1. Local Flaps used
in
Head & Neck Reconstruction
Local flaps
Dr V.RAMKUMAR
CONSULTANT DENTAL&FACIOMAXILLARY
SURGEON
REG NO:4118-TAMILNADU-INDIA(ASIA)
3. What is ……
Flap:
In its basic form is a tongue of tissue
consisting of the entire thickness of skin
and variable amount of subcutaneous
tissue, which is transferred from one site
to another.
(McGregor)
4. Local / Regional flaps – Goals
(Kinnerw & Jeter)
1. Adequate color match
2. Adequate thickness – avoid protrusions or
deficiencies
3. Preservation of clinically perceivable
sensory innervation
4. Sufficient laxity – avoid retraction or
deranged function
5. Resultant suture lines of either primary or
secondary defects are restricted to
anatomic units and fall within natural skin
lines.
5. Delay of Flap: surgical outlining - before
actual transfer -improve circulation.
(1- 2 weeks)
2 basic schools
1. Delay improves nutrient blood flow
2. Delay increases the tolerance of the
cells to ischemia, allowing them to
survive at a lower flow rate.
6. Planning in Reverse : used when a local flaps
jumps over skin and in distant flaps.
( a piece of fabric to represent it the flap is
taken in reverse through various stages of
the mock transfer to ensure that the real
flap is large enough and long enough to
reach its destination without kinking or
undue tension at any stage of transfer)
7. Classification of flaps
1. Based on movement
Local flaps:
Advancement (single / bipedicle, V-Y)
Pivotal : Rotation
Transposition
Interpolation
Distant flaps
Direct
Tube
Microvascular (free)
8. Local Flap:
skin flap taken from an area close to the wound.
E.g. a wound on the lip may be repaired by a
flap from the adjacent cheek.
Regional Flap:
skin flap is not from the adjacent area, but is
from the same region of the body.
E.g. a wound on the tip of nose might be repaired with
a flap from the forehead.
9. Distant Flap:
- When a flap is from a different part of
the body.
- Any flap taken from below the lower
border of the mandible is considered a
distant flap.
A local flap repair is usually
done in one operation, whereas
regional and distant flaps need two or
more operations.
10. Free Flap:
This is a distant flap, but the whole
procedure is done in one stage by
repairing the donor and recipient
blood vessels by microsurgery.
11. 2. Based on blood supply:
Axial
Random
Daniel (1973) blood supply to skin:
Musculocutaneous arteries
random arteries
myocutaneous
Septocutaneous arteries
fasciocutaneous
arterial
Septocutaneous arteries
12. Musculocutaneous system: Vascular system penetrating the
underlying muscles and then continues to supply the skin.
Random cutaneous: it is composed of skin and subcutaneous fat with
multiple musculocutaneous arteries at the base.
Myocutaneous flap: it is composed of skin, subcutaneous fat and
muscle with its blood supply coming from muscular arteries
plus numerous terminal musculocutaneous arteries.
15. Based on vascular pedicle types
In muscles
Mathes and Nahai (1979)
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
16. Areas of skin availability exploited most commonly
for facial local flap transfer
Palpation & PINCH Test
17. Advancement flaps
flap moves in a straight path without any lateral
movement into the primary defect.
(Burrows Triangle’s)
sites – forehead, brow, cheek.
Single advancement flap:
movement is entirely in one direction.
18. Bilateral advancement flap:
When large tissue is required.
Same technique & principle.
used:
forehead, mustache area
and posterior neck.
19. A to T flap:
variant of bilateral advancement flap
Useful for
defects at the periphery of the face
around the nasal ala and upper lip
dog–ear almost always forms
Disadvantages:
number of scars- created with the three limbs and Burow’s triangle
and with the three point closure
20. 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.
It is pedicled from the underlying subcutaneous
tissue rather than the surrounding skin.
Ideal for Lesion in
the cheek
and alar base
21. Burow’s triangular flap
Variation of advancement flap
cover those areas on the face where there are
anatomical structures on one side of the defect
that should not be pulled or stretched.
repair of upper lip or over the lateral eyebrow,
Point C moves to point B
&
point D moves to point F
22. 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.
23. 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
isosceles triangle- triangulation of the defect
24. 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
atleast 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.
25. Rotation flaps: it is semicircular flap that rotates about a pivot point
to fill the defect.
Place the arc closest to the defect higher than the defect itself,
to reach the most distal point of the defect
Should be 5-8 times the width of the defect
26. Simple rotation flap
Ideally suited on a convex surface
cheek
Submandibular area
28. Transposition flaps
Classic form - a rectangle or near square which is raised
and moved laterally into a triangular defect
In a correctly designed flap, the distance from the pivot point to A
equals the distance to B and the transfer is carried without tension
sites of choice
retroauricular area
submandibular area
perioral area for upper and
lower lip reconstructions.
scalp
A
B
29. not to rotate more than 90º
More acute –less dog ear
32. Limberg’s flap:
combination of flap rotation and
transposition
BD=DE=EF
EF at angle of 60º &
Parallel to one side
Disadvantages:
Excess tension
Anatomic landmark displacement because the tissue used to resurface
the rhomboid defect is borrowed from single area.
Rotation pucker at Point C
Best in temple region between the eyebrows and anterior hair line
34. Dufourmental flap:
variation of a rhomboid flap
Need not convert into 60º rhomboid
Such flaps are designed for closure of
square & rectangular defects.
Adv:
less closure tension
Disadv:
rotation puckering at point C
35. Double ‘Z’ rhomboid flap: by Cuono
Advantage over Limberg flap:
Excessive tension is reduced by using
two flaps
anatomic landmark displacement in
minimized because tissue used to
resurface the rhomboid defect is
borrowed from two areas.
Rotation pucker seen with Limberg flap is avoided and the
resultant scar forms an elongated ‘Z’ plasty.
36. Bilobed flap: First by Esser in 1918
popularized by Zimany
reconstruct nasal and facial defects and even full thickness cheek
defects.
Tension free closure of original and secondary defects.
90º is the optimal angle between the first and second flap
Maximum distortion occurs around
the flap bases and the second donor
lobe closure sites
Disadvantages:
Rotation pucker
37. ‘
S’ plasty: Schrudder
First by Szymanowski
modification of transposition flap
Difference between transposition and S- plasty
Proximity of the flap base to the defect.
It is positioned tangential to the wound margin
leaving a ‘V’ shaped flap between them.
Intermediate flap created between the flap and the defect.
38. 60 degree between the flap and the
defect will avoid ‘dog ear’
1/5th to 1/6th higher
½ or ¾ the defect
width
39. 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
Ex: Median forehead flap
Nasolabial flap
40. LOCAL FLAPS
Buccal fat flap / Syssarcosis :
Masticatory space
average volume of the fat is 9.6ml (8.4 to 11.9)
cover defects of up to 4cm
blood supply from branches of facial, transverse facial
and internal maxillary arteries.
epithelization within 2-3 wks
41. Uses:
Oro-antral & oro-nasal communications
reconstruction of ablative defects of the
maxilla and cheek, hard and soft palate, retro-molar
and pterygo-mandibular regions, as
An interpositional graft in OSMF
Advantages:
Easy
Donor site complications rare
Disadvantages:
Facial asymmetry is a possible complication
44. Tongue flaps
First by Gersuny
Eiselberg popularized in 1901
Blood supply: lingual artery
advantages:
reliance on an excellent blood supply
low morbidity
Can be used in irradiated patients
Used to cover defects in cheek, floor of the mouth, soft palate and
hard palate, alveolus, oroantral fistulas and vermillion
and lip reconstruction
45. Classification of tongue flaps:
Flaps from dorsum of tongue
Posteriorly based dorsal tongue flap
Anteriorly based dorsal tongue flap
Transverse based dorsal tongue flap
Flaps from lingual tip
Perimeter flap
Unipedicle and bipedicle
Dorsoventrally disposed flaps
Flaps from ventral surface of tongue
46. Posteriorly based dorsal tongue flap
Uses:
To repair a defect of moderate size in the
retromolar trigone, tonsillar fossa of the
ipsilateral side
To cover a posterior mucosal defect in cheek
minimum thickness of the flap
should be 8mm
48. Anteriorly based dorsal tongue flap
Uses: to repair defects in the
anterior cheek,
lip,
anterior floor of the mouth,
anterolateral floor of the mouth and
palate
50. Perimeter flap
unipedicled or bipedicled
for repair of vermillion border of either lip
Upper and lower lip reconstruction
51. Dorsoventrally disposed flaps
Flaps reflected ventrally on a anterior base:
Used for lining in lower lip reconstruction
Flaps reflected dorsally on a posterior base.
Used for lining in upper lip reconstruction
Flaps from ventral surface of tongue
cover defect on anterior floor
of the mouth
52. Nasolabial flap:
Sushruta in 600 BC
popularized by Esser and Ganzer
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
53. Adv:
It provides thin, local tissue for coverage of small defects.
It may be also be deepitheliazed at the base
for one stage procedure.
Disadv:
Limited donor tissue
Facial scarring
Second surgical procedure might me needed
Difficult to use in the floor of the mouth if
the patient is not edentulous
Transfer of beard in male patients
58. Butterfly shape is used to repair of
defects of the posterior tongue to
allow Mobility, the other wing
closing the defect in the cheek.
The distal extension provides cover
and seal.
The narrow flap repairs central and
alveolar defects
The repair following total
glossectomy should be in the
form of a shield
59. Advantages:
Near to the oral cavity
Hairless
Tissue is firm and holds sutures well
Excellent blood supply
Thin and suitable for intraoral lining
Disadvantages:
Noticeable donor defect
Need to divide the pedicle and close the
oral fistula at a second operation
Bleeding
Flap necrosis can occur
60. Glabellar Flap
- Axial pattern flap
- Based on supra-trochlear
artery
uses:
-nasal reconstruction
-cheek defects
disadvantages:
-donor site morbidity
-limited amount of tissue
61. Temporalis flap:
Golovine in 1898
Type III
Temporoparietal fascia - superficial temporal artery
Temporalis muscle - anterior and posterior deep temporal br. Max. art
62. Uses:
Useful for obliterating skull base,
maxillofacial and orbital defects.
It is also used in cranialisation procedure
Reanimation of the face
Used to close CSF leaks & dural tears
secondary to trauma & cancer surgeries.
Used for midface augmentation for
hypoplasia secondary to trauma &
congenital anomalies.
63. Advantages:
Close to the oral cavity
Good arc of rotation
Reliable and well tolerated
Thin flap
Problems from the loss of muscle function
are minimal
Disadvantages:
Cosmetic deformity in donor site
Traction paresis of Facial nerve
65. Narayanan bilobed flap
Uses:
Useful for obliterating skull base, maxillofacial and orbital defects.
It is also used in cranialisation procedure
Reanimation of the face
Advantages:
Close to the oral cavity
Good arc of rotation
Reliable and well tolerated
Thin flap
Disadvantages:
Cosmetic deformity in donor site
Facial nerve paresis
66. Cervicofacial flap:
•Ideal for Aged patient
•Defects of 4x4 to 6x7 cm.
•based laterally
•It involves lower cheek and upper neck
•useful, well tolerated flap for closing cheek defects with or without
an associated neck dissection.
•maxillary artery, vein and their branches-blood supply
67. Intra –oral flaps
Palatal flaps (Ashley)
Buccal advancement flaps
-Rehrman’s
-Moczair buccal sliding trapezoidal flap.
(is slid to use the papilla of the adjacent tooth
to rotate into the defect)
