Head and neck cancer reconstruction is arguably the most challenging area of reconstruction for the reconstructive surgeon. A clear understanding of the principles of use of local flaps and a comprehensive understanding of the anatomy of these flaps provides the head and neck surgeon with a plethora of local and regional options for primary and secondary reconstruction.

1. Reconstructive Surgery for
Head and Neck Cancer
Dr. Shashank Bhushan
Dept. of.Oral and maxillofacial surgery
Buddha institute of dental science and hospital

2. INTRODUCTION
• Reconstruction within the head and neck is challenging. Defects
can be anatomically complex and may already be compromised by
scarring, inflammation, and infection.
• The principle of this combined approach is to provide
A)The patient with the optimal cancer treatment for the
stage of disease.
B)Maximize the quality of life for the patient, with
preservation or restoration of form and function.
American Cancer Society Atlas of Clinical Oncology Cancer of the Head and Neck Editor Jatin P. Shah,

3. HISTORY OF HEAD AND NECK
RECONSTRUCTION
Historically, the cheek flap and the forehead flap were probably the
first flaps for head and neck reconstruction.
The cheek flap was first described for nasal reconstruction by
Sushruta in 600–800BC, and so plastic surgery as a specialty was
born over 2000 years ago in India.
In his book, the Sushruta Samhita (roughly translated as Sushruta’s
Compendium), Sushruta wrote detailed notes on nasal
reconstruction.

4. Sushruta described the use of a template made from a leaf which
was then placed on the cheek from where the flap was raised. The
cheek rhinoplasty flap of Sushruta was later modified by using a
forehead flap, based probably on the supratrochlear vessels or
midline forehead vessels and became known as the traditional
method of Indian rhinoplasty.

6. It was when British surgeons working in India saw the results of
Indian rhinoplasty and the procedure was described in the Madras
Gazette in the October 1794 issue of the Gentleman’s Magazine of
London.
The first reported case of an Indian rhinoplasty in the Western
world was performed by Joseph Constantine Carpue in 1815 and
the procedure gained popularity subsequently within Europe and
the USA

8. WHY
??
WHEN
??
HOW
??

9. WHY????
• Exposure of vital structures such as the brain, eye, or major
neurovascular structures.
• Impairment in the performance of routine daily functions, such as
speech and swallowing.
• Esthetic disfigurement
• To preserve and restore preoperative activity and quality of life.

10. GOAL OF RECONSTRUCTION
• Restoration of function.
• Restoration of cervicofacial symmetry and form
• Creation of barrier between cavities and spaces in head and neck that
should not communicate.
• Facial reanimation
• Dental rehabilitation.
Maxillofacial surgery Peterward booth 3rd edition

11. WHEN ?????
• Ideally, reconstruction of a surgical defect should be performed
immediately—at the time of tumor resection.
• Immediate reconstruction prevents retraction and fibrosis of the
defect, allow administration of adjuvant therapy, minimizes the
number of surgical procedures and favors psychologic
rehabilitation.

12. • Some authors, advocated delayed reconstruction for the
identification of tumor recurrence, because it might be difficult to
monitor if the cancer defect is covered with a flap.
• With development of better diagnostic techniques (ie, computed
tomographic scanning, magnetic resonance imaging and positron
emission tomography), delayed reconstruction to detect tumor
recurrence earlier is no longer valid.

13. HOW ??
• Surgical options for head and neck reconstruction have been described
schematically as a ladder:
1. Direct closure
2. Skin grafting
3. Local flaps,
4. Regional cutaneous and myocutaneous
5. Distant flaps
American Cancer Society Atlas of Clinical Oncology Cancer of the Head and Neck Editor Jatin P. Shah

14. 1. DIRECT CLOSURE
• The skin in the face and neck is very elastic and its laxity allows
extensive undermining and direct closure, particularly in elderly
patients.
• In order to minimize the visible scar, the excision should be designed
to fall within the relaxed skin tension lines .
• Whenever possible, primary closure should be used for repair of
defects of the eyelids and lips. Up to one-third of the eyelid and lip
can be resected in a V fashion, with primary closure.

17. • Straight-line repair perpendicular to the lid or lip margin will result in the best
esthetic and functional result

18. 2.SKIN GRAFTS
SKIN GRAFTS
• Split-thickness
• Full-thickness
• Skin grafts can used for resurfacing well-vascularized soft tissues,
periosteum and perichondrium.
• Exposed bone, cartilage ,heavily irradiated, unstable or contaminated
tissues will not allow skin grafts
• therefore be covered with well-
vascularized tissues or débrided sufficiently to allow granulation
tissue formation before skin grafting.

20. Split-thickness grafts are used to resurface large defects.
They contract more, are less durable, once healed become more
prominent and recover less sensation than full-thickness skin grafts.
It provide simple and reliable coverage for cutaneous defects of the
head and neck, but because of color and contour mismatch they are
generally considered inferior to full-thickness grafts and soft-tissue
flaps.

21. Full-thickness skin grafts are suitable only for small defects because
their donor sites must be closed primarily.
Color match and texture of full-thickness skin grafts is better,
particularly in the Caucasian patient.
Within the head and neck, they are a good choice for resurfacing
eyelids and small nasal skin defects.
Usual donor sites for full-thickness skin grafts are the forehead,
preauricular, postauricular, contralateral eyelid and supraclavicular
regions.

22. Skin grafts have also been used to resurface intraoral defects
confined to the floor of the mouth, lateral aspect of the tongue,
retromolar trigone or cheek mucosa.
Due to unpredictable scarring and contraction of skin grafts used
intraorally, it is imperative that such defects be limited to achieve
the best results.

23. 3. FLAPS
A flap is a full-thickness segment of tissue that has its own blood
supply.
• A/C the type of tissue
1. Cutaneous or fasciocutaneous
2. Muscle or musculocutaneous
3. Osseous or osteocutaneous.

24. A/C to their location (donor site)
• 1)local, 2)regional 3) distant.
A/C to the method of mobilization of the tissue
• 1)A rotation,2)transposition,3)advancement or free (tissue
transplantation) flap.
A/C to the blood supply they receive:
• 1)random (based on local subdermal blood supply),
• 2)axial (containing a discrete vascular pedicle),
• 3)free (containing a discrete vascular pedicle which is detached
and transplanted to new recipient vessels).

25. • A combination of these terms is used to describe the type of flap
that is used for reconstruction.
• For exampleA pectoralis major flap is a regional myocutaneous
pedicled flap that may be either rotated or advanced to
reconstruct a head and neck defect.

26. LOCAL FLAP
Local flaps consist of tissue that is mostly detached from
surrounding tissue but retains enough connection to preserve an
adequate blood supply to the entire flap.
These are mostly cutaneous flaps that are used very often for
reconstruction of small- to moderate- sized cutaneous defects of the
head and neck.
Local flaps may be transposed, rotated or advanced,and the donor
site closed primarily. Examples of local flaps frequently used for
reconstruction of facial defects include the Limberg or rhomboid
(transposition), V-Y (advancement).

30. The borrowed tissue is mobilized and left attached to the defect for 3
weeks. At this time collateral neo-vascularization to the flap is
developed at the recipient site, the original vascular pedicle is
divided and both defects closed primarily.

31. Random Flaps
A random flap is a cutaneous flap (ie, skin and subcutaneous tissue)
that receives its blood supply through the subdermal capillary
plexus.
Transposition, rotation or advancement flaps
length-to width ratio limits the size of a random flap.( this ratio
should be no larger than 3 to 1).

32. due to delay procedure, the flap consists of partially raising the skin
flap and suturing it back to its vascular bed for 2 to 3 weeks.
In general, delaying a flap allows for the successful transfer of a
larger flap with an increased length-to-width ratio. Expanding
adjacent tissue to obtain larger skin flaps with the same color and
texture as the recipient site functions also as a gradual delay
phenomenon.

33. AXIAL FLAPS
Axial flaps are skin and subcutaneous tissue segments designed to
parallel the major axis of a named vessel.
This allows further mobilization of the cutaneous segment.
Due to an identifiable blood supply, length-to-width ratio of axial
flaps is not a concern and survival is increased when compared to
random flaps.

34. Head and neck reconstruction are based on the median or
paramedian forehead flap (supratrochlear vessels ) and nasolabial
flap (the labial marginal artery and vein ).

35. Scalp and Frontal Flaps
These flaps are based on the superficial temporal vessels,the
supratrochlear vessels and/or the occipital vessels.
Hair-bearing flaps are used for reconstruction of moderate-sized
defects in the frontal or occipital region.

36. The Orticochea triple scalp flap consists of two flaps based on the
superficial temporal vessels on each side and a larger third flap based on
both occipital arteries.
The flaps are elevated in the loose areolar tissue plane between the
pericranium and the galea aponeurotica.
Many parallel incisions are made in the aponeurosis of the flaps to increase
mobilization.
The flaps are then advanced and sutured to each other over the defect

38. Flaps based on the parietal branch of the superficial temporal artery
include only hair-bearing skin (the temporo parieto occipital flap).
This flap may be used for reconstruction of the anterior hairline,
eyebrow, and mustache. Flaps based on the frontal branch of the
superficial temporal artery may include hair-bearing skin and the
forehead (scalping flap), or the entire forehead unit (frontal flap).
An important disadvantage of the scalping of frontal flap is that the
donor site has to be skin grafted

39. Paramedian Forehead Flap
This axial flap is commonly used for external coverage in nasal
reconstruction.
It is based on the supratrochlear artery and vein, running on the
undersurface of the flap.
The distal third of the flap is elevated subcutaneously; the middle third
includes part of the frontalis muscle, and from 1 cm above the
supraorbital rim, flap elevation is in the subperiosteal plane.

41. The flap is rotated 180 degrees and remains attached to the pedicle
for 3 to 6 weeks, to allow development of collateral circulation,
before division of the feeding vessels.
The forehead donor defect is generally closed primarily. When the
donor site cannot be completely closed, healing by secondary
intention of the remaining defect produces good esthetic results

42. Nasolabial Flaps
The skin parallel to the nasolabial fold can be raised as an axial cutaneous
flap.
Depending upon flap design (either superiorly- or inferiorly-based), the
blood supply is provided by branches of the facial,infraorbital and
angular vessels.
Superiorly-based nasolabial flaps are more useful for reconstruction of
small-sized nasal defects, due to easier transposition.
The inferiorly-based pedicle flap is often advanced in a V-Y fashion for
cheek or upper lip defects.

44. Nasolabial flaps are usually elevated in a superficial subcutaneous
plane that excludes the main vascular pedicle.
The donor site is usually closed primarily, with the scar concealed
within the skin fold. Sometimes a secondary revision may be
needed.
Bilateral nasolabial flaps, based on the facial artery and vein, have
been used to resurface floor of mouth and intraoral defects.

45. MUSCLE
AND
MUSCULOCUTANEOUS
FLAPS

46. This development in reconstructive surgery has significantly:
Maximized flap survival
Allowed reconstruction of larger head and neck defects that could
not be covered with local flaps.

47. Temporalis Muscle Flap
The temporalis muscle originates from the temporal fossa and
inserts into the coronoid process of the mandible.
Its blood supply is provided by the deep temporal vessels
The temporal branch of the facial nerve is at risk for injury during
flap harvest.
Functional this flap is minimal and the donor site can be closed
primarily..

49. The temporalis muscle flap may be transferred as a turnover flap
using the coronoid process as rotation pivot.
To maximize flap excursion, the central portion of the zygomatic
arch should be removed temporarily
Its main utility is to cover cheek, palatal and pharyngeal defects.

50. Pectoralis Major Flap
Most frequently used pedicled flap for head and neck reconstruction.
The PM muscle originates from the clavicle, the first five ribs, the
xiphoid, and from the upper abdominal muscles.
It inserts on the humerus.
Its blood supply is provided by branches of the thoracoacromial
trunk.

52. The skin paddle can be located anywhere over the muscle
pedicle.
The vertical paddle up to 8 x 17 cm raised over the sternal origin
of the muscle, which provides thin skin and allows primary
closure of the donor defect.
The skin island may extend into the inframammary fold and
multiple skin paddles can be carried on the same muscle pedicle

55. The PM flap has been used to resurface cervical, facial, intraoral
and pharyngeal defects.
The donor site may be closed primarily; however, a very noticeable
scar and nipple-areola distortion is often observed. Large or
multiple skin islands may result in the need for donor site skin
grafting.

56. Latissimus Dorsi Flap
• The latissimus dorsi (LD) muscle originates from the six caudal
thoracic spines and fascia, the lumbar spines and fascia, and the
posterior iliac crest.
• It inserts into the humerus.
• Its blood supply is from the thoracodorsal artery, accompanied by
the thoracodorsal vein and nerve.

58. One or more skin islands with different orientation may be outlined
over the muscle .
A maximum size of 12 x 35 cm allows direct closure. For head and
neck reconstruction, it is advisable to design the skin island distally
over the lateral border of the muscle in order to reach the defect.
The flap is transferred to the head and neck through a tunnel either
subcutaneously or beneath the pectoralis muscle.

59. As a pedicled flap it is a useful option for neck and cheek defects
that do not extend beyond the buccomandibular subunit. The
donor site is usually closed primarily.

60. Trapezius Flap
The trapezius muscle originates from the occipital bone and the
lateral processes of the seventh cervical and all thoracic vertebrae.
It inserts into the scapular spine, acromion, and lateral third of the
clavicle.
The trapezius myocutaneous flap may be transferred as a
horizontal, lateral or vertical flap.

62. The horizontal myocutaneous trapezius flap (7 ×30 cm) receives
its blood supply from a branch of the occipital artery in the
uppermost part,
This flap has a large arc of rotation
Used for reconstruction of the floor of mouth, cheek, temporal
fossa and occiput .
Closure of the donor site requires a skin graft.

64. The lateral trapezius flap is based on the transverse cervical artery,
arising from the subclavian artery.
The skin island is centered over the acromioclavicular joint, and the
muscle may carry the scapular spine.
This flap has been used for reconstruction of floor of mouth, midfacial
and mandibular defects.

65. The vertical trapezius flap the blood supply comes from the dorsal
scapular artery,, near the cranial border of the scapula.
It descends vertically midway between the vertebral column and
the medial border of the scapula, where the skin island of the flap
usually is centered.
Its caudal end may extend beyond the muscle and has a random
blood supply.

66. The skin island may be as large as 9 x 20 cm.
The donor site may be closed primarily if it is less than 9.0 cm
wide;
This flap has been used for reconstruction of defects centered
around the orbit and upward to the skull, across the midline, or for
intracranial reconstruction.

67. Deltopectoral Flap
• The deltopectoral flap was the workhorse for intraoral, cheek and
neck reconstruction in the 1960s and 1970s.
• The flap is based on the first, second, and third perforators of the
internal mammary artery and associated venae comitantes.
• The base of the flap is located at 2 cm from the sternal edge, where
the perforators pierce.

70. • Cranial incision follows the infraclavicular line and the caudal
incision parallels the cranial incision.
• The flap extends to the shoulder or even the upper arm.
• The deltopectoral flap has been used to resurface defects of the
neck, face, and oral cavity .
• The donor site must be skin grafted, resulting in a significant
disfigurement

71. FASCIOCUTANEOUS
FLAPS

72. Fasciocutaneous flaps were described after recognition of certain
patterns of cutaneous blood supply.
These fascial vessels connect both: to perforating vessels from the
underlying muscles, and to the subcutaneous tissue vessels above
them
At least three types of fasciocutaneous flaps exist according to
their blood supply configuration.

73. Type A flaps are those fed by multiple small, longitudinal vessels that
course with the deep fascia. This type of flap must be raised with a
base of a certain width to ensure its vascular supply and therefore
cannot be raised as an island. The majority are described on the lower
leg.

74. Type B flaps are those fed by a single major vessel within the fascia (scapular
or lateral arm flap).
Type C flaps are those supplied by multiple perforating segments from a
major vessel that courses through intermuscular septa (eg, radial forearm
flap)
All fasciocutaneous flaps described for head and neck reconstruction can
only be transferred as free flaps

75. FREE FLAPS
Different specialized tissues receiving blood supply from specific
vessels are totally detached from the donor site and the artery and
vein are reconnected at the recipient site by performing vascular
anastomoses with the aid of magnification Systems.

76. Radial Forearm Free Flap
fasciocutaneous free flap, based on the radial artery and cephalic
vein or venae comitantes.
It consists of thin, pliable skin with minimal soft tissue and a very
long pedicle with a large diameter.

78. The donor site is closed by
reapproximating 1he proximal skin
flaps as shown. The remainder of the
defect is closed wi1h a split-thickness
skin graft.

79. The radial forearm free flap can be designed to include tendons, muscle, or a
vascularized segment of bone up to 12 cm in length, based on the same
vascular pedicle.
These characteristics have made it a very useful flap for intraoral, pharyngeal
and cutaneous facial defects The radial forearm osteocutaneous free flap has
been very useful for reconstruction of maxillary and mandibular defects

80. Lateral Arm
The lateral arm flap is a useful free flap for head and neck
reconstruction due to the following advantages:
there is no need to sacrifice an artery that may be essential to
the vascularity of the distal upper extremity (as compared to the
radial forearm free flap).
it is possible to close the donor defect primarily
The maximum dimensions of the cutaneous paddle are 18 × 11 cm,
in order to allow primary closure of the posterior aspect of the arm

83. The skin paddle is moderately pliable and the recovery of
sensation is made possible by anastomosing the posterior
cutaneous nerve of the arm to a recipient nerve in the head and
neck.
This sensate lateral arm flap has been used for restoration of the
oral cavity and for partial glossectomy defects.

84. Rectus Abdominis
The rectus abdominis muscle is flat and thin, with a large skin
island over the muscle that may be oriented in a vertical transverse
or oblique fashion.
In obese patients, however, the flap may be too bulky and
therefore it is preferable to transfer the muscle alone, covered with
a split-thickness skin graft.

86. The deep inferior epigastric artery and vein are vessels with a large
caliber (2 to 3 mm) and length (8 to 10 cm).
Another advantage of the rectus abdominis flap for head and neck
reconstruction is the possibility of harvesting the flap at the same
time the ablative procedure is being performed, without needing to
change the position of the patient.

88. Such requirements are usually observed after wide excision of
scalp or skull base tumors, total maxillectomy and midfacial
defects,orbitomaxillectomy, and composite resections of mandible
and soft tissue

89. Latissimus Dorsi
Musculocutaneous flap for head and neck reconstruction.
The latissimus dorsi is a broad and flat muscle that is very useful to
reconstruct extensive scalp defects, especially following resection of
large tumors or débridement of calvaria for osteoradionecrosis.
Used for reconstruction of extensive orbitomaxillary or skull base defects
that require minor soft-tissue fill and a cutaneous surface.

91. For more complex defects of the midface that require two
epithelial surfaces, the latissimus dorsi may be harvested with two
skin paddles; the intervening bridge of skin is de-epithelized and
the muscle folded to repair the inner mucosal lining and the
overlying skin

92. Osseous
and
Osseocutaneous Free
Flaps

93. Fibula
Introduced first for mandible reconstruction in 1989.
The primary application of the fibular donor site is in the
reconstruction of segmental defects of the mandible.
The excellent periosteal circulation permits multiple osteotomies
with reliable perfusion on each bony segment; thus allowing shaping
and remodeling of the bone to duplicate the inferior border of the
mandible

97. Approximately 22 to 25 cm of bone can be harvested from the fibula.
This thick cortical long bone receives its endosteal and periosteal
blood supply from the peroneal artery and veins which run along the
entire length of the fibula.
It has adequate bone stock for incorporating osseointegrated dental
implants.

98. Donor site morbidity is usually minimal. The leg defect may be
closed primarily when a narrow skin island (less than 4 cm in
width) is included with the flap; otherwise a skin graft is
necessary to close the donor site.
Some patients may experience transitory stiffness in the ankle
joint, however, no physical limitations are usually observed

99. Scapula
Large separated skin islands, muscle or musculocutaneous units and
bone may be transferred based on one single pedicle.
The length of bone that can be harvested from the lateral border of
the scapula ranges from 10 to 14 cm.

101. The thickness of this bone, however, is not enough to place
osseointegrated dental implants and therefore it is selected only for
reconstruction of mandibular defects that involve the ascending
ramus and require moderate to large amounts of soft-tissue fill over
the cheek .

102. As an osseocutaneous composite flap the scapular flap also has been
used to reconstruct maxillectomy and midfacial defects. The floor of
the orbit or palate is reconstructed with the bony segment and one
or two skin islands are used for inner lining and/or skin coverage.

103. Visceral Free Flaps
Jejunum
Currently the jejunal free graft is used as a mucosal tube or
mucosal patch (depending on the configuration of the defect) for
reconstruction of the hypopharynx or cervical esophagus.
The small intestine segment to be transferred is usually 40 cm distal
to the ligament of Treitz.

104. A, Defect after total
laryngopharyngectomy
Jejunal free flap.
Pharynx reconstruction
with jejunal free flap.

105. CONCLUSION
In summary, head and neck cancer reconstruction is arguably the
most challenging area of reconstruction for the reconstructive
surgeon. We need to consider functional and aesthetic considerations
as well as some of the unique characteristics of the structures in the
region. The majority of complex defects are reconstructed with free
tissue transfers, pedicled local or regional flaps have a major role to
play in head and neck reconstruction.

106. A clear understanding of the principles of use of local flaps and
a comprehensive understanding of the anatomy of these flaps
provides the head and neck surgeon with a plethora of local and
regional options for primary and secondary reconstruction.

107. Reference
• Stell and Maran's textbook of head and neck surgery and oncology .
• American Cancer Society Atlas of Clinical Oncology Cancer of the
Head and Neck Editor Jatin P. Shah.
• Maxillofacial surgery Peterward booth 3rd edition.
• Fonseca Maxillofacial surgery.
• Urken Atlas of Regional and Free Flaps for Head and Neck
Reconstruction_ Flap Harvest and Insetting

108. THANK
YOU