Transcript Grafts and Flaps in the Head and Neck

Grafts and Flaps in the Head and
Neck
Dr. Supreet Singh Nayyar, AFMC
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Goals of Reconstruction
 Safety
 Functional rehabilitation
 Aesthetic rehabilitation
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Preoperative planning
 Nature of defect
 Clinical stage and prognosis
 Patient factors
 Available flap donor sites
 Compliance, expectations & psychosocial needs
 Clinical experience and skill of surgeon
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Timing of Reconstruction
 Optimally performed in one stage
 Optimal conditions present on resection
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Defect is widely exposed
Tissue requirements accurately assessed
Potential recipient vessels for anastomosis dissected out
Surgical margins cleared by frozen section
 Delayed reconstruction and secondary procedures
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Reconstructive ladder
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Grafts
 Types
 Skin grafts
 Split thickness skin graft (STSG)
 Full thickness skin graft (FTSG)
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Composite full thickness skin & cartilage graft
Pinch graft
Fat grafts
Fascial grafts
Dermal grafts
Mucosal grafts
Nerve grafts
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Skin Grafts
 Physiology
 Serum imbibition
 Revascularization
 Inosculation
 Neovascularization
 Organization
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Skin grafts
 Split thickness skin graft
 Epidermis with portion of
dermis
 Thin – 0.005 – 0.012
inches
 Moderate – 0.012 – 0.018
 Thick – 0.018 – 0.028
 Immobilization is critical
 Anterior thigh – preferred
site
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Skin grafts
 Full thickness skin graft
 Epidermis and entire dermis
 Thick and don’t contract
 Covers the contours well
 Good colour matching
 Slow revascularization and low take rates
 Commonly used after excision of cutaneous malignancies
 Common donor sites
 Primary closure of donor site
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Flaps
 Classification
 Blood Supply
 Axial
 Random
 Free
 Location
 Local
 Regional
 Distal free
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Flaps
 Classification
 Type of tissue
 Mucosal
 Fasciocutaneous
 Myocutaneous
 Osteocutaneous
 Visceral
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Skin and Fasciocutaneous Flaps
 Multiple descriptions of
flaps
 Z-plasty
 All limbs must be equal
 Gains length at expense of
width
 V-Y advancement
 Recruitment technique for
tissue deficiency
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Skin and Fasciocutaneous Flaps
 Rotational
 Need wide arch of rotation to fill
small defect
 Back cut increases arc of rotation
(decreases vascularity)
 Advancement
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Skin and Fasciocutaneous Flaps
 Transposition
 Need to close the “wake”
 Scalp flap
 Rhomboid
 Bi-lobed
 Make first flap 2/3 defect
and second 1/2 of first
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Local flaps
 Effective reconstructive alternatives for small and medium
sized defects
 Use determined by:
 Size and location of defect
 Properties of available tissue
 Vascular supply
 Advantages
 Best match of color and texture
 Less morbidity
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Local flaps
 Mucosal flaps
 Palatal
 Tongue
 Buccal
 Skin and muscle flaps
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Forehead flap
Nasolabial flap
Temporal flap
Temporoparietal flap
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Local flaps
 Nasolabial flap
 Up to 25sq cm is provided for
oral lining
 Vascular supply
 Labial artery
 One / Two stage
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Local flaps
 Nasolabial flap
 Uses
 Anterior oral defects
 Floor of mouth defects
 Coverage of exposed mandible
 Advantages
 Minimal donor site morbidity
 Excellent cosmesis
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Local flaps
 Temporal Flap
 Vascular supply
 Deep Temporal artery
 Uses
 Tissue defects of orbit and lateral face
 Palatal defects
 Reanimation of unilateral facial paralysis
 Complications
 Injury to temporal branch of VII Nerve
 Fibrosis of RMT
 Distortion of facial contour
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Local flaps
 Temporoparietal flap
 Pedicled or free fascial flap
 Vascular supply
 Posterior branch of superficial
temporal artery and vein
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Local flaps
 Temporoparietal flap
 Uses
 Resurfacing the orbit, lateral oral defects, mid face defects
 Auricular reconstruction
 Composite flap for reconstruction of orbit & zygoma
 Advantages
 Well hidden donor site
 Minimal morbidity
 Disadvantages
 Risk of injury to temporal branch of VII N
 Auriculotemporal nerve is sacrificed causing temporal numbness
 Alopecia
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Regional flaps
 Pedicled flaps
 Classification
 Fasciocutaneous
 Myocutaneous
 Muscle
 Selection
 Location and size of defect
 Intrinsic properties of flap
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Deltopectoral flap
 Bakamjian – 1965
 Fasciocutaneous flap
 Axial pattern
 Vascular supply
 2nd and 3rd perforating
branches of internal
mammary artery
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Deltopectoral flap
 Use
 Resurfacing cutaneous neck defects
 Facial, oral, pharyngeal defects
 Advantages
 Technically easy
 Low morbidity
 Disadvantages
 Unreliable distal random portion
 Lack of bulk
 Skin graft for donor site
 Two stage procedure
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Pectoralis Major Flap
 Ariyan – 1979
 “Work horse flap”
 Blood supply
 Pectoral branch of
Thoracoacromial artery
 Skin island - perforators
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Pectoralis Major Flap
 Modifications
 Bipaddled
 Osteomyocutaneous
 Uses
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Oral cavity and pharyngeal defects
Mandibular defects
Cutaneous defects of neck
Protection of great vessels
Obliteration of dead space after mediastinal dissection
Reconstruction of pharynx after pharyngectomy
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Pectoralis Major Flap
 Advantages
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Good vascular supply
Large skin paddle
Versatile
Easy to harvest
Single stage
Supine position
Primary closure of donor site
Low incidence of complications
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Pectoralis Major Flap
 Disadvantages
 Less reliable for cephalic defects of face and scalp
 Effect of gravity
 Excessive bulk
 Transposition of hair
 Complications
 Flap necrosis – total / partial
 Donor site complications
 Haematoma
 Wound dehiscence
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Trapezius flap
 Conley - 1972
 Vascular supply
 Perforating branches of
posterior intercostal arteries
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Trapezius flap
 Use – ipsilateral skin and pharyngeal defects
 Advantages
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Simple dissection
Not prone to wound separation due to gravity
Not in radiated field
Pedicle not threatened during neck dissection
 Disadvantages
 Limited length
 STSG for donor site
 Modifications
 Lateral Island flap
 Lower Island flap
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Free flaps
 Daniel and Taylor – 1973
 Characters defining free flap transfer:
 Anatomical site & characteristics of flap
 Texture , color , contour, vascular pedicle , innervation
 Requirement of bone
 Morbidity of donor site
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Free flaps
 Advantages
 Superior restoration of function and aesthetics
 One stage
 Superior vascular supply
 Greater variety and versatility of donor site
 93 – 96% success rate
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Free flaps
 Disadvantages
 Complexity of technique
 Increased surgical time
 Different color & contour from recipient site
 Multidisciplinary effort
 Morbid in patients with poor surgical risk
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Recipient vessels
 Arteries
 Superficial temporal system – scalp and upper face
 Facial artery—midface and cervical region
(atherosclerosis common)
 Superior thyroid or lingual artery—lower cervical
region
 Other: thyrocervical trunk, external carotid, common
carotid
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Recipient vessels
 Veins
 External jugular
 Branches of internal
jugular (common facial)
 Internal jugular
 Retrograde (superficial
temporal, thyroid)
 Transverse cervical,
occipital (very small)
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Radial Forearm Flap
 Chinese flap - 1981
 Harvested from volar aspect of
forearm
 Vascular supply
 Radial artery & its venae comitantes
 Osteocutaneous flap based on
periosteal perforators
 Sensory innervation
 Antebrachial cutaneous nerves
 Allen’s test
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Radial Forearm Flap
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Radial Forearm Flap
 Uses
 Oral & oropharyngeal defects
 Hypopharyngeal & cervical esophagus reconstruction
 Resurfacing of scalp & face
 Advantages
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Thin, pliable, hairless
Long vascular pedicle, large sized vessels
Sensate
Abundant subcutaneous fat for protection & contouring
Can be used as a osteocutaneous flap
Simultaneous two team approach in supine position
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Radial Forearm Flap
 Disadvantages
 STSG for donor site
 Color & texture match is only fair
 Vascular compromise of hand
 Numbness of hand
 Incomplete healing of STSG due to exposure of tendons
 Osteocutaneous flap
 Restricts dental restoration
 Pathological fracture of radius
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Fibula Flap
 Taylor & co workers –
1975
 Osteomyocutaneous flap
 Vascular supply
 Peroneal artery with 2 venae
comitantes
 Sensory innervation
 Lateral sural nerve
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Fibula Flap
 Uses
 Mandibular reconstruction
 Palatomaxillary reconstruction
 Advantages
 Exceptional bone length
 Thick bone allows fixation plates &
screws
 Dental rehabilitation
 Sensate
 Primary closure of donor site with
minimal morbidity
 Simultaneous two team harvest in
supine position
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Fibula Flap
 Disadvantages
 Limitations imposed by soft tissue component
 Poor arc of rotation of skin island
 Presence of atherosclerosis or congenital anomalies are a
contraindication
 Potential donor site complications
 Injury to peroneal nerve – foot drop
 Instability of knee and ankle joints
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Rectus Abdominis Flap
 Types
 Myocutaneous
 Myofascial
 Muscle
 Vascular supply
 Deep inferior epigastric artery and
vein
 Precaution
 Preservation of anterior rectus
sheath below the arcuate line to
prevent hernia formation
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Rectus Abdominis Flap
 Uses
 Large skull base defects
 Total glossectomy
 Orbitomaxillary defects
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Rectus Abdominis Flap
 Advantages
 Long vascular pedicle with large diameter
 Flexibility in design of paddles
 Minimal donor site morbidity with primary closure
 Suture placement during in setting of flap allows watertight
closure and dead space obliteration in oral cavity and skull base
 Simultaneous two team approach in supine position
 Disadvantages
 Excessive bulk in obese patients
 Segmental nerve supply prevents effective re innervation
 Poor color match of skin
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Visceral flaps
 Types
 Pedicled
 Gastric transposition
 Colon interposition
 Free
 Jejunal
 Gastro - omental
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Causes for flap failure
 Anastamotic failure
 Venous stasis
 Thrombosis
 Hypovolemia, low blood flow states
 Injury to endothelium
 Error in suture placement
 Vascular spasm
 Haematoma formation
 Infection
 Previous irradiation
 Age, tobacco smoking, diabetes mellitus
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Assessment of flap viability
 Clinical
 Color
 Temperature
 Capillary refill
 Bleeding
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Assessment of flap viability
 Monitoring devices
 Transcutaneous PO2 monitoring
 Surface temperature monitoring
 Implantable thermocouple probes
 Dermoflourometry
 Surface doppler USG
 Laser doppler flowmetry
 IV flourescin
 Photopletysmography
 Electrical impedance pletysmography
 Implantable microcatheters
 Radionucleotide scanning
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Conclusion
 There are different types of flaps available for reconstruction
in head & neck
 Appropriate type should be selected based on functional &
aesthetic requirements
 Principles of reconstuctive ladder should be followed
 Post reconstruction, monitoring for flap viability is essential
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Thank You
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