This document provides an overview of reconstruction techniques in head and neck surgery. It discusses Gillie's principles of reconstruction and the reconstructive ladder. It describes various techniques including skin grafts, local flaps such as nasolabial and forehead flaps, distant flaps such as deltopectoral and latissimus dorsi flaps, and free tissue transfers including radial forearm and fibula flaps. It discusses factors to consider for each technique such as blood supply, advantages, disadvantages and appropriate applications in head and neck reconstruction.

1. Reconstruction techniques in head and neck
BY DR. HASEEB AHMED
3RD YEAR RESIDENT
ENT-II , AHF

2. Gillie’s principles of reconstructive
surgery
‘Losses must be replaced in kind’
‘Treat the primary defect’
‘Thou shalt provide thyself with a life boat’
‘Thou shalt not throw away a living thing’
‘Replace things in to their normal position by recreation of the defect’

3. Reconstructive ladder
Secondary Intention
Primary intention
Delayed primary closure
Skin grafts
Tissue expansion
Local tissue transfer
Free tissue transfer

4. Relaxed skin tension lines:
These lines are parallel to natural skin wrinkles and tend to be perpendicular to the underlying muscle
fibers.
Cosmetic subunits:
Ideally, individual subunits should be reconstructed separately and scars shouldn't cross the subunits
if possible.

7. Skin grafts
A skin graft is something that is potentially dead and its survival depends on how its treated.
Lifespan up to 3 weeks if wrapped and moistened with normal saline at 4 degrees
types:
Split thickness
Full thickness
Composite
Pinch
Fat and dermal
Chondro-mucosal

8. Graft take
1.Skin graft adherence
2.Serum imbibition
3.Revascularization
4.Remodeling
Factors affecting the take:
Most common cause of graft loss is haematoma or seroma
Streptococcus pyogenes, Pseudomonas aeruginosa and MRSA
Diabetes , smoking , previous radiotherapy and chemotherapy

9. Split thickness skin graft(STSGs)
Thickness depends upon the amount of dermis that is included with the epidermis
1. Thin
2. Intermediate
3. Thick
Graft taken with dermatome (0.3-0.4mm) or humby knife(0.3mm)
Under goes increased secondary contraction
Less robust , abnormal pigmentation and limited sensory recovery
Donor site heals by re-epithelization by hail follicles

12. Full thickness skin graft
Takes with it full thickness of dermis
Graft is taken with a scalpel
Donor site heals by secondary intention
It is bulky, contracts less and has increased chances of failure due to higher metabolic rate
Pigmentation is almost the same as the recipient
It is more robust and has a better sensory recovery

13. Bare bone or cartilage doesn't take graft
Crane principle is used for this purpose
Surfaces that take graft well are:
1.Granulation tissue
2.Soft tissues of face
3.Muscle fascia and fat cartilage
4.Bone covered with periosteum or perichondrium

16. Flaps
A flap is a graft that remains attached at one or more points to its pedicle which provides an
arterial blood supply with venous and lymphatic drainage.
Types
1.Local
2.Distant axial
3.Myocutaneous
4.Free flap

17. Local flaps
It is composed of tissue adjacent to the defect
Classification based on:
a.Blood supply:
1.Random flaps
2.Axial flaps
b.Method of movement
1.Advancement flap
2.Pivot flap
3.Interpolation flap

18. c.Composition:
1.Skin
2.Visceral
3.Muscle
4.Mucosal
5.Composite

19. Random flaps
Based on rich subdermal vascular plexus of skin
Most of the local flaps are random flaps
length : breadth ratio of up to 3 : 1 in the face.

20. Axial flaps
Derive their blood supply from a direct cutaneous artery or named blood vessel.
Examples :Nasolabial flap (angular artery) ,Forehead flap(supratrochlear artery).
The surviving length of an axial pattern flap is entirely related to the length of the included
artery.

22. Based on vascular pedicle types
In muscles
Type I: one vascular pedicle
Type II: dominant pedicle (s) + minor pedicles
Type III: two dominant pedicles
Type IV: Segmental vascular pedicles
Type V: dominant pedicle + secondary segmental pedicles

24. Advancement flaps
Burrows Triangle’s: Flap moves in a straight path without any lateral movement into the primary
defect.
sites – forehead, brow, cheek.
V-Y adv. Flap: A V shaped flap is moved into a defect with primary closure of the donor area leaving
a final Y shaped suture line. It is pedicled from the underlying subcutaneous tissue rather than the
surrounding skin. Ideal for Lesion in the cheek and alar base.
Panthographic expansion: 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.

27. Pivot Flaps
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
Rhomboid flaps: A flap where the donor defect is closed directly. The rhomboid has sides equal
in length and angles of 120 degree and 60 degree respectively. Scar should be parallel to the
relaxed skin tension line.

28. Pivot flaps cont.
Flag or banner flaps: glabellar flap.
Blobbed flap: The first flap is transposed in to the primary defect, the second flap is transposed
in to the secondary defect and the tertiary defect is closed primarily. Used to deal with defects
on the tip of nose.
Tripier flap

33. Interpolation flaps
An interpolation flap is from a nearby, but not immediately adjacent donor Site and transposed
either above or below the intervening skin to the Recipient defect.
Types:
Cutaneous: requires two stage procedure but more reliable
Subcutaneous Island
E.g.: Median forehead flap ,Nasolabial flap

34. Nasolabial flap
Reconstruction of facial skin defects of the upper lip, nose and cheek following extirpation of
skin cancers.
Superiorly based nasolabial flap- closure of the oro-antral fistulae.
The bilateral inferiorly based nasolabial flap has utility in the reconstruction of the anterior
defects of the floor of the mouth.
Defect in the anterior face, nose and upper lip, floor of the mouth, OAF

36. Median forehead flap
The forehead flap is an axial flap used to reconstruct defects below the level of the eyes. The
most commonly raised forehead flap is the cutaneous axial median forehead flap, based on the
supratrochlear artery. It can be raised and transposed to reconstruct areas in the upper medial
cheek region and the lower half of the nose and alar rim
If a radial forearm flap fails in the mouth and an immediate, reliable 'lifeboat' is required; the
forehead flap may be quickly raised to get the surgeon out of trouble!

38. Distant axial flaps
Deltopectoral flap:
Based on upper 3-4 branches of internal mammary artery
Boundaries:
a. superiorly: clavicle
b. Laterally: acromium
c. Inferiorly: a line drawn from the anteriorly axillary fold to just above the nipple.

39. Deltopectoral flap cont.
Retracts from side to side and not from end to end
Flexibility is due to anomalous pivot point
The pectoral fascia is left on the flap leaving the muscle fibers below absolutely bare.
Donor site is covered with a split skin graft
Uses:
1. To cover the whole anterior neck skin
2. To reconstruct a defect by passing as a bridge over a normal tissue
3. To reconstruct large defects on the lower face and upper neck

41. Myocutaneous flaps
Essential surgical points:
a. Blood supply of the muscle is axial while that of the overlying skin is random
b. There is a minimum size of skin paddle to insure its survival
c. For pec major and lat dorsi flap its 5x3 cm( the size of the palm of an adult hand)

42. Pectoralis major flap
Pec major has a type V blood supply
Flap is based on the pectoral branch of acromiothoracic artery which arises from the first part of
axillary artery.
Highly reliable even if the skin paddle fails the underlying muscle will usually survive and can be
allowed to granulate and heal by secondary intention, or covered subsequently with a skin graft.
With the pt in supine position the surface markings of the acromiothoracic artery are outlined.
A dotted line is marked from the acromium to the xiphoid process and a further dotted line is
dropped to join this line in a perpendicular direction from sternal notch.

43. The point at which line bisects the first line represents the place where the vascular pedicle
meets the first line which then runs in the direction of the first line from the acromium towards
the xiphisternum.
Advantages and uses:
1. Large skin territory
2. Rich vascular supply
3. Large arc of rotation
4. Can be harvested in supine position

44. 5. Can be transferred as muscle only , skin and muscle paddle or as 2 epithelial surfaces for inner
and outer lining with the de-epitheliazed segment b/w them.
6. Primary donor site closure is easily achievable
7. Usually used to fill large defects where mobility is not of paramount
as in the repair of fistulae.
Disadvantages:
1. Bulky
2. Virtually impossible to tube it

45. 3. Cannot be used in females as it violates the breast.
4. Retracts by 10% in all directions
Congenital absence of pec major 1: 11000
Congenital absence of sternocostal head occurs in Poland syndrome.

47. Latissimus dorsi flap
Based on thoracodorsal artery
Flaps measuring 10x8 cm are easily harvested with primary closure of donor site.
Can be used as both myocutaneous or free flap, its long pedicle(10cm) is reliable and can be
lengthened by dividing the circumflex scapular artery.
It is used in filling of larger holes in head and neck and for the repair of nasopharyngeal fistulae
rather than use within the oral cavity, unless required to repair defects following total
glossectomy

48. Advanatages:
1. Large amounts of tissue transferred
2. Pedicled or free tissue transfer
3. Cosmetic advantage especialy females
4. versatile: may be tubed/multiple/osseous components
5. When pedicled can reach the upper face and scalp

49. Disadvantages:
1. Very bulky
2. Occasional donor site dehiscence
3. Reduction in upper limb power
4. Need to move the patient to harvest

51. Sternomastoid flap
Platysma flap

52. Free tissue transfer
Radial free forearm flap:
Based on radial artery
It is one of the workhorses for head and neck reconstruction, providing pliable skin which may
be used to reconstruct three dimensional defects, particularly within the oral cavity. It can
provide skin and fascia and if required, vascularized tendon, nerve and bone may be combined
in the flap. It may be use as a fascial flap for recontouring.
Allen’s and Doppler angiography is done pre-op to check the patency of ulnar artery.

53. The radial artery sits in the condensation of the intermuscular septum in a trench in between
brachioradialis and flexor carpi ulnaris and flap elevation must allow the artery to be raised with
the septum.
Upto 10cm of bone can be taken with the flap between pronator teres and pronator quadratus
The thickness of the bone that can be taken with safety is less than half the cross section of
radius.

54. Advantages:
1.Suited for 3 dimensional intraoral reconstruction
2. Provides a sensate flap via 2 cutaneous forearm nerves
3. Preoperative assessment is possible
4. Easy to raise
5. Reliable
6. Thin , pliable skin
7. Long pedicle
8.Good sized vessels
9. versatile

56. Lat dorsi flap
Rectus abdominus flap
Free jejunal flap
Scapular flap
DCIA flap

57. Fibula flap
Based on peroneal artery
Upto 20-25cm of bone can be harvested
The skin paddle is a fasciocutaneous flap centered on the peroneal intermuscular septum and
therefore the deep fascia must always be included when the flap is raised.
The segment of bone to be used is based on the midportion of fibula
The pedicle is short , and for head and neck reconstruction it may be necessary to take a
saphenous vein graft and perform an A-V fistula in the neck i.e. joining the ECA or 1 of its
branches to the IJV with the graft and allowing this to function.

58. Uses:
Provides good cortical bone which is reliable
Ideally suited for angle to angle mandibular defects
Also useful for maxillary reconstruction
Major disadvantage is that the skin paddle is unreliable.

61. Occasionally used free flaps in head and neck:
Pec minor flap
Temporoparietal flap
Groin flap
Gracilis flap
Serratus anterior flap
Omentum flap

62. Recent advances
Navigational systems
Stereo lithographic models
Robotic surgery
TISSUE ENGINEERING
ALLOTRANSPLANTS

63. Thank you for listening
SOURCES
Stell & Marans 4th edition
Stell & Marans 5th edition
Scott brown 8th edition
internet