Micro vascular Free Flaps Micro vascular Free Flaps Used in Head and Neck Used in Head and Neck
Reconstruction.Reconstruction. INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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OutlineOutline► Radial Forearm FlapsRadial Forearm Flaps► Lateral Arm FlapsLateral Arm Flaps► Lateral Thigh FlapLateral Thigh Flap► Anterolateral Thigh FlapAnterolateral Thigh Flap► Rectus Abdominis FlapsRectus Abdominis Flaps► Latissimus Dorsi FlapLatissimus Dorsi Flap► Gracilis Flap Gracilis Flap ► Temperoparietal Fascial FlapTemperoparietal Fascial Flap► Fibular Osteocutanous FlapFibular Osteocutanous Flap► Iliac Crest FlapsIliac Crest Flaps► Scapular FlapsScapular Flaps► Metatarsal FlapMetatarsal Flap► Rib FlapsRib Flaps► JejunumJejunum► Omentum Omentum ► GastroomentumGastroomentum
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Radial Forearm FlapRadial Forearm Flap► 1981 (China), 1985 (pharyngeal recon)1981 (China), 1985 (pharyngeal recon)► Oral cavity, base of tongue, pharynx, soft Oral cavity, base of tongue, pharynx, soft
palate, cutaneous defects, base of skull, palate, cutaneous defects, base of skull, small volume bone and soft tissue defects of small volume bone and soft tissue defects of faceface
► Thin, pliable skinThin, pliable skin Reconstitution of contours, sulci, Reconstitution of contours, sulci,
vestibulesvestibules Tongue mobilityTongue mobility
► Fasciocutaneous flaps are highly tolerant of Fasciocutaneous flaps are highly tolerant of radiation therapy radiation therapy
► Composite flap with bone, tendon, Composite flap with bone, tendon, brachioradialis muscle and vascularized brachioradialis muscle and vascularized nerve.nerve. Sensory recovery reported in patients Sensory recovery reported in patients
even when a neural anastomosis is not even when a neural anastomosis is not performed.performed.► Fasciocutaneous flaps > Fasciocutaneous flaps >
musculocutaneous flapsmusculocutaneous flaps► Incomplete and unpredictableIncomplete and unpredictable
► Skin from entire forearmSkin from entire forearm► 2 team approach2 team approach
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Neurovascular pedicleNeurovascular pedicle► Up to 20 cm longUp to 20 cm long► Vessel caliber 2 – 2.5 mmVessel caliber 2 – 2.5 mm► Radial arteryRadial artery► Venae comitantes / Venae comitantes /
cephalic veincephalic vein► Lateral antebrachial Lateral antebrachial
cutaneous nerve (sensory)cutaneous nerve (sensory) Anastomose to lingual nerveAnastomose to lingual nerve Increased two point Increased two point
discrimination after insetdiscrimination after inset
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Technical considerationsTechnical considerations► TourniquetTourniquet
► Flap designed with skin Flap designed with skin paddle centered over the paddle centered over the radial arteryradial artery
► Dissection in subfascial level Dissection in subfascial level as the pedicle is approached.as the pedicle is approached.
► Pedicle identified b/w medial Pedicle identified b/w medial head of the brachioradialis, head of the brachioradialis, and the flexor carpi radialisand the flexor carpi radialis
► Radial artery is dissected to Radial artery is dissected to its originits origin Divided distal to the radial Divided distal to the radial
recurrent arteryrecurrent artery
► External skin monitor can be External skin monitor can be incorporated into the flap incorporated into the flap (proximal segment)(proximal segment)
► A -plasty - reduces the A -plasty - reduces the potential for stricturepotential for stricture
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Technical considerationsTechnical considerations► Osteocutaneous flapOsteocutaneous flap
MonocorticalMonocortical Cuff of flexor pollicis longusCuff of flexor pollicis longus 10 – 12 cm of radius10 – 12 cm of radius Up to 40% circumferenceUp to 40% circumference Limited by amount of available bone and risk for Limited by amount of available bone and risk for
pathologic fracture. pathologic fracture. ► Pollicis longus tendonPollicis longus tendon
Suspending flap laterally in palatal and Suspending flap laterally in palatal and total lower lip recontotal lower lip recon
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Radial Forearm FlapRadial Forearm Flap
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Radial Forearm FlapRadial Forearm Flap
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Radial Forearm FlapRadial Forearm Flap
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Radial Forearm FlapRadial Forearm Flap► MorbidityMorbidity
Hand ischemiaHand ischemia Fistula rates - 42% to 67% in early seriesFistula rates - 42% to 67% in early series
► Subsequent series - 15% and 38%. Subsequent series - 15% and 38%. ► Creation of a controlled fistula or use of a Creation of a controlled fistula or use of a
salivary bypass stent can protect the suture line salivary bypass stent can protect the suture line from salivary soilage and decrease the potential from salivary soilage and decrease the potential for fistulization.for fistulization.
Stricture formation - 9% to 50%.Stricture formation - 9% to 50%. Radial nerve injuryRadial nerve injury Variable anesthesia over dorsum of hand.Variable anesthesia over dorsum of hand.
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Radial Forearm FlapRadial Forearm Flap► Preoperative considerationsPreoperative considerations
Allen testAllen test► Tests viability of palmar Tests viability of palmar
arch systemarch system No IVs / blood draws in donor No IVs / blood draws in donor
arm.arm. Skin graft (must preserve Skin graft (must preserve
paratenon layer)paratenon layer) Osteocutaneous flapsOsteocutaneous flaps
► Radius fractureRadius fracture► Weakened supination, Weakened supination,
wrist flexion, grip strength wrist flexion, grip strength and pinch strength.and pinch strength.
Should not be used defect Should not be used defect extends below the thoracic extends below the thoracic inletinlet
► Postoperative managementPostoperative management Forearm and wrist Forearm and wrist
immobilization w/volar immobilization w/volar splintsplint
7-10 days7-10 days Oral intake can generally Oral intake can generally
begin within 7 to 10 daysbegin within 7 to 10 days► 2 weeks is best if the 2 weeks is best if the
patient has been previously patient has been previously irradiated.irradiated.
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Lateral Arm FlapLateral Arm Flap► Described by Song in 1982 Described by Song in 1982 ► Moderately thin fasciocutaneous Moderately thin fasciocutaneous
flapflap► Donor site skin 6-8 cm (1/3 Donor site skin 6-8 cm (1/3
circumference of arm)circumference of arm)► Fascial flapFascial flap
Augmentation of subcutaneous Augmentation of subcutaneous defects from lateral temporal defects from lateral temporal bone resection or total parotidbone resection or total parotid
► Portion of humerus can be taken.Portion of humerus can be taken.► Oropharyngeal reconstructionOropharyngeal reconstruction
Incorporates thin skin from the Incorporates thin skin from the proximal forearm.proximal forearm.►Pharyngeal wallPharyngeal wall
Thick skin from the upper armThick skin from the upper arm►Tongue baseTongue base
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Neurovascular pedicleNeurovascular pedicle► Terminal branch of profunda brachii Terminal branch of profunda brachii
artery and posterior radial collateral artery and posterior radial collateral arteryartery
► Venae comitantesVenae comitantes► Travel with radial nerve in spiral groove Travel with radial nerve in spiral groove
of humerusof humerus Travels in the lateral intermuscular Travels in the lateral intermuscular
septum septum ► Posterior - Triceps Posterior - Triceps ► Anterior - Brachialis and Anterior - Brachialis and
BrachioradialisBrachioradialis► Artery caliber 1.55 mm diameter (1.25 Artery caliber 1.55 mm diameter (1.25
to 1.75 mm) @ deltoid insertionto 1.75 mm) @ deltoid insertion► Skin blood supply – 4 to 5 Skin blood supply – 4 to 5
septocutaneous perforaters septocutaneous perforaters ► Sensory nerves (from proximal radial Sensory nerves (from proximal radial
nerve)nerve) Posterior cutaneous nerve of the Posterior cutaneous nerve of the
arm (lower lateral brachial arm (lower lateral brachial cutaneous nerve)cutaneous nerve)
Posterior cutaneous nerve of the Posterior cutaneous nerve of the forearm (post antebrachial cut forearm (post antebrachial cut nerve)nerve) www.indiandentalacademy.com
Technical considerationsTechnical considerations► No tourniquet.No tourniquet.► Central axis of flap design based on Central axis of flap design based on
intermuscular septumintermuscular septum Lateral intermuscular septum - 1 Lateral intermuscular septum - 1
cm posterior to line drawn from cm posterior to line drawn from insertion of deltoid and lateral insertion of deltoid and lateral epicondyleepicondyle
Can be extended distally over Can be extended distally over the upper forearmthe upper forearm
► Radial nerve identified along the Radial nerve identified along the anterior aspect of the pedicleanterior aspect of the pedicle
► Radial nerve and pedicle are Radial nerve and pedicle are followed into the spiral groovefollowed into the spiral groove
► Must identify and preserve muscular Must identify and preserve muscular branches from radial nervebranches from radial nerve
► Osteocutaneous flapOsteocutaneous flap Humerus segmentHumerus segment
► 10 cm in length10 cm in length► 20% of the circumference20% of the circumference
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Lateral Arm FlapLateral Arm Flap►MorbidityMorbidity
Radial nerve damageRadial nerve damage►Palsy 2/2 constrictive Palsy 2/2 constrictive
dressings or tight wound dressings or tight wound closure.closure.
Primary closure if less Primary closure if less than 1/3 of armthan 1/3 of arm►Use STSG if closure Use STSG if closure
under too much tension.under too much tension.
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Lateral Arm FlapLateral Arm Flap►Preoperative ConsiderationsPreoperative Considerations
Easy scar camouflageEasy scar camouflage Male patients may have less Male patients may have less
hair in this region when hair in this region when compared to forearmcompared to forearm►Consider for intraoral Consider for intraoral
reconstructionreconstruction Flap becomes thinner more Flap becomes thinner more
distallydistallywww.indiandentalacademy.com
Lateral Thigh FlapLateral Thigh Flap►Described by Baek in 1983Described by Baek in 1983► Large surface areaLarge surface area► Expendable tissueExpendable tissue► Flap size up to 25 x 14 cmFlap size up to 25 x 14 cm► Fasciocutaneous flap – Fasciocutaneous flap –
thin to moderately thickthin to moderately thick► Intraoral and pharyngeal Intraoral and pharyngeal
reconstructionreconstruction► Reinnervated via lateral Reinnervated via lateral
femoral cutaneous nervefemoral cutaneous nerve
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Neurovascular pedicleNeurovascular pedicle► Third perforator of profunda Third perforator of profunda
femorisfemoris► Travels w/in intermuscular Travels w/in intermuscular
septumseptum► Pedicle 8 – 12 cmPedicle 8 – 12 cm► Vessel caliber 2 – 4 mmVessel caliber 2 – 4 mm► Lateral femoral cutaneous Lateral femoral cutaneous
nerve of the thighnerve of the thigh Anterosuperior entry into Anterosuperior entry into
flapflap Does not travel with Does not travel with
vascular pediclevascular pedicle
► Terminal cutaneous branch of Terminal cutaneous branch of second or fourth perforators second or fourth perforators are the dominant arterial are the dominant arterial supply (rare)supply (rare) 44thth perforator usually perforator usually
included in dissection to included in dissection to account for variationsaccount for variations
When 2When 2ndnd perforator perforator dominant – pedicle length dominant – pedicle length limited by muscular branch limited by muscular branch vessels to preserve femoral vessels to preserve femoral blood supply.blood supply.
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Lateral Thigh FlapLateral Thigh Flap
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Lateral Thigh FlapLateral Thigh Flap
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Technical considerationsTechnical considerations► Centered over lateral intermuscular Centered over lateral intermuscular
septumseptum Separates vastus lateralis and iliotibial Separates vastus lateralis and iliotibial
tract (fascia lata) anteriorly from the tract (fascia lata) anteriorly from the biceps femoris posteriorlybiceps femoris posteriorly
► Septum located by line b/w greater Septum located by line b/w greater trochanter and lateral epicondyle of trochanter and lateral epicondyle of femurfemur
► 33rdrd perforator at midpoint of line perforator at midpoint of line Terminates in the intermuscular septum Terminates in the intermuscular septum
between the long head of the biceps between the long head of the biceps femoris and the vastus lateralisfemoris and the vastus lateralis
► Lateral femoral cutaneous nerve provides Lateral femoral cutaneous nerve provides sensation to the skin of the lateral thigh sensation to the skin of the lateral thigh and may be incorporated into the flapand may be incorporated into the flap
► Dominant perforator identified in Dominant perforator identified in subcutaneous plane and then traced subcutaneous plane and then traced through the biceps femoris to the main through the biceps femoris to the main pediclepedicle
► Release of the adductor magnus from the Release of the adductor magnus from the linea aspera facilitates dissection of the linea aspera facilitates dissection of the main pediclemain pedicle www.indiandentalacademy.com
Lateral Thigh FlapLateral Thigh Flap►MorbidityMorbidity
Atherosclerosis of profunda femoris and Atherosclerosis of profunda femoris and its branchesits branches
Avoid in pts with h/o PVDAvoid in pts with h/o PVD Sciatic nerve injurySciatic nerve injury
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Lateral Thigh FlapLateral Thigh Flap► Preoperative Preoperative
ConsiderationsConsiderations Assess for PVD Assess for PVD
(palpate peripheral (palpate peripheral pulses)pulses)
Not advised for use Not advised for use in obese individuals in obese individuals or in those with or in those with previous surgery or previous surgery or trauma to the thightrauma to the thigh
► Postoperative Postoperative managementmanagement Primary closure of Primary closure of
donor site donor site Early walkingEarly walking
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Anterolateral thigh flapAnterolateral thigh flap► First reported by Song et alFirst reported by Song et al► Subcutaneous, fasciocutaneous, Subcutaneous, fasciocutaneous,
myocutaneous, adipofascialmyocutaneous, adipofascial► Laryngopharynx, oral cavity, Laryngopharynx, oral cavity,
oropharynx, external skin and oropharynx, external skin and maxillamaxilla
► Flap may be thinned or Flap may be thinned or suprafascial flaps taken for suprafascial flaps taken for thinner flapsthinner flaps
► Popular in AsiaPopular in Asia► Less popular in Europe and Less popular in Europe and
AmericaAmerica Difficult perforator dissection Difficult perforator dissection
(bountiful subcutaneous tissue)(bountiful subcutaneous tissue) Variation in vascular anatomyVariation in vascular anatomy
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Neurovascular pedicleNeurovascular pedicle► Descending branch of lateral Descending branch of lateral
circumflex femoral artery circumflex femoral artery SeptocutaneousSeptocutaneous
►Traverse the fascia lataTraverse the fascia lata Musculocutaneous Musculocutaneous
perforatorsperforators►Traverse the vastus Traverse the vastus
lateralis muscle and lateralis muscle and the deep fasciathe deep fascia
► Venae comitantesVenae comitantes► Descending branch travels Descending branch travels
inferiorly in intramuscular inferiorly in intramuscular space b/w rectus femoris and space b/w rectus femoris and vastus lateralisvastus lateralis
► Caliber – 2.1 mm artery, 2.6 Caliber – 2.1 mm artery, 2.6 mm veinmm vein
► Vascular pedicle up to 16 cmVascular pedicle up to 16 cm
► Lateral femoral cutaneous Lateral femoral cutaneous nerve – sensory nervenerve – sensory nerve Branch of lumbar plexusBranch of lumbar plexus Enters thigh deep to Enters thigh deep to
lateral aspect of inguinal lateral aspect of inguinal ligament near ASISligament near ASIS
Runs with deep Runs with deep circumflex iliac artery circumflex iliac artery and veinand vein
Runs anterior, posterior Runs anterior, posterior or through sartorius, or through sartorius, continuing through fascia continuing through fascia latalata
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Neurovascular pedicleNeurovascular pedicle► Musculocutaneous variationsMusculocutaneous variations
Vertical musculocutaneous perforators (descending lateral Vertical musculocutaneous perforators (descending lateral circumflex femoral artery)circumflex femoral artery)►Pass through vastus lateralis perpendicularly into fascia Pass through vastus lateralis perpendicularly into fascia
latalata Horizontal musculocutaneous perforators (transverse Horizontal musculocutaneous perforators (transverse
branch of lateral circumflex femoral artery)branch of lateral circumflex femoral artery)►Pass through vastus lateralis horizontallyPass through vastus lateralis horizontally
► Skin blood supplySkin blood supply Septocutaneous perforators – 10.7%Septocutaneous perforators – 10.7% Musculocutaneous perforators from descending branch – Musculocutaneous perforators from descending branch –
89%89% Musculocutaneous perforator from transverse branch – Musculocutaneous perforator from transverse branch –
3.5%3.5%www.indiandentalacademy.com
Anterolateral thigh flapAnterolateral thigh flap
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Anterolateral thigh flapAnterolateral thigh flap
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Technical considerationsTechnical considerations► Draw line from ASIS to lateral patellar borderDraw line from ASIS to lateral patellar border► Cutaneous perforator exit point from Cutaneous perforator exit point from
intermuscular septum or from vastus lateralisintermuscular septum or from vastus lateralis 2 cm lateral to and 2 cm inferior to midpoint 2 cm lateral to and 2 cm inferior to midpoint
of line from ASIS and lateral border of patellaof line from ASIS and lateral border of patella► Use Doppler to mark perforatorsUse Doppler to mark perforators► Dissect (medial to lateral) to intermuscular Dissect (medial to lateral) to intermuscular
septum b/w rectus femoris and vastus lateralis.septum b/w rectus femoris and vastus lateralis.► Retract rectus femoris medially exposing Retract rectus femoris medially exposing
perforators perforators Leave muscle cuff around myocutaneous Leave muscle cuff around myocutaneous
perforatorsperforators► Fasciocutaneous flap, suprafascial flap, Fasciocutaneous flap, suprafascial flap,
cutaneous flap (up 5 mm thickness), adipofascial cutaneous flap (up 5 mm thickness), adipofascial flapflap
► May include lateral cutaneous nerve of thighMay include lateral cutaneous nerve of thigh► Max size – horizontal line from greater trochanter Max size – horizontal line from greater trochanter
down to a parallel line 3 cm above patella down to a parallel line 3 cm above patella 25 x 18 cm25 x 18 cm 20 x 26 cm20 x 26 cm
► Close donor site primarily if less than 8 cm wideClose donor site primarily if less than 8 cm widewww.indiandentalacademy.com
Anterolateral thigh flapAnterolateral thigh flap
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Anterolateral thigh flapAnterolateral thigh flap►MorbidityMorbidity
Possible STSGPossible STSG Depends on extent of injury to vastus Depends on extent of injury to vastus
lateralislateralis Thinned flaps with more complications in Thinned flaps with more complications in
intraoral defectsintraoral defects
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Anterolateral thigh flapAnterolateral thigh flap►Preoperative ConsiderationsPreoperative Considerations
Reduced donor site morbidity compared Reduced donor site morbidity compared to RFFto RFF
Can be as thin as RFFCan be as thin as RFF Contraindicated in pts with prior upper Contraindicated in pts with prior upper
thigh surgery, vascular procedures, big thigh surgery, vascular procedures, big eaters…eaters…
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Rectus abdominisRectus abdominis► Easy to harvestEasy to harvest► Long pedicleLong pedicle► Skin from abdomen and lower chestSkin from abdomen and lower chest► Myocutaneous flap or muscle only flapMyocutaneous flap or muscle only flap► Not used for functional motor reconstructionNot used for functional motor reconstruction► Can include entire muscle or only small portion in Can include entire muscle or only small portion in
paraumbilical regionparaumbilical region► Plentiful people – thinner flap created by skin Plentiful people – thinner flap created by skin
grafting the musclegrafting the muscle► Skinny peopleSkinny people
Flap used for moderately volume defectsFlap used for moderately volume defects► Poor color matchPoor color match► Tends to become ptoticTends to become ptotic► Skull base defectsSkull base defects
Muscular component used to seal subarachnoid Muscular component used to seal subarachnoid spacespace
► Able to fill large tissue deficitsAble to fill large tissue deficits► Total glossectomy defectsTotal glossectomy defects
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Neurovascular pedicleNeurovascular pedicle► Two dominant pediclesTwo dominant pedicles
Deep superior epigastric artery/veinDeep superior epigastric artery/vein Deep inferior epigastric artery and Deep inferior epigastric artery and
veinvein► Based on inferior epigastrics Based on inferior epigastrics
when used for h/n recon when used for h/n recon because of larger pedicle sizebecause of larger pedicle size
► Inferior epigastric diameter – 3 Inferior epigastric diameter – 3 to 4 mmto 4 mm
► Reinnervated with any of the Reinnervated with any of the lower six intercostal nerves.lower six intercostal nerves.
► Pedicle may travel along lateral Pedicle may travel along lateral aspect of muscle before taking aspect of muscle before taking intramuscular routeintramuscular route
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Technical considerationsTechnical considerations► Cutaneous blood supplyCutaneous blood supply
Harvest anterior rectus sheath in Harvest anterior rectus sheath in paraumbilical region (dominant perforators paraumbilical region (dominant perforators located here)located here)
Skin paddle designed with epicenter above Skin paddle designed with epicenter above the umbilicusthe umbilicus
► Primary closurePrimary closure► Hernia prevention depends on restoring Hernia prevention depends on restoring
abdominal wall.abdominal wall.► Arcuate line (level of ASIS)Arcuate line (level of ASIS)
Superior – posterior sheath with Superior – posterior sheath with transversalis fascia, internal oblique and transversalis fascia, internal oblique and transversus abdoministransversus abdominis► Closure of posterior sheath prevents Closure of posterior sheath prevents
herniationherniation Inferior – only transversalis fascia posterior Inferior – only transversalis fascia posterior
to muscleto muscle► Must close anterior sheath to prevent Must close anterior sheath to prevent
herniationherniation
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Technical considerationsTechnical considerations1.1. Dissect superiorly firstDissect superiorly first2.2. Dissect down to underlying muscleDissect down to underlying muscle3.3. Split fascia to the costal marginSplit fascia to the costal margin4.4. Lateral and inferior portions of skin Lateral and inferior portions of skin
paddle incised nextpaddle incised next5.5. Small cuff of anterior rectus fascia Small cuff of anterior rectus fascia
preserved medially and laterally, to preserved medially and laterally, to preserve cutaneous perforatorspreserve cutaneous perforators
6.6. Split fascia vertically down to the Split fascia vertically down to the public regionpublic region
7.7. Divide rectus superiorly and free Divide rectus superiorly and free from posterior rectus sheathfrom posterior rectus sheath
8.8. Dissection below the arcuate line Dissection below the arcuate line 9.9. Vascular pedicle identified below Vascular pedicle identified below
arcuate line along the lateral deep arcuate line along the lateral deep aspect of the muscle. aspect of the muscle.
10.10. Divide rectus inferiorlyDivide rectus inferiorly11.11. Pedicle dissected inferiorly to origin Pedicle dissected inferiorly to origin
off the external iliac systemoff the external iliac system
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Rectus abdominisRectus abdominis
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Rectus abdominisRectus abdominis
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Rectus abdominisRectus abdominis
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Rectus abdominisRectus abdominis►MorbidityMorbidity
Abdominal weaknessAbdominal weakness HerniaHernia
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Rectus abdominisRectus abdominis► Preoperative Preoperative
ConsiderationsConsiderations Prior abdominal Prior abdominal
surgerysurgery Prior inguinal Prior inguinal
herniorrhapy may herniorrhapy may compromise pedicle compromise pedicle dissection 2/2 dissection 2/2 scarringscarring
HerniaHernia Diastasis rectiDiastasis recti
► Postoperative Postoperative managementmanagement IleusIleus Avoid abdominal Avoid abdominal
strain for 6 weeks.strain for 6 weeks.
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Latissimus dorsiLatissimus dorsi► Pedicle or free flapPedicle or free flap► Free flapsFree flaps
Better flap positioningBetter flap positioning Cutaneous portion can be centered over pedicleCutaneous portion can be centered over pedicle Less risk of pedicle kinkingLess risk of pedicle kinking
► MusculocutaneousMusculocutaneous Large volume defects of large cutaneous neck Large volume defects of large cutaneous neck
defectsdefects► Muscle-only flapMuscle-only flap
Broad and thinBroad and thin Atrophies to about 4 mmAtrophies to about 4 mm Ideal for scalp reconstructionIdeal for scalp reconstruction Poor for large volume defectsPoor for large volume defects
► Massive scalp defectsMassive scalp defects► STSG for final resurfacingSTSG for final resurfacing► Non sensateNon sensate► Motor reconstruction possibleMotor reconstruction possible► Useful after total glossectomyUseful after total glossectomy
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Neurovascular pedicleNeurovascular pedicle► Thoracodorsal arteryThoracodorsal artery► Arise from subscapular vessels Arise from subscapular vessels
off of third portion of axillary off of third portion of axillary artery and veinartery and vein
► Vessel diameter at origin – 2.7 Vessel diameter at origin – 2.7 mm(1.5 to 4.0)mm(1.5 to 4.0)
► Vein diameter – 3.4 mm (1.5 to Vein diameter – 3.4 mm (1.5 to 4.5)4.5)
► Pedicle length 9.3 cm (6 to 16.5)Pedicle length 9.3 cm (6 to 16.5) Can be lengthened by sacrificing Can be lengthened by sacrificing
branch to serratus anteriorbranch to serratus anterior► Numerous variationsNumerous variations
Most common: independent origin Most common: independent origin of thoracodorsal vein/arteryof thoracodorsal vein/artery
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Technical considerationsTechnical considerations► Lateral decubitis positionLateral decubitis position
If at 15 degrees, flap may If at 15 degrees, flap may be harvested be harvested simultaneously with primary simultaneously with primary lesion resectionlesion resection
Anterior muscle border Anterior muscle border along line b/w midpoint of along line b/w midpoint of axilla and point midway b/w axilla and point midway b/w ASIS and PSISASIS and PSIS
► Vessels enter undersurface of Vessels enter undersurface of muscle 8 to 10 cm below muscle 8 to 10 cm below midpoint of axillamidpoint of axilla
► Serratus vessels ligated during Serratus vessels ligated during harvestharvest
► Can design two paddle flap Can design two paddle flap based on medial and lateral based on medial and lateral branches of thoracodorsal branches of thoracodorsal vesselsvessels
► Total glossectomy insetting.Total glossectomy insetting. Muscle inset as a sling on Muscle inset as a sling on
undersurface of mandible undersurface of mandible Sutured to pterygoid, masseter, Sutured to pterygoid, masseter,
or superior constrictor... or superior constrictor... Thoracodorsal nerve Thoracodorsal nerve
anastomosed to a hypoglossal anastomosed to a hypoglossal nervenerve► Gives reconstructed tongue the Gives reconstructed tongue the
ability to elevate superiorly ability to elevate superiorly toward the palatetoward the palate
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Latissimus dorsiLatissimus dorsi
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Latissimus dorsiLatissimus dorsi►MorbidityMorbidity
Marginal flap necrosisMarginal flap necrosis Pedicled flaps pass b/w pec major and Pedicled flaps pass b/w pec major and
minorminor►Changes in arm position may occlude pedicleChanges in arm position may occlude pedicle►Should immobilize arm in flexed positionShould immobilize arm in flexed position
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Latissimus dorsiLatissimus dorsi► Preoperative Preoperative
ConsiderationsConsiderations Relative Relative
contraindications - contraindications - prior axillary LN prior axillary LN dissectiondissection
Preop angiography Preop angiography advocated to assess advocated to assess vessel patencyvessel patency
► Postoperative Postoperative managementmanagement Suction drainsSuction drains High incidence of High incidence of
seromaseroma
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Gracilis flapGracilis flap►19761976►Thin muscle flapThin muscle flap►Dynamic facial Dynamic facial
reanimationreanimation►Muscle revasularized Muscle revasularized
and reinnervatedand reinnervated►Long vascular pedicleLong vascular pedicle►Easy dissectionEasy dissection
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Neurovascular pedicleNeurovascular pedicle► Terminal branch of adductor artery from Terminal branch of adductor artery from
profunda femorisprofunda femoris► Runs b/w adductor longus (anterior) and Runs b/w adductor longus (anterior) and
adductor brevis and magnus (posterior)adductor brevis and magnus (posterior) Enters gracilis at junction of upper Enters gracilis at junction of upper
third and lower two thirdsthird and lower two thirds 8 – 10 cm inferior to pubic tubercle8 – 10 cm inferior to pubic tubercle
► 2 venae comitantes – drain into profunda 2 venae comitantes – drain into profunda femorisfemoris
► Artery caliber – 2 mmArtery caliber – 2 mm► Vein caliber 1.5 – 2.5 mmVein caliber 1.5 – 2.5 mm► Motor innervation – anterior branch of Motor innervation – anterior branch of
obturator nerveobturator nerve 2 – 3 cm cephalic to vascular pedicle.2 – 3 cm cephalic to vascular pedicle.
► Blood supply to skin variableBlood supply to skin variable Skin supplied mostly by Skin supplied mostly by
septocutaneous perforatorsseptocutaneous perforators
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Technical considerationsTechnical considerations► Muscle can be split into at Muscle can be split into at
least two functional least two functional muscular unitsmuscular units
► Single neuromuscular unit Single neuromuscular unit can be transferred to can be transferred to decrease bulkdecrease bulk
► Orient skin paddle Orient skin paddle longitudinallylongitudinally Must be centered over Must be centered over
dominant dominant musculocutaneous musculocutaneous perforatorperforator
► For synchronous mimetic For synchronous mimetic movement when proximal movement when proximal facial nerve not available.facial nerve not available. 2 stage procedure with 2 stage procedure with
cross face sural nerve cross face sural nerve graftgraft
Tinel sign used to Tinel sign used to monitor axonal growth monitor axonal growth across the face – 9-12 across the face – 9-12 monthsmonths
After adequate axonal After adequate axonal regrowth – muscle regrowth – muscle transferredtransferred
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Gracilis flapGracilis flap
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Temperoparietal Fascia FlapTemperoparietal Fascia Flap► More commonly transferred as More commonly transferred as
a pedicled flap but can be used a pedicled flap but can be used as a free flap when arc of as a free flap when arc of rotation is inadequaterotation is inadequate
► Ultra thin – 2 to 4 mm thickUltra thin – 2 to 4 mm thick► Highly vascular, pliable and Highly vascular, pliable and
durabledurable► Fascial, fasciocutaneousFascial, fasciocutaneous► Up to 17 x 14 cm with Up to 17 x 14 cm with
extensive scalp underminingextensive scalp undermining► Oral cavity, hemilaryngectomy Oral cavity, hemilaryngectomy
defects, middle and upper defects, middle and upper regions of face w/split calvarial regions of face w/split calvarial bone graftbone graft
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Neurovascular pedicleNeurovascular pedicle► 5 layers – scalp5 layers – scalp► Temperoparietal fascia (TPF) Temperoparietal fascia (TPF)
deep to skin and subcutaneous deep to skin and subcutaneous tissue.tissue.
► Superficial to temporalis Superficial to temporalis muscular fasciamuscular fascia
► Above superior temporal line Above superior temporal line it’s continuous with galea it’s continuous with galea aponeuroticaaponeurotica
► Base centered over helixBase centered over helix
► Superficial temporal artery and Superficial temporal artery and vein – travel in TPF layervein – travel in TPF layer 3 cm superior to root of helix3 cm superior to root of helix Vessels branch into frontal and Vessels branch into frontal and
temporal divisionstemporal divisions Most commonly based on Most commonly based on
parietal branchparietal branch Ligation of frontal artery 3 – 4 cm Ligation of frontal artery 3 – 4 cm
distal to branching point to avoid distal to branching point to avoid frontal nerve injuryfrontal nerve injury
Venous pedicle may course with Venous pedicle may course with arteries or 2 to 3 cm posteriorlyarteries or 2 to 3 cm posteriorly
► Middle temporal artery – Middle temporal artery – proximal superficial temporal proximal superficial temporal artery at zygomatic arch artery at zygomatic arch (supplies temporalis muscular (supplies temporalis muscular fascia)fascia)
► Including middle temporal artery Including middle temporal artery enables a two-layered fascial enables a two-layered fascial flap on a single pedicle.flap on a single pedicle.
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Temperoparietal Fascia FlapTemperoparietal Fascia Flap
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Technical considerationsTechnical considerations►Vertical incision over root of helix to Vertical incision over root of helix to
superior temporal linesuperior temporal line►V-shaped extension at superior limit of V-shaped extension at superior limit of
incisionincision►Scalp elevation ant and postScalp elevation ant and post►Dissect deep to flapDissect deep to flap►Loose areolar tissue deep to flapLoose areolar tissue deep to flap
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Temperoparietal Fascia FlapTemperoparietal Fascia Flap
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Temperoparietal Fascia FlapTemperoparietal Fascia Flap►MorbidityMorbidity
Frontal branch weakness (travels in TPF)Frontal branch weakness (travels in TPF) Secondary alopecia – damage to hair Secondary alopecia – damage to hair
follicles due to superficial dissectionfollicles due to superficial dissection
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Temperoparietal Fascia FlapTemperoparietal Fascia Flap►Preoperative ConsiderationsPreoperative Considerations
Relative contraindications - prior XRT, Relative contraindications - prior XRT, neck surgery, bicoronal incision or neck surgery, bicoronal incision or external carotid embolization.external carotid embolization.
Doppler assessment of pedicleDoppler assessment of pedicle
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Fibular osteocutaneous flapFibular osteocutaneous flap► 19751975►Hidalgo – mandibular recon Hidalgo – mandibular recon
19891989► Longest possible segment of Longest possible segment of
revasularized bone (25 cm)revasularized bone (25 cm)► Ideal for osseointegrated Ideal for osseointegrated
implant placementimplant placement►Mandible reconstruction Mandible reconstruction
(near total), maxillary (near total), maxillary reconstructionreconstruction
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Neurovascular pedicleNeurovascular pedicle► Peroneal artery and veinPeroneal artery and vein► Sensate restoration with lateral Sensate restoration with lateral
sural cutaneous nervesural cutaneous nerve► Peroneal communicating branch Peroneal communicating branch
vascularized nerve graft for lower vascularized nerve graft for lower lip sensationlip sensation
► Skin perforatorsSkin perforators Posterior intermuscular septum Posterior intermuscular septum
(septocutaneous or (septocutaneous or musculocutaneous through flexor musculocutaneous through flexor hallucis longus and soleus)hallucis longus and soleus)
Should always include cuff of flexor Should always include cuff of flexor hallucis longus and soleus in flap hallucis longus and soleus in flap harvestharvest
5-10% of cases blood supply to skin 5-10% of cases blood supply to skin paddle is inadequatepaddle is inadequate
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Technical considerationsTechnical considerations► Choose leg based on ease of Choose leg based on ease of
insettinginsetting Intraoral skin paddleIntraoral skin paddle
► Harvest flap from Harvest flap from contralateral side of contralateral side of recipient vesselsrecipient vessels
► 8 cm segment preserved 8 cm segment preserved proximally and distally to proximally and distally to protect common peroneal verve protect common peroneal verve and ensure ankle stabilityand ensure ankle stability
► Center flap over posterior Center flap over posterior intermuscular septumintermuscular septum Anterior to soleus and Anterior to soleus and
posterior to peroneusposterior to peroneus► Doppler cutaneous perforatorsDoppler cutaneous perforators► Greatest number of perforators Greatest number of perforators
present in the 15 to 25 cm present in the 15 to 25 cm rangerange
► Distal skin paddle increases Distal skin paddle increases pedicle lengthpedicle length
► Thigh tourniquet to 350 mm HgThigh tourniquet to 350 mm Hg► Vascularity to skin running Vascularity to skin running
through the septocutaneous through the septocutaneous perforators may be enhanced perforators may be enhanced by harvesting a segment of by harvesting a segment of soleus to capture additional soleus to capture additional musculocutaneous perforatorsmusculocutaneous perforators
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Fibular osteocutaneous flapFibular osteocutaneous flap
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Fibular osteocutaneous flapFibular osteocutaneous flap
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Fibular osteocutaneous flapFibular osteocutaneous flap
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Fibular osteocutaneous flapFibular osteocutaneous flap►MorbidityMorbidity
Donor site complicationsDonor site complications►EdemaEdema►Weakness in dorsiflexion of great toeWeakness in dorsiflexion of great toe
Skin loss in 5 – 10% of flapsSkin loss in 5 – 10% of flaps►reliability of the skin is questionable, and both the reliability of the skin is questionable, and both the
surgeon and the patient should be prepared for surgeon and the patient should be prepared for the possible need for a second soft tissue flap, the possible need for a second soft tissue flap, either free or pedicled, when reconstructing either free or pedicled, when reconstructing composite defects with a fibular osteocutaneous composite defects with a fibular osteocutaneous flapflap
May need STSG over donor site closureMay need STSG over donor site closurewww.indiandentalacademy.com
Fibular osteocutaneous flapFibular osteocutaneous flap► Preoperative Preoperative
ConsiderationsConsiderations AngiographyAngiography MRAMRA h/o distal lower h/o distal lower
extremity fractureextremity fracture Look for varicose Look for varicose
veins, edemaveins, edema
► Postoperative Postoperative managementmanagement Distal pulses Distal pulses
monitoredmonitored Posterior splint for Posterior splint for
10 days10 days
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Iliac crest flapsIliac crest flaps► Osteocutaneous, Osteocutaneous,
osteomusculocutaneousosteomusculocutaneous► Segmental mandibular defectsSegmental mandibular defects► Up to 16 cm boneUp to 16 cm bone► Oromandibular reconstructionOromandibular reconstruction► No motor or sensate reconstructionNo motor or sensate reconstruction► Only vascularized bone used Only vascularized bone used
extensively with simultaneous or extensively with simultaneous or delayed endosteal dental implant delayed endosteal dental implant placementplacement
► Skin paddle was not ideal for relining Skin paddle was not ideal for relining the oral cavitythe oral cavity Too thick for accurate restoration of Too thick for accurate restoration of
the 3D anatomythe 3D anatomy► Inclusion of internal oblique flapInclusion of internal oblique flap
Denervated muscle undergoes Denervated muscle undergoes atrophy that leaves a thin, fixed, soft atrophy that leaves a thin, fixed, soft tissue coverage over the bone.tissue coverage over the bone.
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Neurovascular pedicleNeurovascular pedicle► Deep circumflex iliac artery from Deep circumflex iliac artery from
lateral aspect of external iliac arterylateral aspect of external iliac artery 1 – 2 cm cephalic to inguinal 1 – 2 cm cephalic to inguinal
ligamentligament► Ascending branch of deep Ascending branch of deep
circumflex iliac artery supplies circumflex iliac artery supplies internal oblique muscleinternal oblique muscle
► Deep circumflex iliac vein – 2 venae Deep circumflex iliac vein – 2 venae comitantescomitantes Can pass either superficial to deep Can pass either superficial to deep
to arteryto artery► Artery caliber – 2 to 3 mmArtery caliber – 2 to 3 mm► Vein caliber – 3 to 5 mmVein caliber – 3 to 5 mm► Pedicle to internal oblique can arise Pedicle to internal oblique can arise
separately from deep circumflex separately from deep circumflex iliac arteryiliac artery
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Iliac crest flapsIliac crest flaps
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Technical considerationsTechnical considerations► Skin paddle centered on axis Skin paddle centered on axis
from ASIS to inferior tip of from ASIS to inferior tip of scapulascapula
► Cutaneous perforatorsCutaneous perforators 9 cm posterior to ASIS and 2.5 9 cm posterior to ASIS and 2.5
cm medial to iliac crestcm medial to iliac crest► Generous cuff of external Generous cuff of external
oblique, internal oblique and oblique, internal oblique and transversus abdominis layers transversus abdominis layers must be preserved to must be preserved to maintain cutaneous maintain cutaneous perforatorsperforators Internal oblique muscleInternal oblique muscle
► axial-pattern blood supplyaxial-pattern blood supply► Skin paddle bulky and Skin paddle bulky and
immobileimmobile► Do not rotate skin in order to Do not rotate skin in order to
prevent sheer injuryprevent sheer injurywww.indiandentalacademy.com
Iliac crest flapsIliac crest flaps
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Iliac crest flapsIliac crest flaps
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Iliac crest flapsIliac crest flaps►MorbidityMorbidity
HerniaHernia►Need to approximate cut edge of iliacus muscle to Need to approximate cut edge of iliacus muscle to
transversus abdoministransversus abdominis►Can be reinforced by drilling holes into cut edge of iliac Can be reinforced by drilling holes into cut edge of iliac
bonebone►Approximate external obliques and aponeurosis to Approximate external obliques and aponeurosis to
tensor fascia lata and gluteus musclestensor fascia lata and gluteus muscles►Keep inferior oblique inferior and anterior to ASISKeep inferior oblique inferior and anterior to ASIS
Skin loss from perforator sheer injurySkin loss from perforator sheer injury poor color matchpoor color match
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Iliac crest flapsIliac crest flaps►Preoperative ConsiderationsPreoperative Considerations
h/o hernias, prior iliac bypass grafth/o hernias, prior iliac bypass graft Severe PVD,Severe PVD, Preop angioPreop angio
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Scapular flapsScapular flaps► Fasciocutaneous, Fasciocutaneous,
osteofasciocutaneous, cutaneous flap, osteofasciocutaneous, cutaneous flap, parascapular cutaneous flap, latissimus parascapular cutaneous flap, latissimus dorsi myocutaneous flap, and serratus dorsi myocutaneous flap, and serratus anterior flapanterior flap
► Thin, hairless skinThin, hairless skin► Two cutaneous flaps may be harvestedTwo cutaneous flaps may be harvested
Horizontally oriented flap – transverse Horizontally oriented flap – transverse cutaneous branchcutaneous branch
Vertically oriented flap parascapular flap Vertically oriented flap parascapular flap – descending cutaneous branch– descending cutaneous branch
► Long pedicle lengthLong pedicle length► Large surface areaLarge surface area► Complex composite midfacial or Complex composite midfacial or
oromandibular defects oromandibular defects ► Up to 10 cm boneUp to 10 cm bone► Osseointegrated implants possibleOsseointegrated implants possible► Single team approachSingle team approach www.indiandentalacademy.com
Neurovascular pedicleNeurovascular pedicle► Subscapular artery and veinSubscapular artery and vein
Circumflex scapular artery and vein emerge Circumflex scapular artery and vein emerge from triangular space (teres major, teres from triangular space (teres major, teres minor and long head of triceps)minor and long head of triceps)
Paired venae comitantesPaired venae comitantes Artery caliber – 4 mm at takeoff from Artery caliber – 4 mm at takeoff from
subscapularsubscapular► Subscapular caliber – 6 mm at takeoff from Subscapular caliber – 6 mm at takeoff from
axillary arteryaxillary artery Pedicle length – 7 to 10 cm, 11 to 14 cm (from Pedicle length – 7 to 10 cm, 11 to 14 cm (from
axillary artery)axillary artery) Preservation of thoracodorsal vessels allows Preservation of thoracodorsal vessels allows
simultaneous transfer of latissimus and simultaneous transfer of latissimus and portion of serratus flapportion of serratus flap► Largest amount of tissue available for transferLargest amount of tissue available for transfer
► Thoracodorsal artery and circumflex Thoracodorsal artery and circumflex scapular artery can have separate origins scapular artery can have separate origins from axillary artery.from axillary artery.
► Non-sensate flapsNon-sensate flaps► Scapular vessels - very rarely affected by Scapular vessels - very rarely affected by
atherosclerosisatherosclerosiswww.indiandentalacademy.com
Scapular flapsScapular flaps
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Technical considerationsTechnical considerations► Decubitis positioningDecubitis positioning
15 degree angle15 degree angle Separate axillary incision Separate axillary incision
helpful in dissecting pedicle helpful in dissecting pedicle to axillary artery and veinto axillary artery and vein
Bone harvestBone harvest►Teres major, Teres major,
subscapularis and subscapularis and latissimus dorsi need to latissimus dorsi need to be reattached to scapulabe reattached to scapula
► Flap harvest opposite side of Flap harvest opposite side of modified or radical neck modified or radical neck dissectiondissection
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Scapular flapsScapular flaps
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Scapular flapsScapular flaps►MorbidityMorbidity
Brachial plexus injury 2/2 lateral decubitis Brachial plexus injury 2/2 lateral decubitis positioningpositioning►Use axillary rollUse axillary roll
Stay 1 cm inferior to glenoid fossa Stay 1 cm inferior to glenoid fossa Detach teres major and minor to harvest Detach teres major and minor to harvest
bonebone►Can cause shoulder weakness and limit range Can cause shoulder weakness and limit range
of motion.of motion.
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Scapular flapsScapular flaps► Preoperative Preoperative
ConsiderationsConsiderations Prior axillary node Prior axillary node
dissection – dissection – contraindicationcontraindication
► Postoperative Postoperative managementmanagement Immobilize for 3 to 4 Immobilize for 3 to 4
daysdays Early ambulationEarly ambulation 5 days for bone 5 days for bone
harvestharvest PTPT
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Rib flapRib flap► First vascularized bone to be First vascularized bone to be
used in mandibular used in mandibular reconstruction. reconstruction. (osteocutaneous)(osteocutaneous)
► Blood supply to the rib Blood supply to the rib Internal mammary arteryInternal mammary artery Posteriorly or Posteriorly or
posterolaterally on the posterolaterally on the posterior intercostal vesselsposterior intercostal vessels
Transferred with the Transferred with the pectoralis major, serratus pectoralis major, serratus anterior, or latissimus dorsi anterior, or latissimus dorsi muscle muscle
► Poor bone stock except for Poor bone stock except for condylar reconstructioncondylar reconstruction
► Not commonly usedNot commonly used
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Neurovascular pedicleNeurovascular pedicle
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Metatarsus flapMetatarsus flap►Osteocutaneous flap Osteocutaneous flap
based on the first based on the first dorsal metatarsal dorsal metatarsal artery artery
►Thin sensate skin Thin sensate skin with the second with the second metatarsal. metatarsal.
►Limited bone Limited bone volumevolume
►Not commonly usedNot commonly usedwww.indiandentalacademy.com
Neurovascular pedicleNeurovascular pedicle
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Jejunal flapJejunal flap► 19591959► Circumferential Circumferential
pharyngoesophageal defectspharyngoesophageal defects► Patch graftPatch graft► Diameter of jejunum – good Diameter of jejunum – good
match to cervical esophagusmatch to cervical esophagus► Ideal mucosal surfaceIdeal mucosal surface► Two team approachTwo team approach► AdvantagesAdvantages
Better superior positioningBetter superior positioning► DisadvantageDisadvantage
Inferior positioning limited by Inferior positioning limited by thoracic inletthoracic inlet
3 anastomoses3 anastomoses
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Neurovascular pedicleNeurovascular pedicle►Mesenteric Mesenteric
arcade vesselsarcade vessels Usually 2Usually 2ndnd
arcade is best arcade is best for pharyngeal for pharyngeal reconstructionreconstruction
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Technical considerationsTechnical considerations► Harvest distal to Ligament of Harvest distal to Ligament of
TreitzTreitz► Up to 20 cmUp to 20 cm► Laparoscopic harvest has been Laparoscopic harvest has been
reportedreported► Mark proximal graft with suture – Mark proximal graft with suture –
isoperistaltic placementisoperistaltic placement► Proximal end divided along Proximal end divided along
antimesenteric border to antimesenteric border to facilitate tongue base closurefacilitate tongue base closure
► Distal end – end to end Distal end – end to end anastomosisanastomosis Lock and key closureLock and key closure
► Exteriorize a monitoring segmentExteriorize a monitoring segment
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Jejunal flapJejunal flap
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Jejunal flapJejunal flap►MorbidityMorbidity
Most susceptible to primary ischemiaMost susceptible to primary ischemia Fistula formation – 18%Fistula formation – 18% 11% rate of anastomotic stricture11% rate of anastomotic stricture
►Higher rate if cervical anastomosis stapledHigher rate if cervical anastomosis stapled Wet voice (TEP)Wet voice (TEP) Functional obstruction 2/2 peristalsisFunctional obstruction 2/2 peristalsis DysgeusiaDysgeusia Harvest site complicationsHarvest site complications
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Jejunal flapJejunal flap► Preoperative Preoperative
ConsiderationsConsiderations Absolute contraindicationsAbsolute contraindications
► Disease extension into Disease extension into proximal thoracic proximal thoracic esophagusesophagus
► AscitesAscites► Crohn’s diseaseCrohn’s disease
Relative contraindicationsRelative contraindications► Chronic intestinal diseasesChronic intestinal diseases► h/o abdominal surgeryh/o abdominal surgery
Consider angioConsider angio► Intraperitoneal sepsisIntraperitoneal sepsis
Do not use in laryngeal Do not use in laryngeal sparing proceduressparing procedures
► Postoperative Postoperative managementmanagement Remove monitoring Remove monitoring
segment pod 7.segment pod 7. Jejunostomy tubeJejunostomy tube
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Gastroomental flapGastroomental flap► 1961, 19791961, 1979► Greater omentum – double layer of Greater omentum – double layer of
peritoneumperitoneum Hangs from greater curvature of Hangs from greater curvature of
stomach and transverse colonstomach and transverse colon► Omentum - thin and well vascularizedOmentum - thin and well vascularized
Excellent coverage for great vesselsExcellent coverage for great vessels Plasticity allows for variable placementPlasticity allows for variable placement Form adhesions to inflamed, ischemic, Form adhesions to inflamed, ischemic,
or necrotic tissuesor necrotic tissues► Separates them from surrounding tissuesSeparates them from surrounding tissues
Promotes healing in previously radiated Promotes healing in previously radiated fieldsfields
► Large scalp defects, Large scalp defects, ► Extensive midfacial defects w/coverage Extensive midfacial defects w/coverage
of split rib or calvarial graftsof split rib or calvarial grafts► Facial contouring Facial contouring ► Management of osteoradionecrosis or Management of osteoradionecrosis or
osteomyelitis in head and neckosteomyelitis in head and neck► Pharyngoesophageal reconstructionPharyngoesophageal reconstruction
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Neurovascular pedicleNeurovascular pedicle► Right gastroepiploic Right gastroepiploic
arteryartery Caliber – 1.5 to 3.0 Caliber – 1.5 to 3.0
mmmm
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Gastroomental flapGastroomental flap►MorbidityMorbidity
Intraabdominal complicationsIntraabdominal complications►Gastric leakGastric leak►PeritonitisPeritonitis► Intraabdominal abscessIntraabdominal abscess►VolvulusVolvulus►Gastric outlet obstructionGastric outlet obstruction
If mucosal flap too large or if placed too close to pylorusIf mucosal flap too large or if placed too close to pylorus FistulaFistula
► Preoperative ConsiderationsPreoperative Considerations h/o GOOh/o GOO h/o PUDh/o PUD
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Gastroomental flapGastroomental flap
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BibliographyBibliography1.1. Chepeha, DB, Teknos, TN. Microvascular Free Flaps in Head and Neck Chepeha, DB, Teknos, TN. Microvascular Free Flaps in Head and Neck
Reconstruction. In: Head and Neck Surgery—Otolaryngology, 3rd ed., Reconstruction. In: Head and Neck Surgery—Otolaryngology, 3rd ed., Bailey, BJ Ed. Philadelphia, Lippincott-Raven Publishers, 2001; 2045 – 2065.Bailey, BJ Ed. Philadelphia, Lippincott-Raven Publishers, 2001; 2045 – 2065.
2.2. Urken, ML, Buchbinder, D, Genden, EM. Reconstruction of the Mandible and Urken, ML, Buchbinder, D, Genden, EM. Reconstruction of the Mandible and Maxilla. In Otolaryngology Head and Neck Surgery, 4Maxilla. In Otolaryngology Head and Neck Surgery, 4 thth Ed. Edited by Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1618 – 1635.Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1618 – 1635.
3.3. Chang, KE, Gender, EM, Funk, G. Reconstruction of the Hypopharynx and Chang, KE, Gender, EM, Funk, G. Reconstruction of the Hypopharynx and Esophagus. In Otolaryngology Head and Neck Surgery, 4Esophagus. In Otolaryngology Head and Neck Surgery, 4 thth Ed. Edited by Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1945.Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1945.
4.4. Taylor, SM, Haughey, BH. Reconstruction of the Oropharynx. In Taylor, SM, Haughey, BH. Reconstruction of the Oropharynx. In Otolaryngology Head and Neck Surgery, 4Otolaryngology Head and Neck Surgery, 4 thth Ed. Edited by Cummings CC, Ed. Edited by Cummings CC, St. Louis: Mosby Year Book Inc.; 2004. 1758.St. Louis: Mosby Year Book Inc.; 2004. 1758.
5.5. Lee, KJ. Essentials of Otolaryngology. 891.Lee, KJ. Essentials of Otolaryngology. 891.6.6. Lin, DT, Coppit, GL, Burkey, B. Use of the Anterolateral Thigh Flap in Lin, DT, Coppit, GL, Burkey, B. Use of the Anterolateral Thigh Flap in
Reconstruction of the Head and Neck. Curr Opin Otolaryngol Head Neck Reconstruction of the Head and Neck. Curr Opin Otolaryngol Head Neck Surg. 12: 300-304. 2004. Lippincott Williams and Wilkins.Surg. 12: 300-304. 2004. Lippincott Williams and Wilkins.
7.7. Genden, E, Haughey, BH. Mandibular Reconstruction by Vascularized Free Genden, E, Haughey, BH. Mandibular Reconstruction by Vascularized Free Flap Tissue Transfer. Am Journ Otolaryngol. 1996; 17 (4): 219 – 227.Flap Tissue Transfer. Am Journ Otolaryngol. 1996; 17 (4): 219 – 227.
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