2. Flaps and Grafts

3. “….the application of
anatomical knowledge
to restore form and
function…”

4. Graft VS Flap
What is the difference?

5. What is a Flap?
• 16th century Dutch word “flappe”
– ….something that hangs broad and loose ,
fastened only by one side..”

6. What is a Flap?
• A flap is a unit of tissue that may be transferred
from a donor to a recipient site while maintaining
its blood supply.
– Flaps can be characterized by their component parts
• cutaneous, musculocutaneous, osseocutaneous
– Their relationship to the defect
• local, regional, or distant
– Nature of the blood supply
• random versus axial
– The movement placed on the flap
• advancement, pivot, transposition, free, pedicled

7. • Rung 1: Healing by
secondary intention
• Rung 2: Primary closure
• Rung 3: Delayed primary
closure
• Rung 4: Split thickness
graft
• Rung 5: FTSG
• Rung 6: tissue expansion
• Rung 7: Random flap
• Rung 8: Axial flap
• Rung 9: Free Flap

8. Reconstructive Elevator
• Get off at the right level

9. Composition of a flap
• Skin
– Muscle
– Bone
– Omentum
– Composite

10. Composition of a flap
– Skin
• Muscle
– Bone
– Omentum
– Composite

11. Composition of a flap
– Skin
– Muscle
• Bone
– Omentum
– Composite

12. Composition of a flap
– Skin
– Muscle
– Bone
• Omentum
– Composite

13. Composition of a flap
– Skin
– Muscle
– Bone
• Omentum /
viscera
– Composite

14. Composition of a flap
– Skin +/- fascia
– Muscle (+/- innervation)
– Bone
– Omentum / viscera
• Composite

15. Which flap when?

16. Goals of reconstruction
• Separating the physiological cavities
– Eg brain, orbit, mouth, neck
• Protecting the neck vessels
• Obtaining a healed wound
• Restore function
• Restore swallowing
• No leaks
• Aesthetics

17. • Flaps reduce complications by:
– Obliterating dead space
– Recruiting healthy well-vascularized tissue into the
region, which has commonly been irradiated and
contaminated
– Tension free closure
– Interposing flap skin between irradiated wound
edges

18. Pharyngeal defects
• Partial defects
– Pectoralis major flap with muscle and skin
– Radial forearm free flap
• Circumferential defects
– Tubed radial forearm flap or ALT flap
– Jejunum

19. Goals of reconstruction:
• A single stage, reliable reconstruction
• Prompt discharge from hospital
• Return of swallowing and speech function
• No salivary fistulas

36. Literature Review
• Nelligan (J PlastReconstrAesthet Surg. 2008)
reported a fistula rate of:
– 13% for all fasciocutaneous flaps
• ALT flap 16.4%
• radial forearm free flap 14.4%.
– Jejunum 9.4%
• Charing Cross Study (Moradi et al)
– fistula rate: 2/43 (4.7%)
– stricture rate: 6/43 (14%)

37. Murray D, Novak C, Neligan P. Fasciocutaneous free flaps in pharyngolarngo-
oesophageal reconstruction: A critical review of literature. J
PlastReconstrAesthet Surg. 2008

38. Voice Restoration (Charing Cross
series)
• 22 of 42 received a
primary (TEP)
• 14 of 42 received a
secondary TEP
• 36/42 (85%) received
either a primary or
secondary TEP
• Voice was reported as:
– Good in 17 of 39
– Fair in 11 of 39.
– 28 of 39 (72%) used their
tracheoesophageal
puncture as their primary
mode of communication

39. When to eat?
• No scientific evidence on the timing of oral
intake
• Err on the side of caution if previous
radiotherapy
• Day 10

40. Mandible reconstruction
• Osteoradionecrosis (ORN) is a condition of non-vital
bone in a site of radiation injury
• Characterised by:
– hypovascularity
– hypocellularity
– hypoxia
• ORN occurs when, in the process of otherwise normal
turnover of bone, the degradative function exceeds
new bone production
• Can be either spontaneous or the result of an insult

46. Facial reanimation
• Goal of treatment
– Rest symmetry
– Facial function
– Voluntary function
– Spontaneous movement
– Absence of synkinesis

47. Facial reanimation
• Static vs dynamic
• Static: Divide face into 1/3rds
– Upper:
– Middle:
– Lower:

48. Dynamic: free gracilis

49. Static: slings

50. Tongue reconstruction
• Depending on extent of defect and the status
of the floor of mouth
• Generally use:
– Radial forearm free flap
– Ulnar forearm free flap
– ALT

53. Radial forearm free flap

54. Ulnar forearm free flap

55. Ulnar forearm free flap

56. Ulnar forearm free flap