Grafts and Flaps in the Head and Neck

Grafts and Flaps in the Head and Neck Dr. Supreet Singh Nayyar, AFMC For more presentations, visit www. nayyar. ENT. com 18/07/12

Goals of Reconstruction �Safety �Functional rehabilitation �Aesthetic rehabilitation 2 www. nayyar. ENT. com 18/07/12

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 3 www. nayyar. ENT. com 18/07/12

Timing of Reconstruction �Optimally performed in one stage �Optimal conditions present on resection �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 4 www. nayyar. ENT. com 18/07/12

Reconstructive ladder 5 www. nayyar. ENT. com 18/07/12

Grafts �Types �Skin grafts �Split thickness skin graft (STSG) �Full thickness skin graft (FTSG) �Composite full thickness skin & cartilage graft �Pinch graft �Fat grafts �Fascial grafts �Dermal grafts �Mucosal grafts �Nerve grafts 6 www. nayyar. ENT. com 18/07/12

Skin Grafts �Physiology �Serum imbibition �Revascularization �Inosculation �Neovascularization �Organization 7 www. nayyar. ENT. com 18/07/12

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 18/07/12 www. nayyar. ENT. com 8

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 9 www. nayyar. ENT. com 18/07/12

Flaps �Classification �Blood Supply �Axial �Random �Free �Location �Local �Regional �Distal free 10 www. nayyar. ENT. com 18/07/12

Flaps �Classification �Type of tissue �Mucosal �Fasciocutaneous �Myocutaneous �Osteocutaneous �Visceral 11 www. nayyar. ENT. com 18/07/12

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 12 www. nayyar. ENT. com 18/07/12

Skin and Fasciocutaneous Flaps �Rotational �Need wide arch of rotation to fill small defect �Back cut increases arc of rotation (decreases vascularity) �Advancement 13 www. nayyar. ENT. com 18/07/12

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 14 www. nayyar. ENT. com 18/07/12

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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 16 www. nayyar. ENT. com 18/07/12

Local flaps �Mucosal flaps �Palatal �Tongue �Buccal �Skin and muscle flaps �Forehead flap �Nasolabial flap �Temporoparietal flap 17 www. nayyar. ENT. com 18/07/12

Local flaps �Nasolabial flap �Up to 25 sq cm is provided for oral lining �Vascular supply �Labial artery �One / Two stage 18/07/12 www. nayyar. ENT. com 18

Local flaps �Nasolabial flap �Uses �Anterior oral defects �Floor of mouth defects �Coverage of exposed mandible �Advantages �Minimal donor site morbidity �Excellent cosmesis 18/07/12 www. nayyar. ENT. com 19

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 20 www. nayyar. ENT. com 18/07/12

Local flaps �Temporoparietal flap �Pedicled or free fascial flap �Vascular supply �Posterior branch of superficial temporal artery and vein 21 www. nayyar. ENT. com 18/07/12

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 22 www. nayyar. ENT. com 18/07/12

Regional flaps �Pedicled flaps �Classification �Fasciocutaneous �Myocutaneous �Muscle �Selection �Location and size of defect �Intrinsic properties of flap 23 www. nayyar. ENT. com 18/07/12

Deltopectoral flap � Bakamjian – 1965 � Fasciocutaneous flap � Axial pattern � Vascular supply � 2 nd and 3 rd perforating branches of internal mammary artery 24 www. nayyar. ENT. com 18/07/12

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 25 www. nayyar. ENT. com 18/07/12

Pectoralis Major Flap �Ariyan – 1979 �“Work horse flap” �Blood supply �Pectoral branch of Thoracoacromial artery �Skin island perforators 26 www. nayyar. ENT. com 18/07/12

Pectoralis Major Flap �Modifications �Bipaddled �Osteomyocutaneous �Uses �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 27 www. nayyar. ENT. com 18/07/12

Pectoralis Major Flap �Advantages �Good vascular supply �Large skin paddle �Versatile �Easy to harvest �Single stage �Supine position �Primary closure of donor site �Low incidence of complications 28 www. nayyar. ENT. com 18/07/12

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 29 www. nayyar. ENT. com 18/07/12

Trapezius flap �Conley - 1972 �Vascular supply � Perforating branches of posterior intercostal arteries 18/07/12 www. nayyar. ENT. com 30

Trapezius flap �Use – ipsilateral skin and pharyngeal defects �Advantages �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 31 www. nayyar. ENT. com 18/07/12

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 32 www. nayyar. ENT. com 18/07/12

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 33 www. nayyar. ENT. com 18/07/12

Free flaps �Disadvantages �Complexity of technique �Increased surgical time �Different color & contour from recipient site �Multidisciplinary effort �Morbid in patients with poor surgical risk 34 www. nayyar. ENT. com 18/07/12

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 35 www. nayyar. ENT. com 18/07/12

Recipient vessels �Veins �External jugular �Branches of internal jugular (common facial) �Internal jugular �Retrograde (superficial temporal, thyroid) �Transverse cervical, occipital (very small) 36 www. nayyar. ENT. com 18/07/12

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 37 www. nayyar. ENT. com 18/07/12

Radial Forearm Flap 38 www. nayyar. ENT. com 18/07/12

Radial Forearm Flap �Uses �Oral & oropharyngeal defects �Hypopharyngeal & cervical esophagus reconstruction �Resurfacing of scalp & face �Advantages �Thin, pliable, hairless �Long vascular pedicle, large sized vessels �Sensate �Abundant subcutaneous fat for protection & 39 contouring �Can be used as a osteocutaneous flap www. nayyar. ENT. com 18/07/12 �Simultaneous two team approach in supine position

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 40 www. nayyar. ENT. com 18/07/12

Fibula Flap �Taylor & co workers – 1975 �Osteomyocutaneous flap �Vascular supply �Peroneal artery with 2 venae comitantes �Sensory innervation �Lateral sural nerve 41 www. nayyar. ENT. com 18/07/12

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 18/07/12 www. nayyar. ENT. com 42

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 43 www. nayyar. ENT. com 18/07/12

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 44 www. nayyar. ENT. com 18/07/12

Rectus Abdominis Flap �Uses �Large skull base defects �Total glossectomy �Orbitomaxillary defects 45 www. nayyar. ENT. com 18/07/12

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 46 www. nayyar. ENT. com 18/07/12

Visceral flaps �Types �Pedicled �Gastric transposition �Colon interposition �Free �Jejunal �Gastro - omental 47 www. nayyar. ENT. com 18/07/12

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 48 www. nayyar. ENT. com 18/07/12

Assessment of flap viability �Clinical �Color �Temperature �Capillary refill �Bleeding 49 www. nayyar. ENT. com 18/07/12

Assessment of flap viability �Monitoring devices �Transcutaneous PO 2 monitoring �Surface temperature monitoring �Implantable thermocouple probes �Dermoflourometry �Surface doppler USG �Laser doppler flowmetry �IV flourescin �Photopletysmography �Electrical impedance pletysmography �Implantable microcatheters �Radionucleotide scanning 50 www. nayyar. ENT. com 18/07/12

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 51 www. nayyar. ENT. com 18/07/12

Thank You for more presentations in ENT, please visit www. nayyar. ENT. com 52 www. nayyar. ENT. com 18/07/12