Grafts and Flaps in the Head and Neck

Dr. Supreet Singh Nayyar, AFMC

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Grafts and Flaps in the Head and Neck

www.nayyarENT.com118/07/12Goals of ReconstructionSafetyFunctional rehabilitationAesthetic rehabilitation

www.nayyarENT.com218/07/12Preoperative planning Nature of defectClinical stage and prognosisPatient factorsAvailable flap donor sitesCompliance, expectations & psychosocial needsClinical experience and skill of surgeonwww.nayyarENT.com318/07/12Timing of ReconstructionOptimally performed in one stageOptimal conditions present on resectionDefect is widely exposedTissue requirements accurately assessedPotential recipient vessels for anastomosis dissected outSurgical margins cleared by frozen sectionDelayed reconstruction and secondary procedures www.nayyarENT.com418/07/12Reconstructive ladder

www.nayyarENT.com518/07/12GraftsTypesSkin graftsSplit thickness skin graft (STSG)Full thickness skin graft (FTSG)Composite full thickness skin & cartilage graftPinch graftFat graftsFascial graftsDermal graftsMucosal graftsNerve graftswww.nayyarENT.com618/07/12Skin Grafts PhysiologySerum imbibition

RevascularizationInosculationNeovascularization

Organization

www.nayyarENT.com718/07/12Skin graftsSplit thickness skin graftEpidermis with portion of dermisThin 0.005 0.012 inchesModerate 0.012 0.018Thick 0.018 0.028Immobilization is criticalAnterior thigh preferred site

www.nayyarENT.com818/07/12Skin graftsFull thickness skin graftEpidermis and entire dermisThick and dont contractCovers the contours wellGood colour matchingSlow revascularization and low take ratesCommonly used after excision of cutaneous malignanciesCommon donor sitesPrimary closure of donor sitewww.nayyarENT.com918/07/12FlapsClassificationBlood Supply AxialRandomFree LocationLocalRegional Distal free

www.nayyarENT.com1018/07/1210FlapsClassificationType of tissueMucosalFasciocutaneousMyocutaneousOsteocutaneousVisceral

www.nayyarENT.com1118/07/12Skin and Fasciocutaneous FlapsMultiple descriptions of flapsZ-plastyAll limbs must be equalGains length at expense of width

V-Y advancementRecruitment technique for tissue deficiency

www.nayyarENT.com1218/07/12Skin and Fasciocutaneous FlapsRotationalNeed wide arch of rotation to fill small defectBack cut increases arc of rotation (decreases vascularity)

Advancement

www.nayyarENT.com1318/07/12Skin and Fasciocutaneous FlapsTranspositionNeed to close the wakeScalp flapRhomboidBi-lobedMake first flap 2/3 defect and second 1/2 of first

www.nayyarENT.com1418/07/12

www.nayyarENT.com1518/07/12Local flapsEffective reconstructive alternatives for small and medium sized defectsUse determined by:Size and location of defectProperties of available tissueVascular supplyAdvantagesBest match of color and textureLess morbiditywww.nayyarENT.com1618/07/12Local flapsMucosal flapsPalatalTongueBuccal

Skin and muscle flapsForehead flapNasolabial flapTemporal flapTemporoparietal flap

www.nayyarENT.com1718/07/12Local flapsNasolabial flapUp to 25sq cm is provided for oral liningVascular supplyLabial arteryOne / Two stage

www.nayyarENT.com1818/07/12Local flapsNasolabial flapUsesAnterior oral defectsFloor of mouth defectsCoverage of exposed mandibleAdvantagesMinimal donor site morbidityExcellent cosmesis

www.nayyarENT.com1918/07/12Local flapsTemporal FlapVascular supplyDeep Temporal arteryUsesTissue defects of orbit and lateral facePalatal defectsReanimation of unilateral facial paralysisComplicationsInjury to temporal branch of VII NerveFibrosis of RMTDistortion of facial contourwww.nayyarENT.com2018/07/12Local flaps

Temporoparietal flapPedicled or free fascial flap

Vascular supplyPosterior branch of superficial temporal artery and vein

www.nayyarENT.com2118/07/12Local flapsTemporoparietal flapUsesResurfacing the orbit, lateral oral defects, mid face defectsAuricular reconstructionComposite flap for reconstruction of orbit & zygomaAdvantagesWell hidden donor siteMinimal morbidityDisadvantagesRisk of injury to temporal branch of VII NAuriculotemporal nerve is sacrificed causing temporal numbnessAlopecia

www.nayyarENT.com2218/07/12Regional flapsPedicled flapsClassificationFasciocutaneousMyocutaneousMuscleSelectionLocation and size of defectIntrinsic properties of flap

www.nayyarENT.com2318/07/12Deltopectoral flap

Bakamjian 1965Fasciocutaneous flapAxial patternVascular supply2nd and 3rd perforating branches of internal mammary artery

www.nayyarENT.com2418/07/12Deltopectoral flapUse Resurfacing cutaneous neck defectsFacial, oral, pharyngeal defectsAdvantagesTechnically easyLow morbidityDisadvantagesUnreliable distal random portionLack of bulkSkin graft for donor siteTwo stage procedurewww.nayyarENT.com2518/07/12Pectoralis Major Flap

Ariyan 1979Work horse flapBlood supplyPectoral branch of Thoracoacromial arterySkin island - perforators

www.nayyarENT.com2618/07/12Pectoralis Major FlapModificationsBipaddledOsteomyocutaneousUsesOral cavity and pharyngeal defectsMandibular defectsCutaneous defects of neckProtection of great vesselsObliteration of dead space after mediastinal dissectionReconstruction of pharynx after pharyngectomywww.nayyarENT.com2718/07/12Pectoralis Major FlapAdvantagesGood vascular supplyLarge skin paddleVersatileEasy to harvestSingle stageSupine positionPrimary closure of donor siteLow incidence of complicationswww.nayyarENT.com2818/07/12Pectoralis Major FlapDisadvantagesLess reliable for cephalic defects of face and scalpEffect of gravityExcessive bulkTransposition of hairComplicationsFlap necrosis total / partialDonor site complicationsHaematomaWound dehiscencewww.nayyarENT.com2918/07/12Trapezius flapConley - 1972Vascular supply Perforating branches of posterior intercostal arteries

www.nayyarENT.com3018/07/12Trapezius flapUse ipsilateral skin and pharyngeal defectsAdvantagesSimple dissectionNot prone to wound separation due to gravityNot in radiated fieldPedicle not threatened during neck dissectionDisadvantagesLimited lengthSTSG for donor siteModificationsLateral Island flapLower Island flapwww.nayyarENT.com3118/07/12Free flapsDaniel and Taylor 1973Characters defining free flap transfer:Anatomical site & characteristics of flapTexture , color , contour, vascular pedicle , innervationRequirement of boneMorbidity of donor sitewww.nayyarENT.com3218/07/12Free flapsAdvantagesSuperior restoration of function and aestheticsOne stageSuperior vascular supplyGreater variety and versatility of donor site93 96% success ratewww.nayyarENT.com3318/07/12Free flapsDisadvantagesComplexity of techniqueIncreased surgical timeDifferent color & contour from recipient siteMultidisciplinary effortMorbid in patients with poor surgical riskwww.nayyarENT.com3418/07/12Recipient vesselswww.nayyarENT.com35ArteriesSuperficial temporal system scalp and upper faceFacial arterymidface and cervical region (atherosclerosis common)Superior thyroid or lingual arterylower cervical regionOther: thyrocervical trunk, external carotid, common carotid18/07/12Recipient vesselsVeinsExternal jugularBranches of internal jugular (common facial)Internal jugularRetrograde (superficial temporal, thyroid)Transverse cervical, occipital (very small)

www.nayyarENT.com3618/07/12Radial Forearm Flap

Chinese flap - 1981Harvested from volar aspect of forearmVascular supplyRadial artery & its venae comitantesOsteocutaneous flap based on periosteal perforatorsSensory innervationAntebrachial cutaneous nervesAllens test

www.nayyarENT.com3718/07/12Radial Forearm Flap

www.nayyarENT.com3818/07/12Radial Forearm FlapUsesOral & oropharyngeal defectsHypopharyngeal & cervical esophagus reconstructionResurfacing of scalp & face

AdvantagesThin, pliable, hairlessLong vascular pedicle, large sized vesselsSensateAbundant subcutaneous fat for protection & contouringCan be used as a osteocutaneous flapSimultaneous two team approach in supine positionwww.nayyarENT.com3918/07/12Radial Forearm FlapDisadvantagesSTSG for donor siteColor & texture match is only fairVascular compromise of handNumbness of handIncomplete healing of STSG due to exposure of tendonsOsteocutaneous flapRestricts dental restorationPathological fracture of radius

www.nayyarENT.com4018/07/12Fibula Flap

Taylor & co workers 1975Osteomyocutaneous flapVascular supplyPeroneal artery with 2 venae comitantesSensory innervationLateral sural nerve

www.nayyarENT.com4118/07/12Fibula FlapUsesMandibular reconstructionPalatomaxillary reconstructionAdvantagesExceptional bone lengthThick bone allows fixation plates & screwsDental rehabilitationSensatePrimary closure of donor site with minimal morbiditySimultaneous two team harvest in supine position

www.nayyarENT.com4218/07/12Fibula FlapDisadvantagesLimitations imposed by soft tissue componentPoor arc of rotation of skin islandPresence of atherosclerosis or congenital anomalies are a contraindicationPotential donor site complicationsInjury to peroneal nerve foot dropInstability of knee and ankle jointswww.nayyarENT.com4318/07/12Rectus Abdominis Flap

TypesMyocutaneousMyofascialMuscleVascular supplyDeep inferior epigastric artery and veinPrecautionPreservation of anterior rectus sheath below the arcuate line to prevent hernia formationwww.nayyarENT.com4418/07/12Rectus Abdominis FlapUsesLarge skull base defectsTotal glossectomyOrbitomaxillary defects

www.nayyarENT.com4518/07/12Rectus Abdominis FlapAdvantagesLong vascular pedicle with large diameterFlexibility in design of paddlesMinimal donor site morbidity with primary closureSuture placement during in setting of flap allows watertight closure and dead space obliteration in oral cavity and skull baseSimultaneous two team approach in supine positionDisadvantagesExcessive bulk in obese patientsSegmental nerve supply prevents effective re innervationPoor color match of skin

www.nayyarENT.com4618/07/12Visceral flapsTypesPedicledGastric transpositionColon interposition

Free JejunalGastro - omentalwww.nayyarENT.com4718/07/12Causes for flap failureAnastamotic failureVenous stasisThrombosisHypovolemia, low blood flow statesInjury to endotheliumError in suture placementVascular spasmHaematoma formationInfectionPrevious irradiationAge, tobacco smoking, diabetes mellitus

www.nayyarENT.com4818/07/12Assessment of flap viabilityClinicalColorTemperatureCapillary refillBleeding

www.nayyarENT.com4918/07/12Assessment of flap viabilityMonitoring devicesTranscutaneous PO2 monitoringSurface temperature monitoringImplantable thermocouple probesDermoflourometrySurface doppler USGLaser doppler flowmetryIV flourescinPhotopletysmographyElectrical impedance pletysmographyImplantable microcatheters Radionucleotide scanningwww.nayyarENT.com5018/07/12ConclusionThere are different types of flaps available for reconstruction in head & neckAppropriate type should be selected based on functional & aesthetic requirementsPrinciples of reconstuctive ladder should be followedPost reconstruction, monitoring for flap viability is essentialwww.nayyarENT.com5118/07/12Thank You

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