SEMINAR

ON

FLAPS IN MAXILLOFACIAL RECONSTRUCTION

Presented by

Dr. Jaspreet Kaur Bhasin

Department of Oral and Maxillofacial Surgery,

National Dental College, Derabassi.

PUNJAB.

Contents :

1. Introduction

2. Free skin grafts

3. Skin flaps-

Flaps definition, history and classification

4. Designing of the flap

5. Planning considerations

6. Commonly used local and regional flaps in the reconstruction of

maxillofacial defects

7. References

Introduction – The defects both of the skin and the mucous membrane which follow excision of

malignant tumours, closure by direct suture is used when the defect is small enough and is

otherwise suitable.

When the defect is too large or for other reasons is unsuitable for direct suture, the

potential methods of reconstruction are by the use of a free skin graft, a skin flap, a composite

flap, or a free flap. The skin and/or mucosal defects created sometimes include in addition a

segment of mandible too.

Free Skin Grafts

Free skin graft they consist of the entire thickness of the epidermis and a variable amount

of dermis. They are designated according to their dermal component as whole skin grafts,

containing the entire thickness of the dermis, and split-skin grafts, containing a proportion only.

Split-skin grafts are further subdivided into thin, medium, and thick.

The whole skin graft is cut with a scalpel while the split-skin graft, of is cut with a special

instrument – the Humby Knife or the Dermatome.

The whole skin graft, once cut, leaves behind no epidermal structure in the donor area

from which resurfacing can take place; the split-skin graft leaves adnexal remnants,

pilosebaceous follicle or sweat gland apparatus, from which the donor site can resurface. Donor

area of a split-skin graft requires no care other than that usually accorded any raw surface; the

donor area of a whole skin graft has to be closed, in most instances by direct suture. This limits

the size of the whole skin graft by direct suture. So , extensive defects are split-skin grafted.

While so detached ,such a graft can remain viable for a limited period and depends on the

ambient temperature. The various processes which result in its reattachment and

revascularisation are collectively called take.

The process of take :

The graft initial adheres to its new bed by fibrin and its immediate nutritional requirements

appear to be met by diffusion from the plasma which exudes from the bed providing a so-called

plasmatic circulation,reinforced by the outgrowth of capillary buds from the recipient area. The

presence of circulating blood in a graft can be demonstrated approximately 48 hours post-

application. Gradually , the initial adhesion provided by the fibrin cloth converts into a more

effective definitive attachment of fibrous tissue and provides within 4 days an anchorage which

allows the grafted area to be handled safely if reasonable care is taken.

The speed and effectiveness with which blood supply and fibrous adhesion are provided

are determined by the qualities of the bed, the characteristics of the graft itself, and the

conditions under which the graft is applied to the bed.

The Graft bed

The bed must have a rich enough blood supply to vascularise the graft as rapidly as

possible and be capable also of providing the necessary fibrin anchorage.

Vascularisation.-This is achieved by outgrowth of capillary buds and the more rapid the

process ,the more suitable the particular surface is for grafting. Capillary outgrowth is also the

key factor in the production of granulation tissue. The surgeon can assess the suitability of a

surface by considering the speed with which it would be expected to granulate, left ungrafted.

The soft tissue of the face, muscle, fascia and fat, are so vascular that they all accept

grafts extremely readily. Cartilage covered with perichondrium, whether of nose or ear, takes

a graft without difficulty as does also bone covered with perisoteum.

Bare cartilage cannot be relied upon to take a graft. If the area is small, the blood supply

of the surrounding tissues may be sufficeintly profuse to allow the graft to bridge the avascular

area and cover it successfully (nasal defect reconstruction).

Bare bone, its behaviours varies in different sites. The bare cortical bone of the outer

table of the skull vault and the bare bone of the mandible both lack sufficient vascularity to take

a graft successfully. The hard palate, the neighbouring bone of the maxilla, the walls of the orbit,

the circumorbital bony buttresses are all capable of taking grafts in descending order of case.

The graft

Variations in graft thickness relate to the thickness of the dermal component and this

influences their vascularity ,dermis in general ,being less vascular in its deeper part.

The number of cut capillary ends exposed when a thick split-skin graft is cut is smaller

than with a thin graft and the full thickness graft has even fewer. Thin grafts are generally easier

to get to take than thick grafts.

Conditions for take.

1. Rapid vascularisation is all important. The graft has therefore to be in the closest possible

contact with the bed. The most frequent cause of separation is hematoma acting as a

block to link-up of the out-growing capillaries.

2. At the same time the graft has to lie immobile on the bed until it is firmly attached.

3. It should be free of pathogens.

Preparation of a surface of grafting.- Complete haemostasis is desirable before any

surface is grafted and the various steps of the excisional procedure. The raw surface may be

irrigated with saline to wash off any cloth, but wiping with gauze or the careless use of the

suction nozzle is to be discouraged as it is likely to start fresh bleeding. Keep the volume of

tissue ligated or burned as small as possible.

Clinical methods of grafting. -The methods depend on whether the graft is being

applied on the skin surface or inside the mouth and/or sino-nasal cavity, but in both sites two

distinct techniques are used. In the first, pressure is applied to the graft; in the second, the graft is

left exposed without pressure.

THE SKIN SURFACE

Pressure methods

The pressure is exerted by a bolus applied directly to the graft further pressure is usually

also applied by added dressings. The pressure is merely a means of providing immobility of the

graft and holding it in contact with the bed.

The graft is sutured to the margins of the defect, edge to edge in a full thickness graft, and

with the graft overlapping the defect in a split-graft. The sutures fixing the graft to the margins

are left long and tied over a bolus dressing. Further dressing are provided by crepe bandage

and/or Elastoplast.

Various bolus materials are used – flavine wool, cotton wool moistened with saline or

liquid paraffin, cotton waste and polyurethane foam.

Pressure methods are preferable when the graft is small in area and are invariable when it

is full thickness in type. They are advisable even if the graft is split-skin when the defect is in an

area which is inherently mobile.

When grafting is carried out primarily, pressure methods, apart from helping to create

immobility for the graft and its bed, helps also to achieve haemostasis by maintaining the two in

contact.

Exposed grafting

The graft is laid on the defect, without dressing of any kind, merely protected from being

rubbed off, and allowed to attach by fibrin adhesion alone. Any air trapped under it is pressed out

and the skin is allowed to overlap the defect margins.

If exposed grafting is being used primarily, control of all bleeding points must be

rigorous since pressure is not available to help haemostasis. This is far from easy and for this

reason delayed exposed grafting is more usual. Application of the graft to the defect is postponed

for several days, the skin in the interval being stored in the refrigerator. The time lag between

excision and grafting allows bleeding to stop completely and the waiting period is used to free

the wound of all residual blood clot. As soon as the site is clean ,the graft can be applied; 2-5

days is an average but the time is not critical.

The most important single point of technique is to make sure that the surface of the defect

is not allowed to dry out. It can be avoided by making sure that an occlusive dressing is applied

to the defect as soon as it has been made.. A 5mm thick layer of tulle gras sheeting is used. Its

occlusive properties prevent the surface from drying out and it can be removed with a minimum

of discomfort 24 – 28 hours later.

Storage of skin

The graft is wrapped in gauze moistened with saline, placed in a sterile, sealed container

and stored in a refrigerator until required. A storage temperature of 4oC is likely to give the

longest survival.

Antibiotics in intra-oral grafting

Squamous carcinoma in the oral cavity has been found to harbour anaerobic bacteria.

They are sensitive to the nitroimidazole antimicrobials, such as Metronidazole or Tinidazole.

Skin Flaps

Flap Definition, History, and Classification

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. A skin flap in its basic form is a tongue of tissue consisting of the entire thickness of the skin plus a variable amount of the underlying subcutaneous tissue. It is transferred in order to reconstruct a primary defect and is inset into this defect. The transfer usually leaves a secondary defect which is either closed by direct suture or covered with a free skin graft.

Flaps come in many different shapes and forms. They range from simple advancements of skin to composites of many different types of tissue. These composites need not consist only of soft tissue. They may include skin, muscle, bone, fat, or fascia.

How does a flap differ from a graft? A flap is transferred with its blood supply intact, and a graft is a transfer of tissue without its own blood supply. Therefore, survival of the graft depends entirely on the blood supply from the recipient site.

History of flap surgery

The term flap originated in the 16th century from the Dutch word flappe, meaning something that hung broad and loose, fastened only by one side. The history of flap surgery dates as far back as 600 BC, when Sushruta Samita described nasal reconstruction using a cheek flap. The origins of forehead rhinoplasty may be traced back to approximately 1440 AD in India. Some reports suggest flap surgeries were being performed before the birth of Christ.

The surgical procedures described during the early years involved the use of pivotal flaps, which transport skin to an adjacent area while rotating the skin about its pedicle (blood supply). The French were the first to describe advancement flaps, which transfer skin from an adjacent area without rotation. Distant pedicle flaps, which transfer tissue to a remote site, also were reported in Italian literature during the Renaissance period.

Subsequent surgical flap evolution occurred in phases. During the First and Second World Wars, pedicled flaps were used extensively. The next period occurred in the 1950s and 1960s, when surgeons reported using axial pattern flaps (flaps with named blood supplies). In the 1970s, a distinction was made between axial and random flaps (unnamed blood supply) and muscle and musculocutaneous (muscle and skin) flaps. This was a breakthrough in the understanding of flap surgery that eventually led to the birth of free tissue transfer.

In the 1980s, the number of different tissue types used increased significantly with the development of fasiocutaneous(fascia and skin) flaps (which are less bulky than muscle flaps), osseous (bone) flaps, and osseocutaneous (bone and skin) flaps.

The most recent advancement in flap surgery came in the 1990s with the introduction of perforator flaps. These flaps are supplied by small vessels (previously thought too small to sustain a flap) that typically arise from a named blood supply and penetrate muscle, muscle septae, or both to supply the overlying tissue. An example of this is the deep inferior epigastric perforator (DIEP) flap, which has now become the criterion standard in breast reconstruction.

Classification of flaps

1. Blood supplyI. Random (no named blood vessel)

II. Axial (named blood vessel) - further classified by Mathes and Nahai as: 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)

1. Axial pattern flapFlap is constructed around a pre-existing anatomically recognized arteriovenous system.

This system running along its length makes it possible to construct a flap at least as long as the territory of its axial artery with minimal regard for considerations of breadth.

2. Random Pattern flapFlap has no pre-existing bias in its vascular pattern and this lack places stringent limits on

its dimensions particularly on the ratio between its length and breadth. The degree of stringency depends to a considerable extent on the richness of its subdermal vascular pattern.

Below the level of the zygomatic arch ,there is a very rich subdermal plexus in the fatty layer between the skin and the muscles of facial expression, fed from deeper vessels which emerge from between the facial muscles and In the nasolabial area ,from the facial artery . The branches that pass upwards towards the inner canthal region, lateral to the angle of mouth and the alar base, are conccentrated mainly at the level of these land marks.

Facial flaps are raised deep to the subdermal plexus and they largely rely on its richness. They can be regarded as random.

Above the zygomatic arch vascular anatomy is different. In the scalp proper ,the vessels run horizontally in the dense connective tissue layer between skin and galea with no significant deep vascular connections; in the forehead the situation is similar with frontalis muscle replacing the galea and a looser background of connective tissue.

The arteries and veins are in a line encircling the head at the level of the supraorbital

ridges, the zygomatic arches, the mastoid area on each side and the highest nuchal line on the

occipital bone.

The vessels which cross this line are the superficial temporal artery and vein just in front

of the ear, each dividing into anterior and posterior branches, the posterior auricular and occipital

vessels behind the ear, the supraorbital and supratrochlear vessels on the medial side of each

supra-orbital ridge.

The success of such flaps relates to two factors – the virtual absence of deep vascular

connections and the calibre of the vessels themselves in the plexuses.

2. Tissue content

Cutaneous

Composite

Faciocutaneous

Myocutaneous

osseocutaneous

o Flaps may be composed of just one type of tissue or several different types of tissue. Flaps composed of one type of tissue include skin (cutaneous), fascia, muscle, bone, and visceral (eg, colon, small intestine, omentum) flaps.

o Composite flaps include fasciocutaneous (eg, radial forearm flap), myocutaneous (eg, transverse rectus abdominis muscle [TRAM] flap), osseocutaneous (eg, fibula flap), tendocutaneous (eg, dorsalis pedis flap), and sensory/innervated flaps (eg, dorsalis pedis flap with deep peroneal nerve).

3. Location of donor site-local flaps

-regional flaps

-distant flaps

Local flaps imply use of tissue adjacent to the defect, whereas 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.

4. Configuration Flaps are often referred to by their geometric configuration. Examples of these flaps include bilobed, rhombic, and Z-plasty

5. Method of Transfer The most common method of classifying flaps is based on the method of transfer.

Advancement flaps-single pedicle advancement flap

- V-Y,flap

-Bipedicle flap

Pivotal flaps- rotation flap

-transposition flap(bilobed and rhomboid flap)

-interpolation flap (Z-plasty)

Advancement flaps are mobilized along a linear axis toward the defect .

Rotation flaps pivot around a point at the base of the flap . Although most flaps are moved by a combination of rotation and advancement into the defect, the major mechanism of tissue transfer is used to classify a given flap.

Transposition flap refers to one that is mobilized toward an adjacent defect over an incomplete bridge of skin. Examples of transposition flaps include rhombic flaps and bilobed flaps .

Interposition flaps differ from transposition flaps in that the incomplete bridge of adjacent skin is also elevated and mobilized. An example of an interposition flap is a Z-plasty. Interpolated flaps are those flaps that are mobilized either over or beneath a complete bridge of intact skin via a pedicle. These flaps often require a secondary surgery for pedicle division.

Microvascular free tissue transfer from a different part of the body relies on reanastomosis of the vascular pedicle.

Designing the Flap

A stepwise approach can be helpful in selecting and designing a flap. The characteristics of the defect and adjacent tissue must be analyzed. These include

color, elasticity, and texture of the missing tissue. The defect size, depth, and location are evaluated as well as the availability and

characteristics of adjacent or regional tissue. Determine the mobility of adjacent structures and identify those anatomic landmarks

that must not be distorted. The orientation of the RSTLs and esthetic units should by analyzed closely. Potential flap designs should be drawn on the skin surface being careful to avoid those

designs that obliterate or distort anatomic landmarks. The final location of the resultant scar should be anticipated by previsualizing suture

lines and choosing flaps that place the lines in normal creases. The secondary defect that is created as the tissue is transferred into the primary defect

must be able to be closed easily. When designing a flap, it is important to avoid secondary deformities that distort important facial landmarks or affect function.

Avoid obliterating critical anatomic lines that are essential for normal function and appearance.

Proper surgical technique involves gentle handling of the tissue by grasping the skin margins with skin hooks or fine-toothed tissue forceps.

Avoid traumatizing the vascular supply by twisting or kinking the base of the flap.

Deep pexing sutures minimize tension on the flap and eliminate dead space.

Excessive tension on the flap may decrease blood flow and cause flap necrosis.

Meticulous hemostasis should be achieved prior to final suturing so that a hematoma does not develop beneath the flap.

It is important to adequately mobilize and extend the flap, which should be of adequate size to remain in place without tension to minimize the chance of dehiscence, scarring, or ectropion.

Planning considerations In cancer of the head and neck., the precise characteristics of the resection are rarely known with absolute certainty and time to prepare a flap is seldom available. So both local and distant, flaps have become established for routine use in head and neck malignancy without prior preparation and transferred in a single stage.

Detailed planning often used usually involves making use of the pivot point of the flap or of the method of planning in reverse. The flap must be designed so that the distance from the pivot point to each part of the flap before transfer is at least equal to the distance to be expected after transfer. This ensures that no part of the flap is under unacceptable tension. The method is used most often in planning transposed or rotation flaps.

Planning in reverse is used when the flap is jumping over intact tissue and is not a straightforward transposed flap.

LOCAL FLAPSIf a tumour occurs in a site where skin is lax and available, flaps are less often needed since suture of the defect sufficies. If the tumour occurs where skin is not available. It is then that the need for a flap arises.

It is because area of availability exist in the face that the secondary defect which result from the transfer of such local flaps can be closed by direct suture and do not require to be grafted.

Surgeon needs to be aware which area of availability he is exploiting so that he can assess whether or not the area is present in the particular patient and how abundant the skin is. There is much greater availability of skin in most elderly patients. It is the presence of wrinkles which indicates tissue availability.

The area of availability which are exploited most frequently are the mandibulomasseteric , the nasolabial fold, the glabellar area, the temple area beyond the lateral canthus. To a lesser degree, the forehead, particularly towards the mid-line has a limited availability.

Forehead has only its convenience and effectiveness as a source of hairless skin to cover defect of the middle third of the face – nose, cheek, lower eyelid, is so great that it is regularly used in this capacity.

The movement of tissue as a local flap can be by advancement, rotation, or transposition.The initial step with the rotation flap and the transposed flap in its basic form is the

conversion of the primary defect into the shape of an isoscale triangle. The triangle is outlined beyond the clearance limit of the tumour. The flap is constructed on the skin adjoining one of the equal sides of the traingle. It is rotated or moved laterally into the defect. To close the defect by the movement of one side of the triangle across to the other.

When the flap is a transposed one, involving tissue movement laterally, there is a triangular secondary defect left which corresponds to the triangle of the primary defect.

The advancement principle makes use of a single pedicled rectangular flap, raised and advanced to cover a rectangular primary defect which adjoins its distal end. Advancement creates a triangular dog-ear of redundant tissue at the base of the flap on each side and excision of these completes the procedure.

Even in the face there is always a continuing tendency for the tissue to revert to their original site as a result of differential tissue pull. The method has an extremely limited role.

The rotations flapSince the flap is being rotated to its destination ,its idealised form is as the large arc of a

circle of which the triangular primary defect is a small arc, flap and defect together making a half circle.

With the flap rotated there is a difference in the lengths of the two sides of the defect being sutured together and closure is achieved with a degree of differential tension. The larger the flap in relation to the defect the less the difference in length and the less the differential tension.

The absence of a secondary defect in the rotation flap, or its reduction to a small area compared with the primary defect, is possible only because of the presence of skin laxity. The pivot point of the flap, is approximately at the centre of the curve of the flap. Evidence of this is the dog ear which develops at the apex of the triangular defect when the flap is transferred and the fact that the bulk of the laxity taken up during transfer is at the other extremity of the flap.

Rotation flaps require a reasonably flat surface and are consequently raised on the cheek and submandibular area, the forehead and temple, and the scalp. The scalp fortunately also tolerates closure under tension better than almost any other skin area. When the rotation flap is actually being transferred differential suturing is used. There is a tightness on the flap side of the

suture line and a redundancy on its outer side, representing the discrepancy in a lengths of the two sides. One of the two steps can be taken:1. A back-cut can be made along the diameter line of the circle of the flap until the tension

has been sufficiently reduced. The secondary defect can be convered with a split skin graft.

2. A dog ear may be excised from the redundant tissue outside the flap, usually from the end furthest away from the primary defect to equate the two sides of the suture line.

When a back cut is considered it must be remembered that it is reducing the vascular cross section of the flap.

The transposed flap:In its ‘classic’ form this flap is a rectangle, usually near square, which is raised and

moved laterally into the primary defect, previously triangulated in preparation for it, leaves a secondary triangular defect which is at least equal in area to the primary defect. The cosmetic disability, acts as a significant bar to the widespread used in the head and neck. Its role confined to the hair bearing scalp in the head and neck generally the transposed flap is modified. Flaps are routinely raised which are very much longer than their breadth, on occasion as much as 4:1. At the defects which the flaps are designed to fill are usually comparatively small. Most of the secondary defects can be closed by direct suture. A further variation is to jump over intact tissue in moving to its destination.

Forehead flaps are most often used to cover defects below the level of the eyes and this makes it possible to inset only the distal segment of the flap at the initial transfer. In most flaps outside the neck and head a free bridge segment is tubed but not in forehead flaps, or indeed, in facial flaps generally. The general rigidity of any flap which includes galea would make tubing undesirable, because of the compressing effect it would have on the blood vessels of the flap. Forehead flap is capable of coping with the presence of a raw surface over much of its length, if the raw surface seems undully extensive a split skin graft is applied to the raw surface as an exposed graft.

When a split skin graft has been required, graft only the area of the ultimate secondary defect. The graft in its early appearance tends often to form a depression on the forehead particularly if the frontalis muscle has been included in the flap. This can be partly countered by bevelling the margin of the flap or alternatively, the grafting be postponed for 10 days or so to allow a build up of granulations.

During the three weeks before it is divided the bridge segment spontaneously tubes itself to some extent by wound contraction on its deep surface and by marginal epithelialization .

If the bridge segment is being returned to the forehead all marginal epithelialization should be excised. The fibrous tissue predominantly along the axis of the flap causing it to tube should be excised. In suturing it back, the wound edge tend to invert unless removal of the scar and excision of spread epithelium are both scrupulous and even this does not entirely eliminate the tendency. Vertical mattress sutures are sometimes required to counter the inversion.

When the secondary defect has been closed by direct suture, the bridge segment can either be discarded or returned to its original site.

The distal segment is often raised between muscle and skin, a difficult plane to achieve consistently since it is not a natural one but must be created surgically. In passing from the distal segment to the bridge segment it is usual to deepen the plane immediately to the standard surgical one just superficial to the pericranium to make sure that the maximum of axial vasculature is included this is liable to destroy the nerve supply to the forehead muscle medial to it but this has to be accepted. The extent of the palsy is greatest with the lateral pedicle, less with the inferior pedicle and often nil with the mid line pedicle.

Variations in hair distribution the presence of baldness extend the possible variations in flap. Another variation is the flap which runs vertically from the zygomatic arch instead of curving across the forehead, using as its axial vessel the posterior branch of the superficial temporal artery instead of the more usual anterior branch.

Commonly used Local and regional flaps in the reconstruction of

maxillofacial defects :

LOCAL/RANDOM PATTERM FLAPS:

Buccal fat:

The first reported utilization of the buccal fat pad as a pedicled flap was by Egyedi on the

successful closure of oral antral and/or oral nasal communications following resection. Use of

the fat pad as a free graft has been reported by Neder. The buccal fat pad lies within the

masticatory spaces, and is termed a syssarcosis, as it enhances the motion of the muscles. It is in

intimate contact with the facial nerve, parotid duct and the muscles of mastication, the average

volume of the buccal fat pad was 9.6 ml (8.3-11.9 ml). It receives arterial blood supply from

branches of the facial, transverse facial and internal maxillary arteries.

Technique:

It is assessed via a mucosal incision in the maxillary vestibule in the second molar region , or

directly by dissection at the margin of a surgical resection in the posterior maxilla. The flap is

carefully mobilized by blunt dissection. It is delivered into the defect passively once adequate

mobility is obtained. The fat pad is typically encased within a thin fascial envelope which aids in

this dissection. The fat is sutured into position with absorbable sutures. The authors allow the fat

pad to heal secondarily and rapid mucosalization takes place within weeks.

The donor site exhibits slight edema for the first few weeks. It is adequately vascularized

to allow its transfer to cover defects of the maxilla and cheeks. It can also be utilized to provide

increased soft tissue bulk over reconstruction bars. A defect of 4 cm can usually be covered

adequately. Partial necrosis has been reported in irradiated tissue and can also result from

inappropriate tension, if it is transferred too great a distance. Following ablative surgical

procedures, the most common utilization is the reconstruction of the posterior maxilla and soft

palate and has also been utilized in conjunction with free bone grafting.

Nasolabial:

It is used for the reconstruction of facial skin defects of the upper lip, nose and check

following extirpation of skin cancers. The superiorly based flap can be transferred to an intraoral

location for the closure of oral antral fistulae. The bilateral inferiorly based flap has utility in the

reconstruction of anterior defects of the floor of mouth.

Technique:

It requires the development of finger shaped flaps in the redundant tissue of the

nasolabial fold. In elderly, a flap of 5 cm width can be harvested. The flap is raised in the

subcutaneous fat plane and then tunneled through an incision in the buccal mucosa. The blood

supply is derived from branches of the facial artery. The donor site is closed primarily in a

layered fashion. The pedicle requires division at 2-3 weeks to allow inserting of the flap and

closure of the orocutaneous tunnel. The disadvantages are: limited donor tissue, facial scarring

and a second surgical procedure is extremely difficult to use in dentate patients.

Tongue:

They can be based anteriorly, dorsally, posteriorly or bipedicled dorsally. Anteriorly

based are useful for vermilion or floor of mouth repair. Dorsally based is most useful for closure

of residual cleft fistulae of the hard palate. A posteriorly based flap is helpful in the

reconstruction of defects of the tonsillar, retromolar or lateral floor of mouth defects. A

bipedicled dorsally based tongue flap has been described for replacement of the vermilion, best

results are obtained if the tongue tip is not violated. Second procedure for the division of the

pedicle is not usually required.

Technique:

A finger shaped flap is marked our on the lateral surface of tongue from the circumvallate

papillae to 1-2 cm behind the tongue tip, approximately one third of the tongue can be used. The

flap is raised with a combination of blunt and sharp dissection through the tongue muscle,

multiple small bleeders will be encountered. These vessels are coagulated. The donor site is

closed in two layers. It is best to avoid shortening the tongue by closing it on itself. The main

disadvantage is the limited arc of rotation and its small size. In secondary reconstruction, the

donor site has typically received significant radiation, further decreasing mobility. In cases of

patients with field changes the surgeon runs the risk of transferring tissue to the site of the

ablative operation that has potential for malignant degeneration.

The tongue flap remains, best means of restoring bulk with an adequate color match in

the region of the vermilion. The flap also remains useful as an emergency flap when prior

reconstructive efforts have failed.

Uvula:

The uvula shows great variation in size between individuals. In patients who have a long,

redundant uvula who have undergone a resection of the posterior hard palate or part of the soft

palate, the uvula provides an easily harvested source of muscle and mucosa.

Technique:

A suture is passed through the tip of the uvula and provides traction, while a mucosal

incision is made on the side nearest the defect. The muscularis uvulae is split by sharp dissection

and it is then unrolled from its base to the tip of the uvula. The result is a mobile tissue with

dimmensions of 2-3 cm in length and 1-1.5 cm in width. Usually used to cover other flaps, foe

example buccal fat pad and can be used to provide mucosa for the oral and nasal surfaces of the

hard palate as well.

AXIAL PATTERN/FLAPS

FASCIAL/FASCIOCUTANEOUS:

Submental

The submental artery arises from the facial artery 5-6.5 cm from the origin of the facial

artery on the external carotid. It is easily identified in a groove on the medial surface of the

submandibular gland. It passes anteriorly between the gland and the mylohyoid muscle giving

off multiple branches. Additional muscular branches to the mylohyoid, platysma and digastric

muscles are present. Cutaneous perforating arteries pierce the platysma muscle and form

extensive branches in the subdermal plane. The skin teritory ranges from a 4 x 7 cm to a

maximum of 15 x 7 cm. The submental vein runs with the artery, its average diameter is 2.3-3.2

mm.

Technique:

The head is extended. The inferior border of the mandible is palpated and marked. The

dimensions of the available lax tissue are determined by pinching. The neck is incised through

platysma in the submandibular area. The upper skin platysma flap is retracted carefully, taking

care to protect the marginal mandibular branch of the facial nerve. The submandibular gland is

identified and gently retracted posteriorly. The submental artery and vein are found running in a

horizontal direction, in the tissue plane between the gland and they mylohyoid muscle. The

vessels are carefully dissected until the first cutaneous perforator is identified. It is necessary to

ligate branches to the gland and muscles to achieve adequate mobilization. The incision of the

flap is then completed. The fascia, platysma, fat and skin are carefully handled to avoid shearing

injury to the perforating vessels and the subdermal plexus. The vascular pedicle is then dissected

proximally as far as necessary. The flap is inset after creation of the necessary tunneling. The

donor site is closed primarily in layers. The proximity of the tissue, reliable vascular anatomy are

of rotation and the ease of elevation make this flap useful for intraoral defect reconstruction.

Disadvantages are limited to the incisional scare.

Temporoparietal flap:

The aponeurosis has an intermediate extension between the occipitalis and frontalis

muscles, and a lateral extension also known as the temporoparietal fascia. The temproparietal

fascia is continuous below the zygomatic arch as the superficial musculo aponeurotic system.

Posteriorly is continuous with the occipital fascia. The gliding property of the temproparietal

fascia has been utilized in extremity reconstruction to cover tendons as a free tissue transfer.

It provides with a thin, paliable, abundant and well vascularized tissue with a sufficient

are of rotation to reach the majority of areas of the face, oral cavity and oropharynx. The rich

vascular supply assures the survival of tissues grafted to its surface.

The earliest reported utilization dates back to 1898. This flap makes use of the dense

communications between the posterior branch of the superficial temporal artery and the

retroauricular artery. It receives its blood supply from the superficial temporal artery. The artery

enters near the zygomatic arch where it becomes more superficial, emerging from beneath the

parotid gland, a major division into anterior and posterior branches occurs about 2 cm above and

2 cm anterior to the superior attachment of the helix. It may be absent in patients with severe

forms of hemifacial microsomia. Venous drainage is from the superficial temporal vein. The vein

lies more superficial. It usually is identified on the superficial aspect of the temporoparietal

fascia. The course of the vein can vary significantly.

Technique:

A generous shave and preparation is completed. The doppler probe is used to outline the

course of the superficial temporal artery. A vertical preauricular incision is made in the skin with

the bifurcation at the superior temporal line. The flaps are reflected in a subfollicular plane.

Careful identification and protection of the superficial temporal vein is required. Flap is then

outlined within the temporoparietal fascia with extension to the galea. Above the origin of the

temporalis muscle the flap is harvested in a subpericranial plane. At the superior temporal line

the dissection is carried out within the areolar plane between the temporoparietal fascia and the

superficial layer of the deep temporal fasica.

The vascular pedicle is then carefully skeletonized to allow free rotation without kinking

of the vessels, the zygomatic arch can be osteotomized and later replaced with miniplate fixation.

Blunt dissection is carried out to allow passage of the flap into the area of the surgical defect.

The flap is sutured into position with resorbable suture and is allowed to epithelialize, or it can

be skin grafted. The major donor site complication is alopecia. The temporal branch of the facial

nerve crosses the zygomatic arch within, or just superficial to, the temporoparietal fascia an

average of 2 cm (range 0.8-3.5 cm) anterior to the external auditory canal. Avoidance of injury is

accomplished by limiting the dissection of the temporoparietal fascia anteriorly to above the

anterior branch of the superficial temporal artery. The auriculotemporal nerve lies on the

temporoparietal fascia and is sacrificed in the dissection leaving an area of anaesthesia of the

scalp above the ear.

The major advantages are its robust blood supply, thinness, lack of hair, well

camouflaged donor site and ease of elevation. Disadvantages are limited rotation, lack of skin

paddle for flap monitoring, numbness of the donor site and potential for the development of

alopecia.

MUSCLE/MYOCUTANEOUS:

Platysma:

It is utilized as a means of providing local coverage of defects of the floor of mouth and

posterior pharynx. The plasma muscle is a thin, band like muscle forming the superficial

boundary of the beck and allows successful transfer of a segment of cervical skin to the oral

cavity, pharynx or face in an unpredictable manner.

It extends as an extremely thin and variable muscle from the clavicles superiorly where it

is continuous with the superficial musculo aponeurotic substance (SMAS) and has some

attachments to the mandible. The major blood supply to the platysma is the submental branches

of the facial artery. The motor nerve supply to the muscle is supplied by the facial nerve.

Technique:

Most commonly utilized in conjunction with a neck dissection. The cervical incision of

choice is the McFee incision. The superior and inferior limbs are made in a deep subcutaneous

plane preserving the integrity of the thin platysma muscle. Paddle is taken from the inferior

extent of the neck flaps. Following the elevation the platysma muscle is divided inferiorly. The

dissection is continued on the deep surface taking care not to injury the vascular supply. The flap

is then passed beneath the central limb of the McFee incision in preparation for its insetting.

This flap should not be utilized in previously irradiated patients because the viability of

the flap and the skin are questionable, in such cases. The flap may be used for floor of mouth,

check neck and pharyngeal defects. The viability of the skin paddle is not reliable.

Masseter:

It has been utilized for many years in the reanimation of the paralyzed face. Its use in

intraoral reconstruction was popularized by Tiwari for reconstruction of oral defects following

the ablation of small tonsil and retromolar fossa cancers.

Technique:

At the completion of the neck dissection the inferior border of the mandible is exposed in

a subperiosteal plane. Masseter muscle is elevated from the lateral surface of the mandible. It is

dissected to the level of the coronoid notch. The masseteric artery passes through the notch and

should be carefully protected. The tumour is then resected in continuity with the neck dissection.

When the tumour margins have been confirmed clear by frozen section the masseter muscle is

transposed to the posterior edge of the mylohyoid muscle. It is sutured there with restorable

suture.

Temporalis:

The use of the temporalis muscle for began in 1898, with a report by Glovine on the use

of it for the obliteration of dead space following orbital exenteration.

The origin of the temporalis muscle is along the surface of the lateral skull at the

temporal line. The muscle inserts on the coronoid process of the mandible and is a powerful

elevator of the mandible. The temporalis muscle receives arterial blood from three arteries. The

anterior deep temporal and the posterior deep temporal arteries are branches from the internal

maxillary artery. The middle temporal artery arises from the superficial temporal artery just

below the zygomatic arch.

The importance of this work is the recognition of the bipennate nature of the flap and

gives scientific basis for the methods described for the splitting of the muscle in clinical use. The

arterial blood flow is distributed mainly in the medial and lateral portions of the muscle with

numerous minor interconnecting vessels. It is possible to maintain axial blood flow within a flap

split in the sagittal plane. The unelevated muscle remains viable within the temporal fossa

limiting the cosmetic deformity of the flap harvest.

The anterior deep temporal artery arises from the internal maxillary artery and enters the

temporalis muscle at its anterior inferior aspect. It runs superiorly to the cephalic extent of the

muscle paralleling the direction of its fibres. The posterior deep temporal artery, another branch

of the internal maxillary artery, enters the muscle at its inferior medial aspect. It travels

superiorly to the cephalic extent. However the course of the middle temporal artery is at an

oblique angle to the direction of the muscle fibers. It arises from the superficial temporal artery

and enters the posterior inferior aspect of the temporalis muscle. The vessel travels perpendicular

to the direction of the muscle fibers. The secondary arises run at right angles to the primaries to

interconnect. The result is a biplanar arterial distribution, the venous network closely follows the

arterial distribution.

Technique:

A hemicoronal incision with or without anterior and posterior releases is utilized. The

initial incision is made to the level of the deep temporal fascia. An exception, in which a

tempororparietal flap is additionally required. In that circumstance the temporoparietal flap is

first fully elevated exposing the deep temporal fascia. Dissection in the plane is generally

bloodless. The plane is safe until 1-2 cm above the zygomatic arch where the temporal ramus of

the facial nerve is encountered, the superficial layer of the deep temporal fascia is incised 1.5-2.0

cm superior to the zygomatic arch where it splits into two layers separated by a pad of fat. The

dissection is then continued subperiosteally along the zygomatic arch and the entire temporalis

muscle is exposed. The temporalis muscle is raised from the skull by dividing its fascial origin

above the temporal line. Care is taken to avoid injury to the vascular pedicle on the deep surface

of the muscle. Depending on the bulk and its required rotation it may be passed over or beneath

the zygomatic arch. It is often preferable to perform an osteotomy or resection of the arch to

avoid compression of the pedicle. It may be necessary at times to perform an intraoral

coronoidectomy to further mobilize the temporalis muscle. When doing so the masseteric artery

must be protected. Only the quantity of muscle necessary for reconstruction is harvested,

disturbing the remaining muscle as little as possible. A subperiosteal pathway is cleared for the

transposition of the muscle to the recipient site. The muscle is sutured into position with slow

reabsorbing sutures. The donor site is closed in layers over a suction drain.

The advantages of the temporalis muscle flap are its ease of elevation, reliable blood

supply, proximity to the maxillofacial structures and camouflage of the incision within the

hairline. Disadvantages include sensory disturbance, potential facial nerve injury and temporal

hollowing.

The flap has founmd utilization in the reconstruction of the lateral face, orbit, maxilla,

cheeks and temporomandibular joint. The muscle flap is readily combined with grafts of bone,

cartilage and skin.

Trazepius:

Throughout its length the trapezius muscle has a segmental blood supply derived from

vessels which reach its deep surface after passing through the post-vertebral muscles. It also

has a supply provided by the transverse cervical artery. It crosses the lower part of the

posterior triangle directly from its point of origin, either from the third part of the subclavian

artery or the thyrocervical trunk, reaching the anterior border of trapezius close to the

accessory nerve.

The artery passes deep to trapezius and at the anterior border of levator scapulate it

divides into a deep and a superficial branch. The deep branch passes deep to levator scapula;

the superficial branch continues between trapezius and levator scapulae dividing into an

ascending branch and a descending branch.

The pattern of veins is much less constant. The standard picture os of a vein is nearer the

surface than the artery, but running approximately parallel to it, sometimes superficial and

sometimes deep to omohyoid, finally draining into the external jugular vein just above the

clavicle.

Three basic myocutaneous flaps have been described which make use of trapezius.

1. Upper trapezius flap

2. Lateral trapezius flap

3. Lower trapezius flap

1. Upper trapezius flap:

This flap is the myocutaneous version of the standard nape of neck skin flap in which the

strip of trapezius which directly underlies the skin element is raised along with the skin to form a

composite myocutaneous flap. The bulk which the muscle adds to the flap does however reduce

its flexibility. Flap is unable to turn except in a gentle curve and this has to be taken into account

in the geometry of planning.

The flap has also been used in the form of an island flap. Elimination of the skin element of

the pedicle reduces the safety of the flap to a slight but not prohibitive degree. At the same

time its flexibility is substantially increased.

Transferred with a skin-muscle pedicle the flap finds it has main use in providing skin cover.

The pedicle tolerates the curve to bring the flap forward but the combination of skin and

muscle does not permit the torsion which is also required if mucous membrane is being

replaced. The flap in the form of an island can be rotated to allow the skin paddle to replace a

mucosal defect.

2. Lateral trapezius flap:

This flap is based on the transverse cervical arterio-venous system. Its anterior border

corresponds approximately to the anterior margin of trapezius and from there it extends

backwards and downwards in the general direction of the spine of the scapula. In order to be

certain of including the vessels in the flap both the muscle element and the skin should

extend above the point at which the transverse cervical vessels disappear deep to trapezius,

i.e. approximately 5 cm above the clavicle.

The pivot point of the transfer is the medial end of its feeding arterio-venous system. The

course of the artery is generally reliable; difficulty concerns the vein and whether it reaches

the external jugular vein or passes down behind the clavicle beyond the reach of safe

dissection.

The vessels reach the muscle approximately 5 cm above the clavicle the length of the pedicle

in the posterior triangle can be measured accurately and the pivot point pinpointed.

The island of skin with the underlying muscle is raised from levator scapulae and elevation

of the muscle segment of the pedicle is continued forward at a width similar to that of the

island to the anterior border to trapezius. There is becomes continuous with the purely

vascular element of the pedicle.

The flap can be used in conjunction either with a radical or a functional neck dissection. The

lower posterior triangle is virtually never the site of metastasis in the clinical situation

potentially suitable for the flap so that its use is unlikely to compromise resection.

A flap which combines the island form of the upper trapezius myocutaneous flap with the

vascular pedicle of the lateral trapezius myocutaneous flap the double blood supply which

such a design would provide could be expected to enhance significantly the safety of the

transfer. The double pedicle would however limit the ways in which the flap could be

transferred and its reach within the oral cavity.

3. Lower trapezius flap:

This flap makes use of the anatomical fact that the descending branches of the transverse

cervical arterio-venous system run over the deep surface of trapezius in the general direction

of its lowest point of origin, namely the 12th thoracic spinous process, branches entering the

muscle en route. Using this system it is possible to construct a skin paddle overlying the

lower trapezius and raise it on a muscle pedicle similar in breadth to the skin island and

passing upwards towards the point at which the vessels reach the muscle i.e. 5 cm above the

clavicle.

Trapezius might be left undisturbed above the level of the scapular spine when the muscle

pedicle is being designed so that a degree of accessory nerve function can be maintained.

One of the technical problems of the lower trapezius flap, not immediately obvious, concerns

the thickness of trapezius along its anterior border in the lower part of the neck. The

thickness makes it difficult to hinge the flap upwards without endangering its blood supply

and the bulk created by the curve is not easy to accommodate without compressing it if the

skin is directly closed over.

Sternocleidomastoid:

This muscle does not have a localised vascular hilum. It is supplied segmentally by

vessels which enter it at intervals along its length in the neck. The principal ones enter its

upper half and consist of two branches of the occipital artery, an upper entering the muscle

alongside the accessory nerve and a lower arising close to the origin of the parent vessel and

a branch of the superior thyroid artery.

A myocutaneous flap was described by Owens (1955) and is the myocutaneous

counterpart of the sternomastoid skin flap.

The inclusion of the muscle improves the poor viability record of that flap. It is not

recommended for routine use.

The island sternomastoid myocutaneous flap has very severe restrictions. A radical neck

dissection remvoes sternocleidomastoid and a functional neck dissection disrupts its blood

supply. When either of these procedures has been carried out an island sternocleidomastoid

myocutaneous flap cannot be used.

Sternomastoid has also been used as a pedicle to allow transfer of a segment of clavicle in

order to reconstruct mandible.

Pectoralis major:

The vascular basis of this flap is the pectoral branch of the acromio-thoracic axis and its

associated veins. The point 2-3 cm medial to the carocoid process, is the surface making of

the neurovascular hilum of the muscle. The vessels do not enter the muscle belly

immediately but run over its deep surface in a generally downward and medial direction and

branching as they go. The lateral thoracic vessels also contribute to the blood supply.

Vessels also reach the muscle from perforating branches of the internal mammary system

as well as from branches of the intercostals and injection studies indicate that the several

systems communicate freely.

The pivot point is the neurovascular hilum of the muscle though, depending on the

geometry of the transfer, it is sometimes possible to avoid dividing the lateral thoracic

vessels.

The skin element of the flap can be designed with a composite skin – muscle pedicle

(Arivan, 1979), the skin element extending the entire length of the flap, or as an island flap

(Baek et al, 1979). When an island flap is used the skin paddle lies below and medial to the

nipple, about the level of the 6th rib.

The safe extension varying with the age, sex, adiposity and muscular development of the

patient. 3-4 cm beyond the muscle on to the abdominal skin probably represents an average

extreme and in this extension the aponeurosis overlying rectus abdominis should be raised

with the flap. In the female the breast, particularly it size, is a significant factor in

determining the safe extension. Extension may have to be medial more than lateral and

downwards. In the male patient the lateral extension can include the nipple-areolar complex.

The complex can be excised from the flap and grafted back on its original chest site.

If a composite skin-muscle pedicle is used the parallel lines of the skin element are

centred on the surface marking of the neurovascular hilum.

The skin incisions are deepened to the muscle which is sectioned in the same line as the

skin. If an island flap is used the paddle to be transferred is outlined on the skin which is then

incised down to muscle or aponeurosis. The simplest and most direct approach uses a skin

incision which passes directly downward and medially from the surface marking of the

vascular hilum to meet the skin paddle. This incision precludes absolutely any subsequent

use of a deltopectoral flap. If it is considered that it is desirable to have a deltopectoral flap

available in reserve the incision used to expose the muscle can follow the outline of a

deltopectoral flap, turning down to meet the skin paddle. The use of such an incision, allow a

combined pectoralis major myocutaneous flap and deltopectoral flap to be used

simultaneously, one for oral lining, the other for skin cover.

The width of the muscle pedicle is usually made similar to that of the paddle although

once the flap is raised and its arterio-venous network is visible the pedicle can sometimes be

narrowed. The muscle fibres are incised and the times be narrowed. The muscle fibres are

incised and the flap is elevated from the chest wall, the ribs, the intercostal muscles and

pectoralis minor.

Latissimus dorsi:

It originally designed for defects of the chest wall. Its use in head and neck reconstruction

(Quillen et al, 1978) represents an extension of the technique.

Latissimus dorsi form part of the posterior wall of the axilla as it converges on its

tendinous insertion into the upper humeral shaft. Near its insertion the subscapular artery

arises from the axillary artery and with its venae comitants passes downwards in the general

direction of the muscle. About 4 cm from its origin it gives off the circumflex scapular artery,

continuing on as the thoracodrsal artery to enter the muscle approximately 10 cm from its

humeral insertion. The branching vessels run generally parallel to the muscle fibres.

The skin paddle transferred has varied from almost horizontal to more oblique following

the line of the underlying muscle fibres. The oblique construction has the further advantage

that the procedure can be carried out without need to move the patient from the usual supine

position other than to abduct his arm.

The line of the anterior border of the muscle is marked out on the skin pre-operatively,

remembering that towards its origin the muscle is thin along this border, and the true line

may be as much as 3 cm in front of the estimated one.Towards the lower end of the line, the

skin island is outlined.

The outline of the skin island is incised down to muscle and elevation is commenced

anteriorly. When the anterior border of the muscle is reached the plane of elevation is

continued deep to it, sharp dissection being required to divide the attachment of muscle fibres

to the ribs, exposing the vessels which enter the muscle on its deep surface.

The skin incision is extended from the island upwards along the anterior border of the

muscle and continuing dissection allows the muscle increasingly to fall back as elevation

proceeds, displaying further the blood vessels on its deep surface. The artery and vein to

serratus anterior are divided and nearer the axillary vessels the circumflex scapular vessels

and any unnamed branches are also sectioned.

The clear visualisation of the vascular pedicle, makes it possible to tailor the width of the

proximal muscle pedicle, at the same time making sure that the vessels supplying the island,

usually the anterior branches of the thoracodorsal vessels, are not divided.

Dissection proximally is continued only as far as the geometry of the transfer dictates, but

if need be the entire muscle pedicle can be divided. With a pedicle limited to its vascular

component it is naturally essential to avoid all traction during and after transfer of the flap.

When pedicle and flap are more bulky the direct route to the neck is under pectoralis

major and a window has to be cut in the muscle to allow passage.

If the donor defect cannot be closed directly it is probably wise to use as a delayed graft.

The main virtue of this flap lies in the large area of skin which can be transferred.

AN OVERVIEW OF THE PRINCIPLES OF RECONSTRUCTION

Principles of soft tissue reconstruction:

If non-vascularized transfer of skin is considered, full-thickness grafts should be

preferred, as split-thickness grafts often provide inadequate thickness for fully satisfying

esthetic results and tend to show discoloration by increased pigmentation.

In general, facial skin is best repaired by pedicled transfer of facial skin itself. The

anatomical basis of local flaps in the facial area is different. There is no continuous

superficial fascia overlying the muscles, which usually facilitates the dissection of pedicled

skin flaps and the facial nerve limits the depth of dissection to a level above the mimic

muscles. Axial flaps, which include the facial artery, are therefore impossible to dissect

without violation of the facial nerve function. For this reason, axial flaps are only used in the

forehead region, where the supratrochlear artery, the frontal artery or the superficial temporal

artery can be included. Entire facial skin is equipped with a rich dermal-subdermal vascular

plexus and is particularly intense in the area of the cheek and the nasolabial fold. The length

to width ratio is supposed to be no larger than 2:1 in most regions of the body surface, it can

be upto 3:1 in the maxillofacial area. Thus, in most cases, local random pattern flaps are used

for the closure of facial skin defects.

Skin repair in the head and neck region by local flaps comes to its limits, when large

intra-extraorally perforating defects have to be covered, voluminous flaps with a bulk of

viable soft tissue are required to provide both volume substitute and safe defect coverage.

Pedicled transfer of myocutaneous flaps or free vascularized myocutaneous and

fasciocutaneous grafts are the reconstructive means of first choice in these cases.

Closure of tumour related perforating skin defects below the occlusal plane can be

reliably and conveniently achieved by a pedicled tissue transfer. Suitable flaps for these

locations are the detropectoral flap, a pectoralis major island flap or a pedicled transfer of the

latissimus dorsi.

Posterior defects may be likewise suitable for closure by a trapezius flap. However for

defects above the occlusal plane and extensive defects, involving bone, muscle and

cutancous tissue. Free vascularized grafts are preferble such as a fascioucutancous or

myocutaneous flaps. If the defect is shollow and there is not too much volume to be replaced,

a vascularized flap form the forearm of the lateral thigh may be the method of choice. In

larger defects situations, additional transfer of muscle tissue of fat tissue may be required

using the latissimus dorsi, the rectus abdominis or the parascapular flap.

Reconstruction of subdermal tissue

Reconstruction of subdermal tissue may be necessary in postresectionaldefects, in cases

of posttraumatic atrophy or congental hypoplasia, where the skin surface has been preserved,

but underdevelopment or loss of subdermal soft tissue have resulted in a volume deficit and

loss of contour deviation. In general, fat and muscle can be used for the correction of theses

deformities. The major problem of any flap used of the augmentation of soft tissue contour

and volume in the head and neck region, however, is the long term maintainance of the

grafted tissue volume after term maintainance of the grafted tissue volume after transfer to

the recipient area. Non-vascularized transfer of fat tissue has been subject to resorption of up

to more than 50% of the grafted volume in the long term. Due to necrosis and subsequent

replacement by connective tissue. For this reason, vascularized transfer is considered to be a

precondition for successful grafting of fat tissue. One of the vasularized free flaps most

frequently used for the replacement of subcutaneous soft tissue is the deepithelialized

parascapular flap. This flap offers adequate volume and has a reliable vascular anatomy.

Another frequently used donor site for vasularized fat grafts is the groin area. In soft tissue

defects, which cover more than two third soft the facial height and require correc5tion by a

flat but subtle soft tissue augmentation, the specific arcade-like vascular architecture. Other

grafts of relevance for the correction of soft tissue deficits may be the latissimus dorsi muscle

flap and the rectus abdominis muscle flap. However, when in deepithelialized myocutaneous

flaps are used to fill in defects of the facial contour, denervation atrophy can cause and

unpredictable reduction correction of volume and contour with the option of secondary

surgical reduction.

Reconstruction of muscles

Reconstruction of muscles combines both the replacement oof muscle volume and the

reinstitution of muscle function. The two aims are difficulat to achieve at the same time, as

the transfer of muscles is associated with a division of the nerve supply on the one hand

causing shrinkage of graft volume due to denervation atrophy. On the other hand, it is clear

that even reinnervated muscle grafts are unlikely to replace the lost muscle function

completely. Not all of the muscles in the oral and maxillofacial region require reconstruction

movements of the facial muscles, the movements of the soft plate and the function of the

tongue muscles.

Facial reanimation after long standing paralysis of the facial nerve has made a great

progress with the transfer of neurovascular segments of the gracilis muscle or the pectoralis

minor muscle.

Reconstruction of intraoral mucosa

Superficial defects in the floor of mouth and the cheek may be repaired by avascular

transfer of split thickness skin grafts. With complete defects, pedicled arterialized skin flaps

from the forehead and form the deltopectoral region have long been used as standard means

of reconstruction of intraoral soft tissue. The use of these skin flaps, however, has

shortcomings in terms of are long-term graft performance. Skin contracture, subcutaneous

scarring with subsequent flap shrinkage, desquamationof the surface epithelium and hair

growth occurs. The use of small bowel grafts for repair of large mucosal defects had

considerable improved the functional results, if the defects were located unilaterally in the

floor of the mouth and the cheek. However, when large mucosal defects were associated with

extensive loss of soft tissue volume in subtotal or glossectomies. The replacement of tissue

volume rather than the closure of the surface defect appears to be of major functional

importance. This can be accomplished by the vascularized transfer of the rectus abdominis

and the latissismus dorsi muscle with an overlying skin area for closure of the mucosal

defect.

References :

1. Petersons principles of oral and maxillofacial surgery2. Reconstructive surgery –fonseca vol 73. Langdon patel –maxillofacial surgery 4. Oral and maxillofacial surgery clinics of north America-soft tissue flaps-vol

75. Maxillofacial surgery –vol 1- by Peter Ward Booth6. Closure of oroantral communications with Bichat’s Buccal Fat Pad - J Oral

Maxillofacial Surg 67:1460-1466,2009