Local flaps in Head &Neck

reconstruction
Presenter : Dr Tegegne OMFS R4
Moderator :Dr Tingrt (Consultant OCMFS)
Outlines
• Anatomy and physiology of local skin flaps in head and neck
reconstruction
• Factors and techniques for local flap survival and failures
• Indication of local flap in head an neck reconstruction
• Classification of local flaps for head and neck reconstruction
• Common local flap applications in selected facial aesthetic units
• Complication of local flap and its management
• Take home message
• References
Objectives
• The objectives of this seminar is :
• To understand local flap physiology, mechanics and vascularity
• To understand factors for flap survival and failure
• Indications for local flap for head and neck reconstruction
• To identify local flap types & facial esthetic units for local
reconstruction
• To know the flap design , elevation and harvesting of local flap
• To seek back up plan for the other option for the complication
management
Introduction
• The skin is double layered organ covering the entire
surface of the body
• Epidermis &dermis is separated by the basement
membrane .
• Epidermal appendages
• Hair follicles, sebaceous glands, and sweat glands
• Nerves, blood vessels, and immunologic cells
• The dermis is attached to the subcutaneous adipose tissue
and underlying musculature
• Skin is highly variable
• From one person to another
• Within the same individual(anatomic region )
• Color, texture, thickness,
• Age, sex, elastic fiber
• Content of hair follicles & sebaceous glands
• Skin can also be
• Smooth non hair bearing (glabrous)
• Hair-bearing (non glabrous) areas
• Individuals with fair skin has postoperative pink scar for an extended
period.
• Persons with dark skin has post op pigmented scar for prolonged time
• Individuals with hyper elastic skin have
• Hyperextensibility of the joints
• Post op wide scars
• Patients with atopic dermatitis, psoriasis, dry skin have high counts of
staphylococcal organisms
Epidermis
• Continuously renewing outer most layer
• Keratinizing, stratified squamous epithelium.
• Contains all epidermal appendages :
• Hair follicles
• Sebaceous glands and sweat glands.
• Has four distinct cell types:
• Keratinocytes (80%)
• Melanocytes,
• Langerhans cells, and Merkel cells.
• Has four layers
• Turn over rate 30days
• Thickness 0.075 to 0.15mm
Dermis
• Integrated connective tissue below epidermis
• Makes up the bulk of the skin.
• Accommodates nerve and vascular networks
• Fibroblasts ,macrophages, mast cells
• Collagen and smaller amount of elastin
• Provides skin pliability, elasticity, and tensile strength.
• Has two parts
• Superficial papillary dermis
• The deeper, thicker reticular dermis.
• Thickness is different in :
• Location , age and sex
• The eyelid = 1mm
• Scalp =2.5mm
• Temple =1.5mm
• Back =4mm
Vascular supply
A .Physiology of local flap
• Flap is transfer of tissue from the donor site to recipient with its own blood
supply to reconstruct the defect
• Facial defect can be from cancer, trauma or infection
• The creation of local flap applies specific stresses on normal skin.
• Local tissue trauma
• Reduced neurovascular supply .
• Flap survival depends on the maintenance of the anatomy & physiology
of the flap ,vascular pattern and cutaneous response and biomechanics
to injury.
Vascular supply
• The blood supply to the flap serves two function
• Provides nutritional support
• Thermoregulatory mechanism for the body.
• The amount of blood flow to the skin depends on arteriolar pressure and
flow by
• Pre shunt sphincter in superficial papillary dermis
• SYMPATHETIC AND PARASYMPATHETIC
• Precapillary sphincters in deeper reticular dermis
• HYPOXIA AND METABOLIC DEMAND
.
• Blood supply to local flap is :
• Musculocutaneous arteries
• From overlying muscle
• Septocutaneous arteries
• Travel from fascial septa
dividing muscle segment
• Random pattern bold supply is versatile
• The blood supply is derived from musculocutaneous arteries near the
base of the flap.
• Blood is delivered to the tip of the flap by the interconnecting
subdermal plexus.
• Axial pattern flaps and perforator flaps
• Have improved survival length relative to random cutaneous flaps.
• Incorporation of a septocutaneous artery within the longitudinal axis.
Impaired vascular supply

• Fresh flap is viable and ischemic as neovascularization starts after 2 days

• Narrow base and longer flap length from base
• Surgical insult
• Reperfusion injury
• Peripheral vascular
diseases
• Flap design
• Hypotension
• Compression
• Infection
• Radiation
• Smoking
• Un optimized wound healing
Improved blood supply
• Indirect vasodilator
• Isoflurane GA, LA with OUT adrenaline
• Direct Vasodilator
• Hydralazine, histamine
• Dimethyl sulfa oxide, isoxsuprine
• Free radical scavengers
• VEGF application and HBOT
• Nitric oxide administration
• Allopurinol, super oxide dismutase
• Metabolic manipulation
• Nutrition
• Temperature regulation
• Platelet rich plasma (s/c)
• Increases vascular density
• Promote growth VEGF
• Flap delay and tissue expansion
Flap delay
• Is incising all or a portion of the flap & elevating all or a portion before
returning the flap to its in situ position.
• The incisions are sutured and the flap is left for 10 to 14 days before the
flap is transferred to a recipient site.
• Delay is used major facial defects reconstruction
• Formation of vascular collaterals (AV shunt closed)
• Depletion of vasoconstricting substance
• Stimulation of an inflammatory response
• Release of vasodilating substances
Tissue expansion
• It is surgical insertion of latex balloon around the defect to promote growth
of skin to reconstruct the defect .
• Volume of Inflation ranges from 50cc to 1L with increments of 50cc to
100cc ,done weekly for 3 weeks
• Base of the expander is at least 2x to 3x of the defect
• Broad spectrum antibiotics prescribed for 1 week
• Has 3 stages(insertion, expansion, reconstruction)
• Round shape expander =38% gain of tissue
• Rectangular shape expander =25%
• Crescent shape expander =32%
• Function of tissue expansion
• Increase in the thickness of epidermis
• Increase in mitotic activity of the skin .
• Increase Blood flow
• Promote tissue proliferation
• Used to reconstruct the defect with the same color
• To reconstruct Post operative alopecia
• To reconstruct Post traumatic defect
B. Biomechanics of local flap
• Flap mechanics is defined as mechanical property of the local flap which is
the ratio of stress /strain
• Stress force per unit area
• Strain is the change in length by stress
• Physical mechanics vs skin mechanics
• Skin is living tissue undergoing proliferation in response to stimuli
• It influences blood flow and flap survival
• They are integral part of local skin flaps design for reconstruction of
small & medium-sized facial defects
1.Non linearity
• Defines skin extensibility to stress
• Skin has heterogenous composition
• Epidermis and dermis
• Dermis contains
• Collagen fibers, elastic fibers
• Nerve fibers, capillaries
• Lymphatics
• Ground substance
2.Anisotropy
• Anatomic , injury and individual variations in the extensibility of skin
• Individual variation
• Slim and obese , young and old
• Male and female.
• Tissue injury variation
• Oedema, inflammation, hormonal conditions.
• Anatomic variation
• skin is lax around the eyes and cheek
• Is taut on the nose, chin, and forehead.
• Skin tension is greatest along RSTL and lower at LME(line of
maximal extension)
3.Viscoelasticity
• Skin has both elastic and viscosity properties
• Viscosity material resists shear flow and strain in a linear fashion related to
time in response to a force
• Elasticity materials demonstrate immediate strain when a force is applied
but return to their original state when the force is removed
• Skin is viscoelastic (elastic at low stress and VE at higher load within a
time interval
• The two time dependent skin properties are creep and stress relaxation
• Skin Creep is increase in length under constant stress
• High stress result in medium increase in strain in shorter time
• Small increase in strain is because of compression of collage fibers by
displacing interstitial fluid in ground substance
• Stress relaxation refers to a decrease in stress that occurs when skin is held
under tension at a constant strain.
• It also accounts for the improved vascularity observed in the first 24
hours of flaps closed under tension.
4.Wound tension
& Blood flow
• Longer and tensioned wound flap
• Undergoes necrosis.
• Flaps with ample blood flow
• Can withstand the extremes
of tension
Principles of flap surgery
Flap designing and undermining
• Advancement flaps should be designed with
• L/W of ratio of 1:1 or 2:1
• Will have low-tension closure
• Rotation flaps less thana 90°
• Undermining
• Separates vertical attachments between the dermis & subcutaneous
tissue &increase flap movement
• Should be done within first 1 to 2 cm.
• Too short compromise blood supply tissue
• Too long results in excess tissue
Wound closure techniques
• Flap survival depends on good wound closure and healing
• Tension free everted wound closure
• Gentle manipulation of soft tissue
• Continuous long incision by blade no 15
• Proper stitch material
• Proper dressing (If no dress ,make sure that hemostasis is good)
• Proper Suture needle types (shapes &tip type)
• Stitch removal within 5 to 7 days on facial area
Patient preparation
• Communication with pt and consent
• Option , stages ,risks and benefit of the flap & GA/LA & Preop and
post op PHOTOGRAPHS
• Post op care
• Remove dressing on 1st post op day.
• Clean sutures with cotton-tip applicators and hydrogen peroxide
or soap 3x per day
• Apply bacitracin ointment 3x per day for 3 days.
• Patient may shower the day following the operation with luke
water
Ideal suture materials
• Minimal tissue injury
• Minimal tissue reaction
• Ease of handling
• High tensile strength
• Favorable absorption profile
• Resistance to infection
Indication of local flap for head and neck
reconstruction
• Reconstruction of smaller or medium size defects( < 4cm)
• Full thickness reconstruction
• Adequate flap thickness to reconstruct the defect
• Color match reconstruction
• Technically less demanding
• Preserve sensory function
• Provide functional motor units
Advantages of local flap
• Local flap has these important advantages
• Full thickness reconstruction
• Color match
• Can be operated at later time
• Slightly less technical demanding
• Can preserve sensory function
• Can provide functional motor unit
• Can be a means to control infection
• cover prominent body parts =adequate thickness
Flap ladder for head and neck reconstruction
Defect analysis
• Before performing a local flap , thorough defect analysis has to be done :
• Anatomic site
• Reconstructive goals
• Size of the defect
• Flap plan and back up option
• Composition of the defect lost
• The donor site reconstruction plan
• Contamination of the wound
• Immediate and delayed reconstruction
• Adjacent Skin laxity and
• Near by aesthetic unit
• Composition of the donor site
Flap Classification & design
• Flap is transfer of tissue from donor to recipient site with its own direct
blood supply to reconstruct the defect
• Defect can resulted from cancer, trauma or infection
• Terminology associated with the flaps are :
• Primary defect is the wound to be closed by flap
• Secondary defect is the wound created after flap raising
• Primary tissue movement is the movement of tissue when the flap is
transferred to the defect
• Secondary flap movement is the displacement of skin surrounding the
defect toward the center of the primary defect
• Wound closure tension is the amount of stress per unit area along the
suture line of a repaired wound.
• Relaxed skin tension (RSTL)line is intrinsic to facial skin which is
oriented along the line of collagen fibers and perpendicular to maximal line
of skin extensibility (MLE)
• Maximal line of skin extensibility is the lengthening of skin under tension
due to stretching of elastic fiber
Flap pedicle is portion of the flap together with adjacent
tissue responsible for providing vascularity to the flap
• Pivot point :the point around which the flap moves
• Promontory : the end point of the flap that moves to wards distant part of
the defect
• Back cut : incision made at inside part of promontory of the flap to reduce
tension and increase flap movement
• Burrow triangle : a triangle of skin is removed from outer part of
promontory to remove dog ear deformity.
• Undermining : releasing skin and subcutaneous tissue from the flap and
the surrounding tissue to increase flap movement
• Facial aesthetic regions & borders is important in designing local flaps for
facial reconstruction.
• Flap should be designed within the same aesthetic region containing the
primary defect.
• Scars are best camouflaged by placing incisions along aesthetic borders.
• When a defect involves two or more aesthetic regions, it is best to
compartmentalize the repair with individual flap units.
• Limberty & Comark local flap classification
• The 6 c’s classification
• Circulation
• Direct = axial,septocutaneous, endosteal
• Indirect= myocutaneous , periosteal
• Composition
• Skin,fasciocutaneous,fasciomusculocutaneous,osteomusculoc
utaneus
• Contiguity destination
• local , regional, distant
• Construction (direction of Blood flow)
• Uni Pedicle , Bi Pedicle
• Anterograde, Retrograde
• Conditioning changes
• Flap Delay
• Tissue expansion
• Conformation (design)
• Pivotal
• Advancement
• Hinge
A. Pivotal flap
• All pivotal flaps are moved toward the defect by pivoting the flap
around a fixed point at the base of the pedicle
• The greater the pivot , the shorter the flap length except island flap
skeletonized to the pedicle
• Four types of: rotation, transposition, interpolated & island.
Rotation flap
• Rotation flaps are pivotal flap designed adjacent to the defect to close
triangular defects .
• Defect changed in to isosceles triangle and arc of rotation is done using
the side of the triangle
• Borrow triangle to avoid the dog ear cutaneous deformity
• Back cut
• Needed to increase flap movement
Transposition flap
• Transposition flaps have a linear configuration to reconstruct linear defects
• Can be rhomboid or modification of rhomboid
• Good option for small to medium size defect for HAN reconstruction
Interpolated flap
• Transposition flap where the base of flap is not contiguous to the defect
• The Pedicle cross over or tunneling tissue
• Two stage procedure (flap insetting & flap release )
• Nasolabial
• Forehead
Paramedian flap
Island Flap
• Is designed by incising on all borders of the flap having no cutaneous
attachments B/n the skin of the flap & the adjacent skin of the donor site
• The pedicle of the flap consists only of subcutaneous tissue or an individual
artery and vein unencumbered by surrounding tissue
• Nasolabial flap
• Paramedian forehead flap
• VY flap
B.Advancement Flap
• Designed by linear configuration and moved by sliding towards the defect.
• It works best in areas of greater skin elasticity.
• Involves undermining and direct advancement of tissue side to side to close
the defect with no secondary defect
• Additional incisions is made for removal of standing cutaneous deformities
• Uni pedicle
• Bi pedicle
• VY
• Island flap
C. Hing flap
• Designed in a linear or curvilinear shape with the pedicle based on one
border of the primary defect.
• The flap is dissected & turned to the defect like a page in a book.
• The exposed subcutaneous surface of the hinge flap is covered by a
second flap or skin graft
• The vascular supply of hinge flaps is derived from the soft tissue border
of the defect that the flap is designed to repair
• Used to reconstruct Full thickness nasal , sino facial or salivary fistula
and pharyngeal defect
Local flap application in head and neck
reconstruction
• Rotation flap
• Used for less than 2cm defect
• Scalp
• Dorsal nose
• Face
Limberg & Dufourmentel flap
Note flap
Z Plasty
W Plasty
• Popular scar revision surgery
• Serial triangular incision
• on either side of the scar
• No rotation
• Easy to manipulate
• Camouflage scar
• No tension on the wound
• Limitation
• Resulting scar is Longer
Bilobed flap
Key stone flap
• Perforator type flap design with 1:1 flap to defect ratio
• Contain Musculocutaneous of fasciocutaneous perforator vessels
Hinge flap
• To reconstruct
• Oval shape defect
• Pharyngo cutaneous
• Laryngocutaneous
• Design
• Draw on either end of longer
side along 180
using shorter radius
• Draw 2 half circle using longer R
Nasolabial flap
Paramedian forehead flap
• Has rich blood supply
• Bulk of tissue can be gained
• Uses
• Nasal defect reconstruction
• Dorsal defect
• Lateral defect
• Tip defect
• Limitation
• Two stage surgery
• Frontal paresthesia
Tongue flap
• Has robust blood supply
• Anterior , posterior based tongue flap
• median or paramedian tongue flap
• Sliding flap for tongue defect itself
• Anterior hemi tongue flap for hemi glossectomy
• Posterior sliding flap for lateral glossectomy
• Uses
• Palatal defect
• FOM & Buccal mucosa defect
• Lip defect
• Tongue defect
• Complication
• Post op edema
• Patient intolerance
• Feeding difficulty
• Post op flap detachment
• So Post op MMF is mandatory
Buccal pad fat flap
• Has rich vascular supply
• Enhances Healing
• Anti-infective
• Promotes granulation
• Alleviate dead spaces
• Uses
• Defects less than 5cm by 4cm
• Post surgical maxillary defect
• Skull base defects
• TMJ surgery
• Buccal mucosa &RMT defect
• Limitation
• Only used for medium size defect
• Not able to add bulk , only cover defect
• Cheek deformity
• Complication
• Hemorrhage & hematoma
• Partial flap loss
• Trismus
• Vestibular obliteration
• Cheek sinking
Temporalis flap
• Torrential blood supply
• Bulk of tissue can be gained
• Uses
• TMJ surgery
• Maxillary defect &Palatal defect
• Orbital defect &Auricular defect
• Skull base defect
• Limitation
• Temporal hallowing
• Frontal facial palsy
Palatal flap
• Based on greater palatine artery
• For defects less than 2cm
• Has high bound of oral mucosa
• Palatal defect (soft &hard )
• Maxillary defect & RMT defect
• Alveolar , tuberosity, tonsillar fossa
• Prevents buccal vestibule obliteration
• Limitation
• Only for smaller defects
• Axis of rotation is less than 90 degree
• OHM is difficult
Karapanzic flap
• Axial MCF to reconstruct lip defect
• Based on labial artery
• Defects larger than 2/3 of lip defect
• Larger central lip defect
• NVS is preserved
• Designed around nasolabial
& Labiomental crease
• Limitation
• Microstomia
• Philtrum shift
Abbe flap
• Two staged cross lip flap
• Based on Labial artery
• Used for full thickness lip defect
• Defects less than 2/3
• Defect not involve commissure
Complication and its management
• Flap tearing
• Flap dehiscence
• Flap necrosis
• Management
• Proper flap planning and designing
• Full thickness flap elevation
• Meticulous tissue manipulation and dissection
• Tension free wound closure
• Back plan &Wound care
Take home message
• Local flap in HAN reconstruction is important to reconstruct defects with
similar color and texture
• Thorough understanding of anatomy & characteristics of skin is the bases
for local flap survival in HAN reconstruction
• Flap planning and designing is crucial for flap success
• Always think of the back up plan before executing the predetermined
local flap used in reconstruction of HAN defects
• Start from simple to complex flap reconstruction
References