Flaps used in Maxillofacial Surgery.pptx

FLAPS IN HEAD & NECK RECONSTRUCTION
Dr. Rishabh H. Jain
Dept. of Oral & Maxillofacial Surgery

CONTENTS
 Introduction
 History
 Skin Flap Physiology
 Basic Principles Of Flaps
 Reconstructive Ladder
 Criteria For Choosing A Flap
 Classification
 Types Of Flaps
 Individual Flaps
• Local Flaps
• Regional Flaps
• Distant Flaps
• Free Flaps

 Free Flaps
• Radial Forearm Flaps
• Anterolateral Thigh Flap
• Fibula Free Flap
• Scapular Flaps
• Iliac Free Flap
 Specific Free Flaps For Specific Needs
• Muscular Needs
• Osteocutaneous
• Fasciocutaneous
• Musculocutaneous
• Hollow Viscus
 Monitoring Of Flap
 Measures To Increase The Viability Of Flaps
 Fate Of Flap
 Conclusion
 References
CONTENTS

Flaps in
Reconstruction
Post-traumatic
defects
Post-burn defects
Cancer Surgeries Facial Reanimation
Oro-antral
communications
Major pathologies
Rhinoplasties
Cleft palates
Sub-mucous Fibrosis
Hair
Transplantations
INTRODUCTION

INTRODUCTION
• Reconstruction of maxillofacial defects still remains a
challenge, in spite of numerous advances in regenerative
medicine.
• These challenges stem from the complex set of criteria
that needs to be met for a successful substitute to restore,
maintain, and improve tissue function.
• There are many causes of tissue loss, including
 Trauma
 Pathologic process
 Congenital anomalies

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 in the 16th century from the Dutch word
“FLAPPE” which means “anything that hung broad and
loose, fastened only by one side”.

A flap is one which contains within its substance a network of blood
vessels, arterial, venous, capillaries and it is the effectiveness of the
circulation through this network in perfusing the tissues of the flap
at each stage of its transfer from donor to recipient site which
determines its survival.
- Petersons Principles of Oral & Maxillofacial Surgery, 2nd
Edition
DEFINITION

• 1440 : Dutch word "flappe" something broad to strike with, specially a Flyswatter.
• 1522 : English : anything that hangs broad and loose, fastened only by ONE side.
• 1807 : English : (surgical context) Portion of the skin or flesh, separated from the
underlying part, but remaining attached at the base.
• Sushruta samhita, Circa, 700 B.C. : forehead flap for the reconstruction of a nose.
• 695 A.D, Justinian II of the Byzantine Empire: had a flap restoration of his
mutilated nose.
HISTORY

• Tansini (1896) : Described the concept of muscle and skin flap (LDMF)
• Gillies (1920) : Described the tubed pedicle flap
• Stark (1946) : Muscle flap for osteomyelitis
• Ownes (1952) : SCM flap
• Conley (1960) : Regional flaps
• Mcgregor (1963) : Temporalis Flap
• Bakamjian’s (1965) : Deltopectoralis flap
• Ariyan and Miller (1977) : Pectoralis flap
HISTORY

During the 1st
and 2nd
World War, Pedicled Flaps were used
extensively;
• In 1950 and 1960s – Axial Pattern flaps.
• In 1970 – Axial and Random pattern flaps ( unnamed blood
supply ) and ( muscle and musculocutaneous flaps).
• 1980s - The number of different tissue types used extentively
increased with the development of various fascio-cutaneous ,
myo-cutaneous, osseous and osseocutaneous flaps.
HISTORY

??
• Flap: Maintains its own blood supply
• Graft: Depends on various factors to form its own
blood supply. Regains blood supply at recipient site.

SKIN FLAP ANATOMY &
PHYSIOLOGY
• Skin is continually renewing, keratinizing,
stratified squamous epithelium.
• Skin layers: Epidermis, Dermis,
Subcutaneous fat, Fascia and Muscle.
• Epidermis and Dermis is attached by
Basement membrane zone known as
Dermal-Epidermal Junction (DEJ).
4 types of cells:
1. Keratinocyte
s (80%)
2. Melanocytes
3. Langerhan
Cells
4. Merkel Cells
4 Cell Layers:
1.Basal Layer (Stratum
Germinatium)
2.Spinous Layer (Stratum
Spinosum)
3.Granular Layer (Stratum
Granulosum)
4.Cornified Layer (Stratum
Corneum)

Musculocutaneous
Septocutaneous
• Under ordinary skin
temperatures the amount of
blood flowing through the skin
(0.25 L/m2 of body surface
area) is approximately 10 times
the flow required for nutritional
support.
• Blood flow can increase up to
seven times this value with
maximal vasodilatation.
• When the body is exposed to
extreme cold, the blood flow can
SKIN FLAP ANATOMY &
PHYSIOLOGY

• Venous flow outflow from
the skin is also impaired
with flap elevation.
Venous flow can occur
through the subdermal
plexus.
• Complete venous
occlusion is more
damaging to flap survival
than inadequate arterial
supply.
SKIN FLAP ANATOMY &
PHYSIOLOGY

SKIN FLAP ANATOMY & PHYSIOLOGY
Neural supply:
• Sensory nerves –
segmental fashion
forming dermatomes
• Sympathetic nerves – in
the area of cutaneous
arterioles

FLAP
SURVIVAL
• Length : Width
• Increased width of base
would increase feeding
vessels with same
perfusion pressure.
• The relationship between
perfusion pressure and
critical closing pressure is
not altered, and no
change in survival length
occurs.

FATE OF FLAP
• In surviving flaps, the blood flow gradually increases if the
flap is in a favorable recipient site
• A fibrin layer forms within the first 2 days
• Neovascularization of the flap begins 3 to 7 days after flap
transposition.
• Revascularization adequate for division of the flap pedicle by
7th
day
• The return of blood flow to a flap that is ischemic due to
excessive release of norepinephrine occurs in approximately
12 – 48 hours

RESTING SKIN TENSION LINES
• 1st
proposed by Dupuyt
• Described by Bonges in
1973
• Due to orientation of the
collagen fibres of the skin
• Perpendicular to the
underlying muscle pull
• (Mention clinical
application)

ESTHETIC UNITS OF
FACE
• Familiar patterns in a
particular facial unit, such as
skin thickness, color, texture,
amount of hair, underlying
bony contour, amount of
subdermal fat and underlying
muscle tone.
• Scars are best camouflaged
by placing incisions along
aesthetic lines.
• When a defect crosses the
aesthetic zone, it is best to

IMPORTANT TERMINOLOGIES
• Movements :
Sliding and Lifting of tissues
• Defect :
Primary defect – caused due to surgery or trauma
Secondary defect - caused by tissue movements to close the
primary defect
Pedicle of flap : Area of flap and adjacent tissue that provides
blood supply to the flap.

BASIC PRINCIPLES OF FLAPS
1. Planning
2. Design
- Should not violate its blood supply
- Should generously fit the wound.
- Avoid areas of tension
- Ratio Length: Width (2:1)
3. Transfer
- Avoid kinking, compression, tension or severe angulation.
- Always favor gravity and venous drainage.
4. Positioning
- Use always two layers of sutures
5. Support

GILLIES PRINCIPLES OF RECONSTRUCTION
• Principle I – Replace like with like
• Principle II – Think of reconstruction in terms of
units
• Principle III – Always have a pattern and a
backup plan
• Principle IV – Steal from Peter and pay Paul
• Principle V – Never forget the donor area

Heal by secondary intention
Direct tissue closure
Skin graft
Local tissue transfers
Distant tissue transfers
Free tissue transfers
RECONSTRUCTION LADDER

Adequate
amount of skin
or mucosa
Adequate bulk
Good location
and colour
match
Predictable
blood supply
Distance from
irradiated
sites.
Low donor
morbidity .
CRITERIA FOR CHOOSING A FLAP

CLASSIFICATION
Based on the location of donor site:
1. Direct flaps:
Tissue moved from site adjacent or near the primary defect
maintaining some form of vascular supply
2. Indirect flaps:
Where the tissue is harvested from a remote site from the
primary defect and transferred either by microvascular
surgery or by staged movement of pedicle to recipient
site

I. By the tissues they contain
1) Skin flaps
2) Composite flap
3) Free flaps
II. By the vascular system on which they are based
1) Axial 2) Random
III. By method of movement from the donor site
1) Advancement flaps 2) Transposition flaps
3) Rotation flaps 4) Interposition flaps
IV. By distance from donor site
1) Local Flaps
2) Regional flaps
3) Distant flaps
CLASSIFICATION

Based on tissue content:
1. Cutaneous
2. Myo-cutaneous
3. Myo-osseo-cutaneous
4. Osseo-cutaneous
5. Fascio-cutaneous
CLASSIFICATION

Based on Blood Supply:
CLASSIFICATION

Axial Pattern Flaps
This type of flaps is constructed around a pre-existing
anatomically recognized arteriovenous system.

Random Pattern Flaps
Majority of the local
cutaneous flaps of
the face are random
pattern.

• A flap may be raised from the tissue immediately adjoining, or very close to, the
primary defect, in which case it is called a local/regional flap; alternatively it may
involve the movement of tissue at a distance from the primary defect and is then
called a distant flap.
• A Local flap is one where tissue immediately to, or near the primary defect is
used to cover the defect.
• A Regional flap is one where tissue is harvested from a site not located on the
face, scalp or neck. However, the pedicle is sufficiently long to enable the flap to
reach the primary defect.
• A Distant flap is one that is harvested from sites so removed from the face that
the pedicle is not sufficiently long to enable the flap to reach the face. Distant
flaps are usually transferred to the face as free flaps, sometimes referred to as
microsurgical flaps. (Local Flaps in Facial Reconstruction, Baker, 2008)

• Baker, defines a local cutaneous flap as an area of skin & subcutaneous
tissue with a direct vascular supply that is transferred from its in situ
position to a site located immediately adjacent to or near the flap.

Local Flaps
Classification of Local Cutaneous Flaps by
Methods of Transfer:
 Advancement flaps
Single pedicled Flap
Bipedicled
V-Y & Y-V Flap
 Pivotal Flaps
Rotation flaps
Transposition flaps
Interpolation flaps
 Hinged Flaps

• They have a linear configuration and are moved by sliding
toward the defect. This involves stretching the skin of the flap.
• They work best in areas of greater skin elasticity.
• Advancement flaps may be categorized as:
1. Unipedicle
2. Bipedicle
3. V-Y & Y-V
4. Island
Advancement flaps

1) Unipedicle Advancement Flaps
1. Unipedicle Advancement Flaps
• It’s a flap created by parallel incisions that allow a sliding movement
of tissue in a single vector towards a defect.
• The movement is one direction and the flap advances directly over
the defect.
• Complete undermining of the advancement flap as well as the skin
and soft tissue around the pedicle is important to enhance tissue
movement.
• Two standing cutaneous
deformities are created in all
unidpedicle advancement flaps
compared to a single deformity in
Pivotal flaps. Burrow’s Triangle

• An alternative to the technique of
Burrow’s triangle excision is to invert
the triangular excision and close the
skin defect by advancing the
triangular flap created by the inverted
excision. This is referred to as Inverted
Burrow’s triangle excision.
• When used this technique results in a
irregular suture line.
• Although it gives a longer scar, the
irregular scar may create a less
conspicuous and less contracting scar.

Bilateral Unipedicle advancement flap:
• When large tissue is required. Same technique & principle.
• Commonly combined to close various defects, resulting in H or
T shaped repairs.
• Repair is then referred to as H-plasty or T-plasty.
• Used:
• Forehead, mustache area and posterior neck.

Bipedicled flap in closure of oroantral fistula

2) V-Y advancement flap: (Herbert flap)
• A V shaped flap is moved into a defect
with primary closure of the donor area
leaving a final Y shaped suture line.
The flap is allowed to move to the
recipient site in a nearly tension free
fashion.
• It is pedicled from the underlying
subcutaneous tissue rather than
the surrounding skin.
• It is particularly useful when a
structure or region requires
lengthening or release from a
contracted state, such as
vermilion or eyelids.

The Y-V Advancement Flap
• It has a similar principle to the V-Y flap
except that the V-shaped flap is stretched
or pulled to a linear incision made at the
apex of the triangular flap.
• The maximum wound closure tension is at
the apex of the flap.
• Has fewer applications but can be used to
relocate, in a more natural position, a
distorted facial structure,
eg; an oral commissure that has been
displaced medially by scar.

Panthographic expansion:
• Variation of the advancement
• Instead of the flap being advanced as a rectangle,
• the limbs of the flap are designed at 120º with back cuts at the
bottom so that it looks like an inverted tumbler.
• The flap is then advanced so that the donor site closes primarily.
This technique is particularly useful on the cheek and neck.

Pivot flaps
• All pivotal flaps are moved toward the defect by pivoting the flap around a fixed point
at the base of the pedicle.
• The greater the pivot, the shorter is the effective length of the flap.
• Derives its name from the pivot point at the base of the flap as well as its arc of
rotation.
• When flap moves laterally into the primary defect, transposition flap, when it is rotated
into the defect - rotation flap.
• In case of a rotation flap, the flap rotated directly over the defect, whereas in the
transposition flap the flap rotated over an intervening area of normal skin.

Pivot point
• Is the axis around which the transfer takes place.
• Flap is designed so that the distance from the pivot point to each part of
the flap before transfer is at least equal to the distance to be expected
after transfer.
• Pivot point is on the side of the flap away from the direction of
movement of the flap.
• The reduction in effective length must be accounted for when
designing pivotal flaps so that greater pivoting requires a longer
flap.

• Pivoting a flap with a cutaneous pedicle 45
degrees from its in situ position reduces the
effective length by 5%.
• A 90 Degree and 180 Degree pivot reduces
effective length by 15% & 40%.
• Thus increasing the flaps pivot will change
the flap’s shape, shorten the effective length,
increase wound closure tension & deform
the flap’s base by development of a standing
cutaneous deformity.
• To limit these restricting factors, a flap’s arc
of pivot should not exceed 90 degrees
whenever possible.

Rotation Flaps
• It is a simple pivotal flap, which is curvilinear in shape and which rotates
around a pivotal point near the defect. Designed immediately adjacent to
the defect and are best used to close triangular defect.
• As a general rule, when designing rotation flaps on the face the length of
the incision should be four times the width of the defect. With this 4:1 ratio,
excision of a Burrow’s triangle is usually not necessary.

• A back cut at the base of the flap shifts the
position of the pivotal point, and thus
changes the wound closure tension as
well as the location of the standing
cutaneous deformity.
• Inherent with rotation flaps is the unequal
length of the flaps border compared to
the length of the primary and secondary
defect.
• To equalize this discrepancy, it may be
necessary to excise an equalizing Burrow’s
triangle. Ideally, the triangle should have

Advantages:
• The flap has only two sides; this, it lends itself to placing one side in a border
between aesthetic regions of the face.
• The flap is broad based, and therefore its vascularity tends to be reliable.
• There is greater flexibility in the design & positioning of the flap.
• When possible, the flap should be designed so that it is inferiorly based,
which promotes lymphatic drainage & minimizes flap edema.
Disadvantages:
• The defect itself must be somewhat triangular or must be modified by
removing normal tissue to create a triangular defect.
• The configuration of the flap includes a right angle at the distal tip & the
surgeon must take care in positioning the tip so that it is not subjected to
excessive wound closure tension & vascular compromise.
•

• Classic form - a rectangle or near square which is raised and
moved laterally into a triangular defect. It has a curvilinear
configuration.
• The ability to construct a flap some distance from the defect
with its axis independent from the linear axis of the defect is
one of the greatest advantages of transposition flaps.
• This fact enables the surgeon to recruit skin at variable
distances from the defect, selecting donor sites with the
greatest skin elasticity or redundancy.
A
B
Transposition Flaps

Not to rotate more than
90º
More acute – Less dog ear

Transposition
Flap
Rhombic Flap Bilobed Flap

Transposition Flaps
Rhombic Flap – Limberg’s Flap
• A rhombus is an equilateral
parallelogram. A rhombus defect must
be thought of as two equilateral
triangles placed base to base to form a
rhombus with adjacent angles of 60
degrees and 120 degrees.
• Once the 60-120 degrees rhombus
defect has been created with all sides
equal, the flap is designed by directly
extending the short diagonal a distance
equal to all other sides.
• The greatest wound closure tension
when using a rhombus flap is at the
donor site and has been calculated to

• Advantages of the rhomboid flap
1. Works with great reliability if
performed well.
2. Geometry allows the precise
incision and wound closure that
results in predictable sets of
straight line.
3. Majority of the skin tension is at
the base of the flap and not at
the closing points.

• Disadvantages of the flap:
1. The rhombic flaps do not heal well in certain areas such as the
forehead.
2. Scalp is not a good location where hair is present.
3. To convert a circular defect into a rhomboid, a large amount of tissue
needs to be discarded.
4. The design of the rhombus flap is more complex than most other
facial skin flaps because of the geometry.

Dufourmental Flap
Disadvantages:
1. Risk of flap
necrosis,
2. Trap door

Webster 30 degree flap
• Advantages:
Easier closure and less
tendency for cutaneous
deformities

Multiple rhombic flaps
Initially described by Limberg, then again by Lister and Gibson.

Bilobed flap
• 1st
developed by Essar in 1918.
• Original design included a 90
degree tissue transfer between
each lobe.
• Total transposition over 180
degrees.
• This greater movement about a
pivotal point, together with the use
of two tissue flaps, assists to
minimize wound closure tension of
primary and secondary defects.

• Designed for nasal and cheek
defects.
• Disadvantages:
1. Incisions necessary to
produce two lobes of the
flap produces scars that do
not parallel RSTL’s.
2. The resulting scar is also
lengthy due to the
requirement of elevating two
lobes.

Zitelli modification of Bilobed Flap

Total transposition not more than 90-110 degrees
The complications of trap door and pin cushioning eliminated

• Indications :
• For limited defects of nose approx. 1-1.5 cm
• Helical rim defects
• Cheek defects
• Advantage :
• The primary design is placed with little tension and little
tendency to distort surrounding structures such as alar
rim and nasal tip

• Disadvantages:
• Curvilinear designs create scar that cross the RSTLs
• During healing, the flap may become elevated due to
narrow pedicle that is more prone to congestion
• Scar tissue impedes lypmhatic drainage
• The curvilinear scars tend to bunch up when the flap
shortens

Karapandzic flap – circumoral advancement flap
B/L circum oral incision from the edge of defect maintaining equal distance
from the white line to the point just medial to the nasolabial fold.

• 1st
described by von Burns
in 1957, commonly
employed for lower lip,
modified by Karapandzic
in 1974.
• Structures at lip corners
maintained to allow
optimal motion and
sensory function.
• Careful dissection to
separate the orbicularis
oris, thus maintaining lip
Indications:
Used in any patient
with a full thickness
lip defect involving
the vermilion and
perioral skin.

Advantages:
• Maintains a continuous
circle of functioning
orbicularis oris muscle
and sensate perioral
skin that results in a
“functional
reconstruction”.
Disadvantages:
• Microstomia
• Clown like appearance
• May require
commisuroplasty

Estlander flap
Inclusion of the commissure and addition of a Z-plasty at donor site
for closure.

Interposition flaps – z plasty

Buccal fat pad flap
• Axial flap supplied by the
subcapsular plexus formed
by the facial, transverse
facial and internal maxillary
arteries
• Approached by cutting
through the buccinator
muscle to reach the fat pad,
pulled by gentle traction
into the operative site

• Indications of buccal fat pad flap:
• OAF
• Oro nasal communications
• Surgical defects following tumor
excision(defect less than 5cm)
• OSMF
• Primary or secondary palatal clefts
• Works as a back up flap for failed
buccal advancement/ palatal
rotation / tongue flaps

Interpolation flaps
• Mobilized either over or under the complete bridge of intact
skin via a pedicle.
• Often require a second surgery for pedicle division.
• It is possible to perform a single stage procedure by de
epithelization of the pedicle and passing it under the
intervening skin.
E.g.: 1. Forehead flap
2. Nasolabial flap
3. Lip switch (Abbe flap)
4. Tongue flap

Abbe flap:
• Cross lip flap
• Sabbatini first
described it in 1836 ,
later popularised by
Abbe in 1899
• Transfer of a full
thickness lip tissue in
a triangular flap
from lower lip to a
defect in upper lip
and vicer versa
• Labial artery
preserved and
pedicled with the

• Flap turned 180 degrees on
its pedicle into the defect
• Donor site closed primarily
• Pedicle released after 2-3
weeks as a second procedure
• Height of flap equal to height
of defect
• Width of flap ½ the width of
defect

• Indications :
• Full thickness central
defects involving upto ½
of either lip(not
commisure)
• To reconstruct philtrum

• Advantages:
• Provides nearly identical
tissue including red lip,
orbicularis oris and
intraoral mucosa
• New lip segment regains
motor innervation within
8 weeks and sensation
within several months
• Disadvantages :
• Two stage procedure
• Adynamic or a poor
functioning segment
of lip
• Microstomia
• Trap door deformity

Nasolabial flap
The nasolabial sulcus created by the insertion of several mimetic facial
muscles into skin of lip at junction

Nasolabial flap
Used by Diffenbach as a superiorly based flap in 1830 to
reconstruct ala of nose
In 1864, von Langenbeck used the flap to reconstruct nose
Esser described the inferiorly based nasolabial flap to close
the palatal fistula
It may be superiorly or inferiorly based or can be taken as
an island flap (Seagull flap)

Superiorly based nasolabial flap
• Based on
infraorbital and
transverse facial
artery
• Indicated for
central, lateral alar
and nasal defects
and defects of
lower eyelid

• Superiorly based
• Used to reconstruct
maxillary defect, lip, buccal
mucosa and nasal defect.

INFERIORLY BASED NL FLAP
• Based on the superior
labial, alar and angular
arteries
• Indicated for upper and
lower lip,
collumella,intraoral
defects

• Inferiorly based
• Used in reconstructing perioral
defects – upper or lower lips,
comissure and buccal mucosa

• The length to width ratio should
be 4:1.
• Medial incision : in the
nasolabial sulcus
• Lateral incision: in the cheek
tissue, should be as short as
possible
• Width of the flap should be as
much as the height of the defect
• As thin as possible consisting
only skin and subdermal layer,
maintaining the subdermal
plexus

• Before transposition, wide
undermining of flap
• To remove dog ear often a
burrow’s triangle created
• If skin bridge is large
between the defect and
the flap, a second surgery
to detach the flap may be
needed.

• Advantages:
• Incision hidden in
nasolabial fold
• Good colour match
• Abundant tissue
• Can accept cartilage
grafts
• Disadvantages:
• Blunting and assymetry of
nasolabial fold needing
surgical revision
• Hair growth
• Pedicle crossing over the
occlusal surface
troublesome in dentate
patients

• Intraoral applications of NL Flap:
• After OSMF surgeries
• Closure of palatal fistulae
• Coverage of alveolar ridge
• Small defects in floor of mouth
• Small defects on lateral tongue

Forehead flap
• May be median or a para median flap
• Called the INDIAN / LIFEBOAT FLAP
• Robust and dependable
• Based mainly on the supratrochlear artery
• Due to the rich vascularity, it is possible to include
cartialge or tissue grafts

• Elevation in the
subgaleal /
subcutaneous plane
• Pedicle always includes
the frontalis muscle
• Width of pedicle 1-
1.5cms
• Pedicle divided at 3
weeks
• Pedicle inset at the
glabellar area to
establish brow symmetry

• Advantages:
• Highly vascular
• Hairless
• Near the oral cavity
• Tissue is firm and holds
sutures well
• Thin and suitable for
intraoral lining
• Disadvantages:
• Noticable donor defect
• Need to divide the pedicle and close
the oral fistula at 2 nd operation
• Although rare, flap necrosis may
occur
• A skin graft required to cover the
defect caused by flap may be
needed
( 2nd
site morbidity)

Forehead flap: McGregor.
Blood supply
superficial temporal artery and posterior auricular artery.
Hemiforehead flap or total forehead flap

Glabellar Flap
- Axial pattern flap
- Based on supra-trochlear artery
uses:
-nasal reconstruction
-cheek defects
disadvantages:
-donor site morbidity
-limited amount of tissue

Median Forehead Flap
Uses :
• For nasal reconstruction – defects larges than 2.5 cm in length along the
horizontal transverse plane.
• Defects of medial canthal region, upper or lower eyelids, medial cheek,
melolabial region, upper lip
• In combination with other larger flaps – complex facial defects

Tongue flap
• Described 1st
by Eiselburg in 1901 as a pedicled tongue flap to treat
intraoral defects
• In 1909, Lexer used posteriorly based tongue flap in treatment of
retromolar and tonsillar defects
• Based on the lingual artery, it is a highly vascular flap.
• Types: 1. dorsal tongue flap
• 2. lateral tongue flap
• 3. double door tongue flap
• 4. median transit tongue flap
• 5. ventral tongue flap

• Advantages:
• Adjacent tissue
• Abundant vascularity and low morbidity
associated with it
• Half of the tongue can be rotated to use as a flap
without compromising its function
• Adequate color match
• Emergency flap, when recon plates in mandible
have been exposed
• Reinnervated from adjacent host tissue
• Provide – 90 to 100 cm2
of mucosal surface for
rotation
• Half of tongue can be used – without compromising
the functions.
• Can be used in irradiated patients
• Disavdantages:
• In irradiated patients, the tongue itself
achieves significant radiation thus mobility
may be reduced
• Field cancerization
• Difficulty with speech and deglutition
• Normal tongue movements may pull away
the flap from defect if not anchored well

Considerations in flap design of tongue flap
• To maximise survival, elevation posterior to the circumvallate
papilla avoided
• Posteriorly based is more predicatble because of less mobility
of tongue base, but less versatality due to less rotation
• Anteriorly based greater tongue mobility and more versatality
• In the 1st
stage, flap to recipient site is transferred whereas in
the 2nd
stage, transection of the pedicle carried out

Vasculature :
• Deep lingual artery
• Dorsal lingual artery
• Sublingual artery
• Suprahyoid artery
Types :
I : Random flap design
a) Dorsal tongue flap
Posteriorly based – to treat defects of soft palate, retromolar
region.
Anteriorly based – hard palate anterior buccal mucosa and
lips

b) Lateral tongue flap
Treatment of defects - buccal mucosa, lateral palate, alveolus,
oroantral communication
c) Double door tongue flap
Used to reline large defects of buccal mucosa extending form
the commissure to the anterior mandibular ramus.

VENTRAL TONGUE FLAP
Advantages :
•Easily harvested – thin, supple mucosa
•Accomodation to dentures – because of limited bulk.
•Tongue mobility impaired
•Flap easily adheres to periosteally deprived mandibular
surfaces

Ventral tongue flap Lateral tongue flap

Double door tongue flap
• Reported by Domarus
• Used in large buccal mucosa
defects
• Recommended in
edentulous patients
• Hrizontal incision on lateral
border of tongue same as
the length of the defect
• 5-7mm thickness
• Swinging upward and
downwards to be sutured at
the margin of the buccal
mucosa defect
• 3 weeks later, the flap
divided and donor site
closed

Median transit tongue flap
• Introduced by Calamel to reline
defects of sublingual region
• A midline incision of the same
size of the defect.
• A tunnel created to allow the
flap to reach the floor of mouth
• Flap secured in place and 2-3
weeks later, pedicle divided

II. Axial flap design
Sliding posterior tongue flap
• Coverage of lateral tongue defect measuring 4-6 cm.
• Created by releasing the tongue from the hyoid bone and
maintaining the dorsolingual branch of the lingual artery.

CLINICAL INDICATIONS
• Repair of oronasal communications
• Repair of oroantral communications
• Lip reconstruction
• Buccal mucosa reconstruction
• Reconstruction of the hypopharynx.

Platysma Flap
1st used by – GERSONY – 1887 for reconstruction of a through
and through cheek defect.
1951 – EDGERTON described lateral cervical island flap based on
platysma muscle.
1959 – desprez and Klehn – modified apron flap
Origin:
• Subcutaneous tissues, caudal to the clavicle and acromion.
• Superficial fascia of pectoral & deltoid m.
Insertion:
• Just cephalad to inferior border of mandible.
Innervations:
• Motor: cervical branches of facial nerve (CNV7)
• Sensory: cervical branches of C2, C3, C4

• Blood supply (Randomised)
Anterior superior
– Facial, submental, submandibular arteries
Posterior superior
– Occipital and posterior auricular arteries
Anterior midportion
– Superior thyroid artery
Inferiorly
– Transverse or superficial cervical arteries
– Direct branches of subclavian arteries
• Size of the flap depends upon the requirements of the
wound.
• Arch of rotation is upto 180 degrees.
• Shape : oval, rectangular or square

Indicated:
In palatal defects, buccal region, base of tongue, the
supraglottis, larynx, and cervical esophagus.
Advantages:
• Close proximity to I/O defects
• Thin, delicate, pliable flap
• Good arch of rotation
• Primary closure of donor site rarely requires split-thickness
skin grafts.
Disadvantages:
• Vulnerable to radical ablations
• Not suitable where bulk is necessary
• Hair bearing area (males).

Masseter Flap
1987 – Tiwari – used masseter muscle as a cross-over flap to facilitate primary
closure in the tonsillar repair and retromolar trigone.
• Origin:
– Superficial – anterior 2/3 lower border of zygomatic arch
– Middle - middle 1/3 lower border of zygomatic arch
– Deep – inner surface middle 1/3 of zygomatic arch
• Insertion:
– lateral surface of mandibular ramus
• Innervations:
– Masseteric nerve (CN V3)
• Blood supply:
– Masseteric artery (internal maxillary artery)

• Masseter flap:
– Reconstruction of ablative
procedures of parotid gland,
mandible, palate and nasopharynx
– Does not restore emotional
mimetic movement, training is
necessary
– Limited arch of rotation,
– Limited size defect can be restored

Temporalis Flap
• Origin:
– Deep – temporal fossa calvarium
– Superficial – deep temporalis fascia
• Insertion:
– Coronoid process and anterior ramus of mandible
• Innervations:
– Motor : anterior and deep temporal branches
– Sensory : auriculotemporal nerve
• Blood supply:
– Deep temporal fascia : middle temporal branch (superficial
temporal a.)
– Temporalis muscle : Anterior, middle and Posterior deep
temporal a.
Introduced by Golovine – 1898
1981 – Bradley and Brockbank described the use of the flap for oral
reconstruction.

Temporalis flap:
Temporoparietal fascia - superficial temporal artery
Temporalis muscle - anterior and posterior deep temporal br. Max. art
Golovine in 1898
Type III

• Temporalis flap:
– Uses
• TMJ surgeries
• Obliteration of orbital defects
• Skull base recons.
• Intraoral defects after
maxillectomy
• Palatal cleft
• Cranialization procedures
• Facial reanimation surgeries
– Adv
• Variable amount of tissue can
be harvested
• Minimal esthetic morbidity
• Thin flap
• Reliable and well tolerated
• Loss of muscle function
minimal
• Good arc of rotation
– Complication
• Facial nerve injury
• Temporalis tendinitis

Pectoralis Major Flap
• It is an axial pattern flap and is fan
shaped
• Boundaries
– Superior: clavicle
– Medial: sternum
– Lateral: axillary fold
• Fascia connects: serratus anterior and
rectus abdominis muscle.
• Origin
– Clavicular : medial aspect of clavicle
– Sternocostal : lateral sternum, 1st-7th
costal cartilages and rectus abdominus
muscle.
• Insertion
– Bicipital groove humerus
It was 1st described by Hueston and McConchie in 1968 and was
introduced into head and neck reconstruction by ariyan in 1979.

• Blood supply
– Thoraco-acramian artery Perforating
branches of internal (thoracic)
mammary artery
– Lateral thoracic artery
• Innervation
– C5, C6 and C7 (lateral pectoral nerve)
– C8, T1 (medial pectoral nerve)
– Sensation : intercostals nerves
• Pectoralis major flap
– Elevation of the flap depends on the
exact location of the defect > location
of vascular pedicle (Doppler).
– To stay 2 cm lateral to the lateral
border sternum when dividing the
flap medially (IMA)
• Pectoralis major flap designs

Advantages :
• Non delayed, one staged procedure.
• Highly reliable
• Primary closure of the donor site
• May be used along with other flaps.
• It may be transposed with an attached
rib skin coverage, muscle bulk and good
blood supply.
• Success rate is close to 95%.
Disadvantages :
• Excessive bulk and thickness may
compromise its blood supply.
• Hair bearing area
• Shoulder disability

Deltopectoral Flap
• Axial pattern flap
• Composed of fascia, subcutaneous tissue
and skin; muscle is not transferred with
this flap
• Horizontal flap design with round tip.
• Perfused by intercostal perforating
branches of internal mammary artery.
• Outlined along the inferior border of the
clavicle, beginning at sternum extending
lateral to acromion process. Returning at
level of 5th rib.
• Elevation beneath the level of the pectoral
muscle fascia, lateral to medial.
• Base: 2cm from the lateral sternal border.
The medially based deltopectoral skin flap was introduced by Bakamjian in 1965.
Alternative for the more commonly used pectorals major flap.

Deltopectoral Flap
Characteristics and advantages:
• Usually not delayed
• Unilateral or bilateral
• Deltoid portion usually not hair bearing
• Excellent blood supply
• Donor site hidden, thus cosmetically acceptable
• useful when repair of the defect requires large
amounts of skin for external coverage of face and
neck.
• Used for the repair of defects in cervical
esophagus, hypopharynx, oropharynx, base of
tongue mandible, maxilla, and skin of cheek, chin
and neck.

Deltopectoral Flap
Disadvantages:
• Requires a second stage to close an orocutaneous fistula unless an
epithelial shave is performed.
• Failure rate is 9 to 18%.
• Blow out of the carotid artery ,if flap fails.

Sternocleidomastoid flap
• Can be used or muscle flap only,
myocutaneous flap or as a composite flap.
• Can be based superiorly or inferiorly
• Superior thyroid vessels & spinal
accessory nerve should be preserved at all
times.
• Limited rotational angle (random-pattern)
& size of flap
1st
described by OWENS in 1955.

Sternocleidomastoid flap
As a muscular flap its indications include:
• Obliteration of dead space above a
bone graft
• The enclosure of a bone graft in a
vascularised muscle sheath when the
recipient tissue is other wise poorly
vascularised.
• The provision of a thickness of soft
tissue for the placement of a bone graft.
As a myocutaneous flap its indication
include:
1. The provision of an epithelial lining for
mucosal reconstruction.
2. For the closure of orocutaneous fistulas.
3. The release of scar contractors in the
submandibular and angle regions.

Lattisimus Dorsi Flap
 Useful when other flaps are not available or when very large
defects require coverage.
Origin:
• Posterior iliac crest, therocolumbar fascia, external
oblique fascia and lower six vertebrae.
Insertion:
• Intertubercular groove of the humerus
Blood supply :
• Circumflex subscapular artery (thorocodorsal artery)
Innervation :
• Thorocodorsal nerve
• This flap was used by Tansini (1896) to cover a
mastectomy defect.
• 1st
in Head and Neck reconstruction by Quillen et al
in 1978.

Lattisimus Dorsi Flap
Flap Characteristics :
• Good for scalp, forehead and anterior cranial defects
• Can be transferred as free or pedicle flap.
• As only muscle or as musculocutaneous flap (bulky)
• Reliable and provides large amount as soft tissue for massive defects
• Not good for reconstruction which need good esthetic results.
• Position of pt. to be changed during surgery
• 3flap designs – horizontal, thin & thick vertical

Introduction
• The first reported free tissue transfer was vascularized jejunum
performed by Siedenberg in 1959.
• Panje performed first free flap for oropharyngeal reconstruction in
1976.
• fibula free flap used for mandible reconstruction by Hidalgo in 1989.
• Today the most common free flaps in head and neck reconstruction are
the radial forearm, the rectus abdominis, and the fibula.

• Radial Forearm Flaps
• Lateral Arm Flaps
• Lateral Thigh Flap
• Anterolateral Thigh Flap
• Rectus Abdominis Flaps
• Latissimus Dorsi Flap
• Gracilis Flap
• Temperoparietal Fascial Flap
• Fibular Osteocutanous Flap
• Iliac Crest Flaps
• Scapular Flaps
• Metatarsal Flap
• Rib Flaps
• Jejunum
• Omentum

Advantages
• A wide variety of tissue types including skin,
muscle, fascia, and bone are available for transfer
• Control over the bulkiness of flaps.
• Innumerous number of orientations to fit the
recipient site.
• Better toleration to radiation.
• Chance to receive implants, post operatively
• No staged procedures
• Better success rate.

Disadvantages
• Long operating time
• Significant technical expertise.
• Special equipment.
• Cost.
• Donor site morbidity.

Principles of microvascular anastomosis

Radial Forearm Free Flap
Radial artery with its two vena comitans
Cephalic vein
Lateral antebrachial cutaneous nerve – sensate flap

Radial Forearm Free Flap
• The incision is extended towards the cubital fossa for exposure of the vessels.
• The incisions are carried down through the fascia.
• The vessels are located distally and ligated.
• Care must be taken to avoid injury to the superficial branch of the radial nerve.
•The flap is raised in a sub-fascial plane.
•The vascular pedicle with its septocutaneous perforators are identified between
the bellies of the brachioradialis and flexor carpi radialis muscles.

Radial Forearm Osteo-cutanesous Free Flap

Anterolateral Thigh Flap
The ALTFF was described in China by Song, et al, in
1984 and used for head and neck reconstruction by
Koshima, et al, in 1993.
Based on the descending branch
of the lateral circumflex femoral
artery and its two vena
comitantes

Advantages of the ALTFF include
• its versatility,
• large caliber vessels,
• low donor site morbidity
1. The ALTFF provides a large amount of skin and
a variable amount of muscle.
2. The thickness of the flap depends on thickness
vastus lateralis taken with the flap.
3. Thicker flaps may be used for total glossectomy
or lateral temporal bone defects.
4. Thinner flaps are well-suited for oropharyngeal
or hypopharyngeal reconstruction.

Disadvantages:
Gait disturbances
Technique sensitive

Fibula Free Flap
• The fibula free flap was first used for mandible
reconstruction by Hidalgo in 1989.
• It is the most common free flap for mandible reconstruction
today.
• The flap provides up to 25 cms of vascularized bone with or
without a skin paddle.
• The vascular pedicle includes the peroneal artery and vein.
• Preoperative imaging of the vessels of the lower extremity is
indicated to identify those patients who have insufficient
collateral blood supply to the foot.
• If the patient's blood supply to the foot is dominated by the
peroneal artery then a FFF from that leg is contraindicated.

Fibula Free Flap
Disadvantages
• Tenuous blood supply of the skin paddle
• Need for a skin graft to close the donor site
• Bone does not mimic the curvature of the mandible.
• Less success rate as compared to the DCIA based free iliac
flap

Scapular Flaps
In 1978, Saijo was 1st
to describe the scapular
fasciocutaneous flap anatomy based on the
circumflex scapular artery (CSA).
This donor site was popularized for head and
neck reconstruction by Swartz et al in 1986
Based on the subscapular artery and vein, branches
of the third part of the axillary artery and vein.

Scapular Flaps
Flaps based on the subscapular arterial
system include the following:
1. Scapular/parascapular fasciocutaneous flap
2. Scapular/parascapular osteocutaneous flap
3. Latissimus dorsi muscle flap
4. Latissimus dorsi musculocutaneous flap
5. Serratus anterior muscle flap
6. Serratus anterior musculocutaneous flap
7. Dorsal thoracic fascia flap
Indications:
Oromandibular defects,
scalp defects,
Palatal / midface defects,

Iliac crest flaps
• Osteocutaneous, osteomusculocutaneous
• Segmental mandibular defects
• Up to 16 cm bone
• Oromandibular reconstruction
• No motor or sensate reconstruction
• With or without simultaneous implant
placement.
• Skin paddle is not ideal for relining the oral
cavity as it is too thick
• Denervated muscle undergoes atrophy that
leaves a thin, fixed, soft tissue coverage over
the bone.

Neurovascular pedicle
• Deep circumflex iliac artery from lateral
aspect of external iliac artery
– 1 – 2 cm cephalic to inguinal ligament
• Ascending branch of deep circumflex iliac
artery supplies internal oblique muscle
• Pedicle to internal oblique can arise
separately from deep circumflex iliac artery
• Deep circumflex iliac vein – 2 venae
comitantes
– Can pass either superficial to deep to
artery

SPECIFIC FREE FLAPS FOR SPECIFIC NEEDS
MUSCULAR - PECTORALIS MINOR
Blood supply: Pectoral Branch of Thoracoacromial artery
Nerve: Medial pectoral nerve.
Anatomy: A flat triangular muscle lying just under pec major that
attaches to ribs 2-5 and coracoid process
Advantages:
Minimal to no post-operative disability
Size, shape, lack of bulk good for facial soft-tissue and reanimation procedures
Good reinnervation potential
Can be used as a composite graft when includes underlying rib
Disadvantages:
Short vascular pedicle (usually < 3 cm)
Sometimes not enough bulk

FASCIOCUTANEOUS
RADIAL FOREARM FLAP
Blood supply: Radial artery and vena comitantes
Nerve: Medial and lateral cutaneous sensory nerves
Anatomy: Fairly thin flap along anterior forearm, can include bone
Advantages:
Ease of pre-operative evaluation
Easy to harvest
Reliable blood supply
Good source for mandible when bone is taken
Preop tissue expansion for larger defects
Disadvantages:
Vascular supply to hand at risk
Postoperative dysfunction
Usually requires skin graft for closure
Significant risk of pathologic fractures with bone

FASCIOCUTANEOUS
LATERAL THIGH
Blood Supply: Septocutaneous branches of the 3rd perforator of the profunda
femoris system and associated vena comitantes
Nerve: Lateral femoral cutaneous nerve
Anatomy: Fasciocutaneous tissues of the lateral thigh
Advantages:
Thin pliable flap for intraoral and pharyngeal reconstructions
Reinnervation possible for sensate flaps
Two-team approach
Primary closure
Disadvantages: Anomalous vasculature may require intraoperative modifications

OSTEOCUTANEOUS
ILIAC CREST
Blood supply: Deep circumflex iliac artery (DCIA) and vein
Anatomy: Osteocutaneous flap utilizing the iliac crest and
overlying skin
Advantages:
Reliable flap
Good for large bony defects
Minimal donor deformities
Defect closed primarily
Disadvantages:
Risk of damage to femoral nerve, iliac vessels, peritoneum and bowel
Difficult to elevate and find vessels
Painful site of healing and long scar

OSTEOCUTANEOUS - FIBULA
Blood Supply: Endosteal and periosteal branches of the
peroneal artery and vein
Nerve: None
Anatomy: Up to 25 cm of fibular bone accompanied by
overlying skin
Advantages:
Minimal donor site morbidity
Excellent periosteal supply allows the use of osteotomies to shape the
graft
Two-team approach possible
Disadvantages:
Variability of the septocutaneous perforators to the skin may limit
viability
Questionable osseointegration

OSTEOCUTANEOUS
SCAPULA FLAP
Blood supply: Subscapular artery and subsequent circumflex scapular branch
with the venous drainage being the vena comitantes.
Nerve: none
Anatomy: Thin pliable flap mostly skin and subcutaneous tissue (with bone if
desired) 6 x 8 cm width by 10 to 18 cm length
Advantages:
Long vascular pedicle (6-8 cm)
Large, thin, pliable fasciocutaneous flap
Two bone segments available with independent pedicles by harvesting the
angular branch of the thoracodorsal artery
Composite flap with each component having an independent vascular supply
Can include lat. dorsi muscle in flap
Very reliable
Donor site closes primarily
Disadvantages:
Patient must be in the lateral decubitus
The shoulder must be immobilized for 4-5 days
Some potential for post-operative shoulder dysfunction

MUSCULOCUTANEOUS
LATISSIMUS DORSI
Blood supply: Two major branches off the thoracodorsal, the interior longitudinal
and posterior transverse branch (the posterior transverse branch is vital to flap
survival)
Nerve: Thoracodorsal nerve (runs in neurovascular bundle)
Anatomy: Very large triangular muscle
Advantages:
Large amount of tissue (25 x 35 cm) available
Easily closed donor defect with minimal morbidity
Long vascular pedicle possible
Very reliable flap
Disadvantages:
Requires patient in lateral decubitus position.
Sometimes flap too bulky

MUSCULOCUTANEOUS
INFERIOR RECTUS ABDOMINIS
Blood supply: Inferior epigastric artery.
Anatomy: Large flat musculocutaneous flap
Advantages:
Large flaps
Long, reliable vascular pedicle
Can be closed primarily with minimal donor defect
Disadvantages:
Often bulky
Possible hernia formation

HOLLOW VISCUS
JEJUNUM
Blood supply: Vascular arcade based on the superior mesenteric artery and vein
Anatomy: Second loop of jejunum most reliable (1.5 to 2 feet beyond ligament of Treitz)
Advantages:
Minimal donor defect (often none noticeable).
Most physiologic choice for pharyngoesophageal reconstruction.
Disadvantages:
Bowel or pharynx fistulas.
Need for abdominal procedure

Monitoring of Flaps
Signs of abnormal perfusion
– Arterial compromise
• Skin – Pale, slow capillary refill; cool.
• Muscle – Pale; no brisk bleeding; skin graft not adherent; no doppler
signal.
• Fascia – No palpable pulse; skin graft not adherent; no doppler signal.
– Venous compromise
• Skin – patchy; bluish fast capillary refill; cool.
• Muscle – Dark; dark red bleeding; skin graft not adherent.
• Fascia – Dark; greyish, doppler signal may remain normal for a longer
period.

Possible causes of impaired perfusion
• Inflow –
– Arterial kinking
– Inset too tight
– Damage to pedicle
– Arterial insufficiency
– Thrombosis in extremity.
• Outflow –
– Venous occlusion
– Tunnel too tight.
– Venous thrombosis in major veins.
– Kinking of pedicle.
• Hematoma under flap

Monitors for Cutaneous Microcirculation
1. Clinical tests:
1. Skin colour
2. Temperature of flap
3. Capillary refill and bleeding characteristics.
2. Chemical methods:
1. Fluorescein (resorcinol pthalein)
2. Atropine – subcutaneous injection in flap to check the systemic effects.
3. Fiberoptic flurometry
4. Fiberoptic dermoflourometer – with flourescein delivery.
3. Radioisotopic methods:
1. 24
Na, 131
I, 99m
Tc, 133
Xe.
4. Instrumental methods:
1. Temperature
2. Transcutaneous gas measurements.
3. Photoelectric method – photoplathysmography & reflection
spectophotometry.
4. Doppler shift flowmetry
5. Electromagnetic flowmetry
6. Interstitial fluid pressure measurement.

References
1. Grabb’s Encyclopedia of Head and Neck Reconstruction:1998
2. Plastic Surgery, McCarthy, Vol 5 , Tumours of Head & Neck
3. Fundamental techniques of Plastic surgery and their surgical
applications. 9th edition I A McGregor & A D McGregor.
4. Cancer of Face and the Mouth, Pathology and management for surgeon
- Mcgregor.
5. Basic principles of oral and maxillofacial surgery, Peterson.
6. Facial Plastic and Reconstructive surgery, Ira A Papel. 1992
7. Local Flaps in Facial Reconstruction, Shan Ray Baker & Neil A Swanson.
8. Maxillofacial Surgery Vol 1; P W Booth, Stephen A Schendel.
9. Designs of Local skin flaps, W F Larrabee, otolaryngology clinics of North
America, 0ct 1990, 23: 5
10. Reconstruction of the mandible and oropharynx, otolaryngology clinics
of North America dec 1994, 27 : 6
11. Soft Tissue Flaps, Oral and Maxillofacial Surgery Clinics of North America,
Nov 2003, 15 : 4

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