation due to gravity • Not in radiated field • Pedicle not threatened during neck dissection
- 27. Trapezius Flap • Disadvantages: • Limited length • STG for donor site • Modifications: • Lateral island flap • Lower island flap
- 28. Free Flaps • Daniel and Taylor- 1973 • Characters defining free flap transfer: • Anatomical site and characteristics of flap • Texture, color, contour, vascular pedicle, innervation • Requirement of bone • Morbidity of donor site
- 29. Free Flaps • Advantages:- • Superior restoration of function and aesthetics • One stage • Superior vascular supply • Greater variety and versatility of donor site • 93-96% success rate • Disadvantages: • Complexity of technique • Increased surgical time • Different color and contour from recipient site • Multi disciplinary effort • Morbid in patients with poor surgical risk.
- 30. Recipient vessels • Arteries:- • Superficial temporal system- Scalp and under face • Facial artery- midface and cervical region(Atherosclerosis common) • Superior thyroid or lingual artery- lower cervical region • Other: Thyrocervical trunk, External carotid, common carotid
- 31. Recipient Vessels • Veins:- • External jugular • Branches of internal jugular (Common facial) • Internal jugular • Retrograde (Supf temporal and thyroid) • Transverse cervical, occipital (very small)
- 32. Radial Forearm Flap • Chinese flap-1981 • Harvested from volar aspect of forearm • Vascular supply- • Radial artery and its venae comitantes • Osteocutaneous flap based on periosteal perforators • Sensory innervation • Antebracheal cutaneous nerve • Allen’s test
- 33. Radial Forearm Flap • Uses:- • Oral and oropharyngeal defects • Hypopharyngeal and cervical esophagus reconstruction • Resurfacing of scalp and face • Advantages:- • Thin, pliable, hairless • Long vascular pedicle • Sensate • Abundant subcutaneous fat for protection and contouring • Can be used as osteocutaneous flap • Simultaneous two team approach in supine position
- 34. • Disadvantages:- • STSG for donor site • Color and texture match is only fair • Vascular compromise of hand • Numbness of hand • Incomplete healing of STSG due to exposure of tendons • Osteocutaneous flap • Restricts dental restoration • Pathological fracture of radius
- 35. Fibula Flap • Taylor and co-workers- 1975 • Osteocutaneous flap • Vascular supply- Peroneal artery with two venae comitantes • Sensory innervation- Lateral sural nerve • Uses- • Mandibular reconstruction • Palatomaxillary reconstruction
- 36. Fibula Flap • Advantages:- • Exceptional bone length • Thick bone allows fixation plates and screws • Dental rehabilitation • Sensate • Primary closure of donor site with minimal morbidity • Simultaneous two team harvest in supine position
- 37. Fibula Flap • Disadvantages • Limitations imposed by soft tissue component • Poor arc of rotation of skin island • Presence of atherosclerosis or congenital anomalies are a contraindication. • Potential donor site complications • Injury to peroneal nerve- foot drop • Instability of knee and ankle joints
- 38. Causes of flap failure • Anastomotic failure • Venous stasis • Thrombosis • Vascular spasm • Hematoma formation • Infection • Previous irradiation • Age, tobacco smoking, diabetes Mellitus
- 39. Assessment of flap viability • Clinical • Colour • Temperature • Capillary refill • Bleeding
- 40. Assessment of flap viability • Monitoring devices • TcPO2 monitoring • Surface temperature monitoring • Implantable thermocouple probe • Dermofluorometry • Surface doppler USG • Laser doppler flowmetry • IV fluorescin
- 42. Conclusion • There are different types of flaps available for reconstruction in head and neck • Appropriate type should be selected based on functional and aesthetic requirements • PrinciplPrinciples of reconstructive ladder should be followed • Post reconstruction, monitoring for flap viability is essential