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Flaps and Grafts
“….the application of anatomical knowledge
to restore form and function…”
Graft VS FlapWhat is the difference?
What is a Flap?
• 16th century Dutch word “flappe”– ….something that hangs broad and loose ,
fastened only by one side..”
What is a Flap?
• A flap is a unit of tissue that may be transferred from a donor to a recipient site while maintaining its blood supply.– Flaps can be characterized by their component parts
• cutaneous, musculocutaneous, osseocutaneous
– Their relationship to the defect • local, regional, or distant
– Nature of the blood supply• random versus axial
– The movement placed on the flap • advancement, pivot, transposition, free, pedicled
• Rung 1: Healing by secondary intention
• Rung 2: Primary closure
• Rung 3: Delayed primary closure
• Rung 4: Split thickness graft
• Rung 5: FTSG • Rung 6: tissue
expansion • Rung 7: Random flap • Rung 8: Axial flap • Rung 9: Free Flap
Reconstructive Elevator
• Get off at the right level
Composition of a flap• Skin
– Muscle – Bone– Omentum – Composite
Composition of a flap
– Skin
• Muscle – Bone– Omentum – Composite
Composition of a flap
– Skin – Muscle
• Bone– Omentum – Composite
Composition of a flap
– Skin – Muscle – Bone
• Omentum – Composite
Composition of a flap
– Skin – Muscle – Bone
• Omentum / viscera– Composite
Composition of a flap
– Skin +/- fascia– Muscle (+/- innervation)– Bone– Omentum / viscera
• Composite
Which flap when?
Goals of reconstruction
• Separating the physiological cavities – Eg brain, orbit, mouth, neck
• Protecting the neck vessels• Obtaining a healed wound• Restore function• Restore swallowing• No leaks• Aesthetics
• Flaps reduce complications by:– Obliterating dead space– Recruiting healthy well-vascularized tissue into the
region, which has commonly been irradiated and contaminated
– Tension free closure– Interposing flap skin between irradiated wound
edges
Pharyngeal defects
• Partial defects– Pectoralis major flap with muscle and skin– Radial forearm free flap
• Circumferential defects– Tubed radial forearm flap or ALT flap– Jejunum
Goals of reconstruction:
• A single stage, reliable reconstruction • Prompt discharge from hospital • Return of swallowing and speech function• No salivary fistulas
Literature Review• Nelligan (J Plast Reconstr Aesthet Surg. 2008)
reported a fistula rate of:– 13% for all fasciocutaneous flaps
• ALT flap 16.4% • radial forearm free flap 14.4%.
– Jejunum 9.4%• Charing Cross Study (Moradi et al)
– fistula rate: 2/43 (4.7%)– stricture rate: 6/43 (14%)
Murray D, Novak C, Neligan P. Fasciocutaneous free flaps in pharyngolarngo-oesophageal reconstruction: A critical review of literature. J Plast Reconstr Aesthet Surg. 2008
Voice Restoration (Charing Cross series)
• 22 of 42 received a primary (TEP)
• 14 of 42 received a secondary TEP
• 36/42 (85%) received either a primary or secondary TEP
• Voice was reported as:– Good in 17 of 39– Fair in 11 of 39. – 28 of 39 (72%) used their
tracheoesophageal puncture as their primary mode of communication
When to eat?
• No scientific evidence on the timing of oral intake
• Err on the side of caution if previous radiotherapy
• Day 10
Mandible reconstruction
• Osteoradionecrosis (ORN) is a condition of non-vital bone in a site of radiation injury
• Characterised by:– hypovascularity– hypocellularity– hypoxia
• ORN occurs when, in the process of otherwise normal turnover of bone, the degradative function exceeds new bone production
• Can be either spontaneous or the result of an insult
Facial reanimation
• Goal of treatment– Rest symmetry– Facial function– Voluntary function– Spontaneous movement– Absence of synkinesis
Facial reanimation
• Static vs dynamic• Static: Divide face into 1/3rds
– Upper: – Middle: – Lower:
Dynamic: free gracilis
Static: slings
Tongue reconstruction
• Depending on extent of defect and the status of the floor of mouth
• Generally use:– Radial forearm free flap– Ulnar forearm free flap– ALT
Radial forearm free flap
Ulnar forearm free flap
Ulnar forearm free flap
Ulnar forearm free flap