A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply or from a anastomised vessel. Flaps come in many different shapes and forms. They range from simple advancements of skin to composites of many different types of tissue

1. Pedicle flap in
Maxillofacial Surgery
Presented by
Dr Kamini Dadsena
Final year PG

2. Outline
• Introduction
• Classification of flaps
• Pedicled flaps in maxillofacial region
• Flap monitoring
• Complications
• Conclusion
• References

3. Definition
• A flap is a unit of tissue that is transferred from one
site (donor site) to another (recipient site) while
maintaining its own blood supply or from a
anastomised vessel.
• Flaps come in many different shapes and forms.
They range from simple advancements of skin to
composites of many different types of tissue.

4. Timeline of the development of flap surgery
600 BC Sushruta Samhita Pedicle flaps in the face and forehead for nasal reconstruction
1597 Tagliacozzi Nasal reconstruction by tubed pedicle flap from arm
1896 Tansini Latissimus dorsi musculocutaneous flap(post- mastectomy)
1920 Gillies Tubed pedicle flap
1946 Stark Muscle flaps for osteomyelitis
1963 McGregor Temporalis flap
1965 Bakamjian Deltopectoral flap (aymard flap)
1972 McGregor and Jackson Groin flap
1972 Orticochea Musculocutaneous flaps
1977 McCraw et al Musculocutaneous territories
1979 Ariyan PMMC flap
1981 Mathes and Nahai Classification of muscle flaps based on vascular anatomy
1981 Ponten Described fasciocutaneous flap

5. Classification of flaps
• Four basic types
• Blood supply
• Location
• Composition
• Configuration
• Method of transfer

6. Based on Blood Supply
• Random flaps are supplied by the dermal and subdermal plexus alone
and are the most common type of flap used for reconstructing facial
defects.
• Axial pattern flaps are supplied by more dominant superficial vessels
that are oriented longitudinally along the flap axis.
• Pedicle flaps are supplied by large named arteries that supply the skin
paddle through muscular perforating vessels.
• Free tissue transfer refers to flaps that are harvested from a remote
region and have the vascular connection reestablished at the recipient
site.

7. Based on location
• Local flaps imply use of tissue adjacent to the
defect.
• Regional flaps refer to those flaps recruited from
different areas of the same part of the body.
• Distant flaps are harvested from different parts of
the body.

8. Based on configuration
• Bilobed
• Rhombic
• Z-plasty.

9. Based on Type of Tissue Transfer
• Skin (cutaneous)
Fascia
Muscle
Bone
Visceral (eg, colon, small intestine, omentum)
Composite
• Fasciocutaneous (eg, radial forearm flap)
Myocutaneous (eg, PMMC flap)
Osseocutaneous (eg, fibula flap)
Tendocutaneous (eg, dorsalis pedis flap)
Sensory/innervated flaps (eg, dorsalis pedis flap with deep
peroneal nerve)

10. Based on method of transfer
• Advancement flaps
• Rotation flap
• Transposition flap
• Interposition flaps
• Interpolated flaps
• Microvascular free tissue transfer

11. Based on method of transfer
• Advancement flaps
• Rotation flap
• Transposition flap
• Interposition flaps
• Interpolated flaps
• Microvascular free tissue transfer

12. Muscle and Myocutaneous flaps
• One vascular pedicle (eg, tensor
fascia lata)
• Dominant pedicle(s) and minor
pedicle(s) (eg, gracilis)
• Two dominant pedicles (eg,
gluteus maximus)
• Segmental vascular pedicles (eg,
sartorius)
• One dominant pedicle and
secondary segmental pedicles
(eg, latissimus dorsi)
Mathes and Nahai classification

13. Type I – single unbranched nerve enters muscle.
Type II- Single nerve, branches prior to entering.
Type III – Multiple branches from same nerve trunk.
Type IV – Multiple branches from different nerve trunks.
According to mode of innervation (Taylor)

14. Pedicled flap
1. Palatal flap
2. Buccal fat pad
3. Nasolabial flap
4. Tongue flap
5. Submental island flap
6. Platysma Flap
7. Temporalis Flap
8. PMMC flap
9. Fore Head flap
10. Lattissmus dorsi flap
11. Deltopectoral flap
12. Trapazius flap
13. FAMM flap

15. Palatal flap
• The palatal flap was initially described in 1922 by Victor
Veau to address oronasal fistulas associated with cleft
repair.
• It was later popularized by Millard for palatal
lengthening during cleft repair in the 1960s.
• In 1977 Gullane and Arena used the flap for
postablative defects.

16. Anatomy

18. Indications
• Indicated in defect at
• Retromolar trigone
• Soft palate
• Tonsillar fossa
• Cheek
• Posterior one-third of the floor of the mouth
• Oronasal and oroantral fistula closures.
• Up to 75% of the palatal mucosa may be used,
allowing defects of up to 16 cm2 to be closed.

19. Contraindications
• History of ipsilateral internal carotid artery ligation
• Surgeries with adjacent incisions, or radiation
therapy, which have been shown to increase the
risk of flap failure.
• Children less than 5 years of age, concerns
regarding iatrogenic midface growth restriction
limit its use.

21. From: The Palatal Island Flap for Reconstruction of Palatal and Retromolar Trigone Defects Revisited
Case 1. Intraoral photograph with the contralateral palatal island flap sutured into position and relining the oral cavity defect.
Figure Legend:

22. Technique

23. Complications
• Flap failure
• Flap necrosis
• Bleeding

24. Buccal fat pad
• Heister in 1732, “Glandula Molaris”
• Bichat in 1801, verified its fatty histology.
• BFP flaps for reconstruction of oral defects was introduced by EGEYDI
in 1977.
Heister L. Oral Maxillofac Surg Clin North Am 1990; 2: 377.
Bichat FMX. Plast Reconstr Surg 1990; 85: 29.
Egyedi P. J Max-Fat Surg 1977; 5: 241.
Dean A, et al. Head Neck 2001; 23: 383–388.
Hudson JW, et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995: 80: 24–27.

25. Surgical anatomy

26. Blood supply

27. Clinical Application
OAF
MRON CLEFT PALATE
OSMFINTERPOSITIONAL
GRAFT IN TMJ
ANKYLOSIS
RECONSTRUCTION
AFTER
CANCER SURGERY
LIP
AUGMENTATION
MALAR
AUGMENTATION

28. Healing of the BFP
• Clinically, in the typical course, the surface of the orally
exposed fat becomes yellowish-white in 3 days and then
gradually becomes red within 1 week, which is most likely due
to the formation of young granulation tissue.
• This changes into firmer granulation tissue during the 2nd
week, and becomes completely epithelialized with a slight
contraction of the wound by 3 weeks after the operation.
• The BFP healed in 2 weeks and completely epithelized in 6
weeks.

29. BFP FOR OROANTRAL FISTULA CLOSURE
• Emad T. Daif pedicled BFP is a durable,
straightforward, convenient, and reliable method
for the treatment of a large OAF.
Emad T. Daif, J Oral Maxillofac Surg 74:1718-1722, 2016

30. Closure of palatal fistula with BFP Flap
• A. K. Ashtiani, et al. pedicled BFP flap is a simple
and relatively secure method for palatal fistula
management.
A. K. Ashtiani, et al. Int. J. Oral Maxillofac. Surg. 2011; 40: 250–254.

31. Immediate Reconstruction after cancer surgery
and Postoperative Radiation Therapy
• Weimin Ye, that BFP grafting is an effective and reliable
method for the reconstruction of small to medium-size
palate defects.
WeiminYe, J Oral Maxillofac Surg 72:2613-2620, 2014
1 year
3 weeks

32. BFP for Treatment of OSMF
• Rohit Sharma, et al . BFP is reliable for the
treatment of OSMF.
Rohit Sharma, et al. J Oral Maxillofac Surg 70:228-232, 2012
BFP sutured over defect

33. Oral Submucus Fibrosis

34. FINAL RESULT
Pre OP IID- 5mm Post OP IID- 30mm

35. • V. Singh, et al. used it as interpositional graft after release of
TMJ ankylosis.
• P. R. Bueno, Recomonded it for Lip augmentation.
• H. Rotaru, et al. using it for the management of denuded
bone in patients with MRONJ.
• Kazem Khiabani et al used for malar augmentation.
Virendra Singh, et al. J Oral Maxillofac Surg 70:997-1006, 2012
Pilar Rubio-Bueno, J Oral Maxillofac Surg 71:e178-e184, 2013
Horatiu Rotaru, et al. J Oral Maxillofac Surg 73:437-442, 2015
Kazem Khiabani et al, J Oral Maxillofac Surg 72:403.e1-403.e15, 2014
TMJ Ankylosis Recon. In MRONMalar Augmentation Lip Augmentation

36. Advantages
• Location of the BFP
• Simplicity, versatility, excellent blood supply, low rate of
complications minimal to no donor site morbidity
• Quick surgical technique
• Good rate of epithelialisation
• No loss of vestibular depth
• The possibility of harvesting under local anaesthesia

37. Complications
• Pain
• Swelling
• Hematoma
• Infection
• Arterial bleeding.
• Donor site morbidity.
• Scarring
• Limited mouth opening and trismus
Y. Toshihiro. Int. J. Oral Maxillofac. Surg. 2013; 42: 604–610
Colella G, et al. Br J Plast Surg 2004: 57: 326–329.
El-Hakim IE, et al. J Laryngol Otol 1999: 113: 834–838.
Rapidis AD, et al. J Oral Maxillofac Surg 2000: 58: 158–163.

38. Limitation
• The indications for BFP grafting should be
determined carefully because of limited volume
and length of the pedicled BFP.
Y. Toshihiro. Int. J. Oral Maxillofac. Surg. 2013; 42: 604–610

39. Nasolabial flap
Has been used for reconstruction of facial skin defects of the
upper lip, nose & cheek
Flap may be inferiorly based or superiorly based
Can be used unilaterally or bilaterally
Is a axial flap based on the nasolabial branch of the facial artery

40. Anatomy
in the nasolabial region, the arterial
supply runs deep to the mimetic muscles
(zygomaticus major and minor, levator anguli
oris, nasalis, and quadrates oris). Throughout its
course, the artery has vertically oriented perforator
vessels, which run through the mimetic muscles to
provide a rich blood supply to the subcutaneous
tissue. The lower third of the nasolabial region
has the most robust blood supply.
The venous drainage in the nasolabial area is
through the facial vein, which runs along the entire
length of the region. It runs deep and lateral to the
facial artery.

41. Indications and contraindication of
Nasolabial Flap
Indications
• Superior based flap
• Nose (lateral wall,
• tip, ala)
• Inferior based flap
• Upper lip
• Buccal mucosa
• Floor of mouth
• Palate
• Relative contraindications include previous neck dissection,
simultaneous free flap surgery using the facial artery, history
of radiation, defects greater than 5 cm 5 cm, and sites
distant to the arc of rotation.

42. Technique
Preoperative planning and preparation
• Skin laxity
• Arc of rotation
• Color Doppler

43. Nasolabial flap
Disadvantages
• Limited donor tissue
• Facial scarring
• Second surgical procedure
• Extremely difficult to use in dentate patient
Uses
• Major use is in closure of oro-antral fistula & coverage of
small defect of anterior floor of the mouth in edentulous
patient
• Oral submucous fibrosis

44. Nasolabial Flap

48. Tongue flap
• A muscular random pattern flap
• Can be based anteriorly, posteriorly, laterally or bipedicled
Uses
• Anteriorly based - for vermilion or floor of the mouth
• Dorsally based - for palatal fistula closure
• Posteriorly based - for the tonsillar, retromolar or lateral
floor of the mouth defect
• Bipedicled dorsally based - for replacement of vermillion
• Best results are obtained if tongue tip are not violated

49. Anatomy

51. Blood suply

52. Tongue flap
Technique
• Finger shaped flap is marked out on the surface of the
tongue from the circumvallate papilla to 1-2 cms behind
the tongue tip
• Silk traction suture are used to provide traction
• Combination of blunt & sharp dissection
• Multiple small bleeders will be encountered
• Width can be increased by longitudinally scoring the
muscle with a scalpel blade allowing it to “unroll”
• Site is closed in two layers

53. Tongue flap
• Main disadvantage limited arc of rotation & small size
• Decreased mobility in patient who have undergone
radiotherapy
• In palatal reconstruction it should be securely anchored
• Remains the best means of restoring bulk with an adequate
color match in the region of the vermillion

54. Tongue flap

55. Tongue Flap

59. Submental flap
• The submental island flap is Initially described in
1993 by Martin and colleagues,
• The donor site scar is well hidden in the shadow of
the mandible.

60. USES OF THE SUBMENTAL ISLAND
FLAP
• Soft tissue defects of the lower part of face.
• Tongue and/or floor of mouth defects.
• Buccal mucosa defects.
• Palatal defects.
• Nasal reconstruction.
• Lip reconstruction.
•

61. Contrandications
• severe medical comorbidities that preclude major
surgery.
• regional metastatic disease involving the ipsilateral
Level I lymphatic tissue bed.
• Prev. Radiation or prev surgery in same area

62. Technique

65. COMPLICATIONS
• Flap failure
• Hematoma
• Infection
• Wound dehiscence
• Injury of marginal mandibular branch of facial
nerve
• Incomplete neck dissection of Level I

66. TEMPORALIS MUSCLE FLAP
• Golovine 1898 - orbital
exenteration
• Gilles - reanimation of
paralyzed face
• Fan - shaped muscle
arising from temporal
fossa & the superior
temporal line
• The muscle is bipennate,
with an additional
superficial origin from the
temporalis fascia

68. INDICATIONS
• Reconstruction of
• oral defects
• Cranial base
reconstruction
• Facial reanimation
surgery
• Midface augmentation
• Obliteration of orbital
defects
CONTRAINDICATION
• Previous surgery or
trauma to the scalp or
temporozygomatic
regions
• prior radiation to the
temporoparietal area

69. TEMPORALIS MUSCLE FLAP
ADVANTAGES
• Ease of elevation
• Reliable blood supply
• Proximity
• Camouflage of incision
with in hair line
• Muscle support graft &
alloplast well
DISADVANTAGES
• Sensory disturbances
• Potential facial nerve
injury
• Temporal hallowing

70. TEMPORALIS MUSCLE FLAP
• Main blood supply - anterior &
posterior deep temporal artery
• Anterior deep temporal artery &
Posterior deep temporal enter the
muscle approximately 1cm &
1.7cm posterior to coronoid
process respectively
• This vascular anatomy allows
splitting of muscle into anterior &
posterior flap

71. TEMPORALIS MUSCLE FLAP
• Mobilized flap consists of fascia,
muscle, & pericranium
• Two distinct fascial layers, the
superficial & deep temporal
fascia
• Superficial temporal fascia is a
thin, highly vascular layer of
moderately dense connective
tissue
• The absence of vascularity
between this two layers

72. TEMPORALIS MUSCLE FLAP
• Hemicoronal flap provides excellent access
• Incision ends above the superior temporal line
• Dissections proceeds down to the deep temporal fascia until the
entire muscle is exposed
• Dissection in this plane protects the temporal branch of facial
nerve
• Reflection of the muscle of the temporal bone should be
performed in a strict subperiosteal plane
• Rotation can be improved by dividing ZA & base of the coronoid

73. TEMPORALIS MUSCLE FLAP
• Donor site - secondarily reconstructed by alloplastic
implants
• Alopecia avoided by careful placement of coronal incision
parallel to hair shaft

77. PECTORALIS MAJOR MYOCUTANEOUS FLAP
• PMMC flaps were originally
developed in 1947 for the
reconstruction of cardiothoracic
tissue defects.
• Ariyan reported the first use of the
PMMC flaps in head and neck
reconstruction in 1979
• Large fan-shaped muscle that covers
much of the anterior thoracic wall

78. PECTORALIS MAJOR MYOCUTANEOUS FLAP
• Origins -three portions.
1 cephalad - medial third
of the clavicle
2 central, sternocostal-
sternum &cartilages of
the first six ribs
3 aponeurosis of the
external oblique, is
variable in size

79. Anatomy
• Vessels

80. Anatomy
• Vessels

81. PECTORALIS MAJOR MYOCUTANEOUS FLAP
Types

82. PECTORALIS MAJOR MYOCUTANEOUS FLAP
ADVANTAGES
• One stage
• Generous portion of skin & soft tissue(400cm2)
• Consistent blood supply – highly reliable
• Adequate arc of rotation for facial defects
• Donor site can be closed primarily
• Two skin islands on the same muscle paddle
• Protects the carotid artery
• Technically, the flap is easy to elevate

83. PECTORALIS MAJOR MYOCUTANEOUS FLAP
DISADVANTAGES
• Arc of rotation limited for oromaxillary defects
• It can be too bulky
• There is distortion of symmetry at the donor site
• Shoulder function is impaired
• Distal skin of the flap is not reliable

87. POTENTIAL PITFALLS
• Incidence of total flap necrosis was reported to be
1.0%, 1.5%, 3%, and 7%.
• Partial flap necrosis- 14%-30%
• Pedicle compression
• In male patients may lead to problems with
excessive hair growth in the oral cavity or pharynx

88. GOOD MORNING

89. Forehead flap
• Provides largest area of donor site (25cm) with matching color &
texture to facial skin
• One of the safest cutaneous flap
• 85% to 95% success
• Long enough to reach any part of the ipsilateral face
• Provides approximately 90sqcm of tissue
• Different types due to variation in flap pedicle

90. Forehead Skin Flap
• Lateral forehead – Zygomatic &
anterior branch
• Main artery- STA superficial to ZA
divides into Anterior STB &
posterior STB
• Cadaver studies
Point of origin
• Failure to include the large
Zygomatic branch may be reason for
reported cases of failure

91. Forehead Skin Flap
• ASTB sends perforating
branches through the
frontalis muscle to supply
the skin
• Centrally forehead is
supplied bilaterally by
• Supratrochlear
• Supraorbital

92. Forehead Flap

93. Forehead Flap
Variations of pedicle of forehead flap
McGregor Millard Wilson

94. Forehead Flap
Various forms of forehead flap

95. Forehead Flap
Operative technique
• STA lies superficial to the
epicranial aponeurosis
• Periosteum from frontal bone
should not be lifted
• Coagulation diathermy should
be minimal
• Small defect direct closure
• Marginal step deformity should
be kept to a minimum

96. Forehead Flap
Outline of various forehead flaps for intraoral use

97. Forehead Flap

98. The finger forehead flap

99. Midline Forehead Skin Flap (Seagull Flap)

100. The Axial Paramedian Forehead flap

101. Island Forehead Skin Flap

102. LATISSIMUS DORSI MYOCUTANEOUS FLAP
• Distant flap, provides largest possible skin paddle, involves
the most complex donor site dissection, and arc of rotation
extremely versatile
• Donor site skin paddle measures 40 X 25 cm & still allows
primary closure
• The latissimus dorsi is very broad muscle of the back with a
fascial origin from T7 to T12, from the lumbar & sacral
vertebrae, from posterior crest of the ilium & also minor
origination from the last four ribs
• Insertion on the intertubercular groove of the humerus

103. LATISSIMUS DORSI MYOCUTANEOUS FLAP
• Extend, adduct, & medially rotate the arm
• Major pedicle is thoracodorsal artery, a terminal branch of
the subscapular artery
• Perforators enter the muscle medially along the spine –
secondary supply

104. LATISSIMUS DORSI MYOCUTANEOUS FLAP
ADVANTAGES
• Size – largest flap in the
body
• Flap location
• Arc of rotation - 180
• Large, reliable unicentric
neurovascular pedicle
• Donor area
• 90% success rate

105. LATISSIMUS DORSI MYOCUTANEOUS FLAP
DISADVANTAGES
• Repositioning of the patient
• Skin paddle is thick & has strong attachment to the
underlying muscle
• Considerable bulk
• Donor area may need skin graft
• It is in competition with other very suitable flaps

106. TRAPEZIUS FLAP
• Mutter 1842
• Originally described as
superior based cutaneous flap
• Flat & triangular and cover the
superoposterior aspect of the
neck & shoulder
• Dominant pedicle, the
transverse cervical artery
• Functions to rotate the
scapula & to elevate, rotate &
adduct upper arm
• 10 x 20 cm in size

107. TRAPEZIUS FLAP
• Lateral positioning of
patient to elevate flap
• Ideally suited for radical
parotidectomy
• Limited to small defects in
oral cavity
• Generous amount of soft
tissue & large portion of
skin island
• 90 – 95 % of success

108. TRAPEZIUS FLAP
ADVANTAGES
• Flap is versatile
• Regionality of flap
• Strong vascular security
• Supplies considerable bulk
• Arc of rotation 90 – 180 degree
• One stage procedure
• Minimum deficit at donor area

109. TRAPEZIUS FLAP
DISADVANTAGES
• Venous system difficult to preserve
• Vascular supply in general difficult to preserve
• Can present with excessive bulk
• Cannot be easily tubed
• Moderate shoulder drop postoperatively

110. DELTOPECTORAL FLAP
• First axial pattern skin flap
• The base of flap is parasternal includes the first three or four
perforating branches of internal mammary artery, second
perforator is largest
• Artery has rich anastomosis, accompanied by vein
• It extend laterally over the upper chest at the level of clavicle on to
the deltoid muscle & shoulder
• Width 8 - 12 cm, Length 18 - 22 cm
• Reverse of deltopectoral flap - Thoracoacromial flap

111. DELTOPECTORAL FLAP
• Superior incision is placed just below the clavicle inferior one run
parallel to it
• Flap raised from lateral extent medially
• Incision is carried down through the pectoral fascia
• Plane of dissection is sub fascial
• Dissection proceeds up to 2 cm of lateral
border of sternum
• Back cut on medial aspect -
improve the flap rotation
• 90% success rate

112. DELTOPECTORAL FLAP
ADVANTAGES
• High biologic dependability
• Readily accessible
• Arc of rotation 45 - 135
• May be used in male, female &
children
• Hairless skin

113. DELTOPECTORAL FLAP
DISADVANTAGES
• Donor site require skin grafting
• Moderate amount of scarring & deformity is unacceptable
in women
• Physiologic disadvantage in malnourished patient or post
operative irradiation
• Flap should not be used if previous scarring on donor area

114. Deltopectoral Flap

115. CONCLUSION
• Goal of flap surgery is to restore-
• Form
• Function and
• Esthetics
• Success in reconstruction of the craniofacial region by local
and regional flaps requires knowledge ,careful preop
planning, skilled tecqniques, and meticulous care after the
surgery

116. References
• Operative Oral and Maxillofacial Surgery 2nd edition
Langdon JD and Patel MF.

117. Lip reconstructions
1/3 of lip defect can be closed primarily
Other reconstructive procedures use residual lip tissues
• Abbe lip switch
• Estlander lip transfer
• Karapandzic maneuver

118. The lip-switch (Abbe) flap
• Most commonly switched
from the lower to the
upper lip
• Composite flap based on
one inferior/superior labial
vessel
• One-third of lip
• Donor lip is closed directly
& reduced in width

119. The lip-switch (Abbe) flap

120. The modified lip-switch (Abbe-Estlander) flap
• Defect extending to the angle of the mouth, same method can
still be used, pedicle becoming the new angle

121. ABBE Estlander Flap

122. The Fan flap
• Used for very large central
full thickness defects of both
upper & lower lips
• Axial flap with small pedicle
• Angle of mouth remains in
its original site
• Donor site primary closure
• Secondary procedure -
commissuroplasty

123. Karapandzic maneuver

125. STERNOCLEDOMASTOID MYOCUTANEOUS
FLAP

126. STERNOCLEDOMASTOID MYOCUTANEOUS
FLAP
• Long strap muscle
• Muscular origin Tendinous
origin
• Insertion
• Spinal accessory nerve
• Dominant blood supply –
branches of occipital artery &
its draining vein
• Middle third of the muscle
• Inferior third of the muscle

127. STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
REPORTED INDICATIONS
• Provision of epithelial lining for mucosal reconstruction
• Closure of orocutaneous fistulas
• Release of scar contracture in submandibular & angle
region
• Provision of additional vascularized tissue around a
bone graft when the tissue bed has been heavily
irradiated

128. STERNOCLEDOMASTOID MYOCUTANEOUS
FLAP
• Superior blood supply
• 6 x 8 cm paddle of skin
• Skin paddle should be kept
overlying the muscle above
the level of clavicle
• Skin paddle is tacked down
to the muscle fascia
• Muscle dissected & elevated
by incising the fascia

129. STERNOCLEDOMASTOID MYOCUTANEOUS
FLAP
• Inferior blood supply
• Branches of superior thyroid
artery are noted to enter the
anterior aspect of muscle at
the level of carotid
bifurcation

130. Temporalis Myofascial Flap

131. Temporalis Myofascial Flap

132. MASSETER FLAP
• Lexer and Eden in 1911
• Short, flat, thick quadrangular
muscle
• Superior belly - downwards &
backwards
• Deep belly - vertically &
slightly forwards
• Massetric nerve & artery
• Hemimandibulectemy
 suturing the masseter to
the hyoid bone to assist in
laryngeal elevation during
swallowing

133. MASSETER FLAP
DISADVANTAGES
• Muscle eliminated in extensive ablative surgery
• Limited in size & volume
• Does not have skin paddle
• Restricted arc of rotation

134. Methods to Improve the Arc of Rotation
• Ariyan's -incorporated a long segment of skin that
extended from the clavicle to the caudal extent of the
muscle
• Distal skin paddle placed over the caudal extent of the
muscle
• Maghee- skin paddle extended over rectus abdominus
• Lee and Lore -removal of a segment of the clavicle to
gain up to 3 cm of length.
• Wilson et al. -tunneling the muscle pedicle deep to the
clavicle in a subperiosteal plane

136. Methods to Deal with Excessive Bulk
• Sharzer et al. - harvesting a vertically oriented
"parasternal” skin paddle that extended across the
sternum to the opposite internal mammary
perforators.

137. • Murakami et al. -eliminating the skin paddle
entirely
• Two-stage procedure
a split-thickness skin graft was placed over the
muscle  3 to 4 weeks later harvest the muscle-
skin graft unit
• Maintain nerve supply or not
Methods to Deal with Excessive Bulk