local flaps in ent
TRANSCRIPT
Dr. Ajay ManickamJunior Resident ENT & Head Neck SurgeryR.G. Kar Medical College
Simple injury/ surgical
Repairable ….??? Many defects can be
directly closed if small & enough tissue available locally
If the defect becomes larger...... Ablative cancer surgery
Larger defects 1. Grafts2. Local flaps3. Pedicled flaps4. Free flaps5. Combination
These are parallel to natural skin wrinkles Surgical incision placed parallely Least tension as skin contraction is at its
greatest
Ellipse three times as long as its wide If ellipse is too short dog ear deformity
Eye lid Helical rims of ear Lips Not only skin – composite tissue - closed in layers1. Lips – mucosa, orbicularis
oris, skin2. Ear – cartilage and skin
both anterior & posterior3. Eyelids – conjunctiva,
tarsal plate, orbicularisoculi and skin
1817 – Sir Astley Cooper 1871 – Lawson – elective
full thickness graft 1872- Ollier – split skin
graft 1929 – Brown & Blair –
differentiated full thickness and split thickness skin grafts advantages & disadvantages
Split thickness – part of dermis
Full thickness – all of dermis
Composite – skin & another tissue
Graft origin1. Auto graft – same person2. Isograft – identical twin3. Allograft –same species4. Xenograft – diff species5. Alloplastic - synthetic
SPLIT THICKNESS
More likely to take Contracts more Pigment abnormal Limited sensory recovery
FULL THICKNESS
High risk for graft loss Less Better colour match Better sensory recovery
Imbibition – plasma – 48 hours Inosculation - Graft revascularization – graft
anastomosis Neovascularization – atleast a month
Relies on skin elasticity Modified in a number of ways – burow
triangle Simple
Rintalla flap Modified
V-Y flap (axial flap) Bipedicled flap
Tripier flap
Simple flap lesions in nasal tip
Kind of advancement flap modified
Lower eyelid reconstruction Bipedicled flap – receives blood supply from
both ends
Moves around a pivot point – transposition flap or rotation flap
Rhomboid flaps – transposition flaps – donor defect closed directly
Flag or banner flaps – transposition flaps –donor site closed directly
Bilobed flaps – two transposition flaps
Pivot flap Rhomboid needs to be 120 & 60 degree So that scar becomes parallel
Pivot flap – axial transposition flap
Flap lengh 3 times the length of base
Primary defect closed directly
Two transposition flaps Defects in tip of nose
Large flaps that rotate into primary defect
Flap circumference should be atleast 8 times
Repairs defect of scalp or cheek
Based on named arterial pedicle runs within skin superficial to the underlying muscle layer parallel to the skin overlying
Forehead flapNasolabial flapSubmental island flapFacial artery myomucosal flapTemporo parietal fascial flap
Mc gregor Cutaneous axial
median forehead flap – supra trochlear artery
Cheek , External nose
Forehead flap contracts excessively
Susruta 600 Bc – defects around face – anterior oral cavity
Based on distal branches of the facial artery Extremely reliable based inferiorly Anterior floor of mouth , gingiva – simple & effective
Reconstruction of facial skin or intra oral lining
Supplied by facial artery branches
Can be tunneledunder mandible through submentaland submandibular space for oral reconstruction / tranposed onto face for soft tissue coverage
Pribaz Oral mucosa
and buccinatormuscle branches of facial artery
Small mucosal defects of the oral cavity, mucosa of lip, tongue, palate
Golovine Free facial flap for
reconstruction of head & neck
Superficial temporal artery – external carotid artery
Teardrop, elliptical shape Orbital reconstruction,
auricular reconstruction, palate reconstruction, buccal mucosal reconstruction.
Deltopectoral flap Myocutaneous and muscle only axial distant
flaps 1. Pectoralis major2. Lattissimus dorsi3. Sternomastoid4. Trapezius5. Platysma
Bakamjian and littlewood 1964 Upper 3 perforating internal mammary artery
branches Single stage reconstruction – anterior neck skin Two stage reconstruction – over neck structures to
resurface distant sites
Ariyan described it in 1970 pectoral branch of acromio thoracic artery Large skin territory – can be harvested in
supine position
Local flaps & regional flaps plays an important role in head & neck reconstruction
When using local flaps in the head & neck preoperative planning of the flap is prime importance
Grafts are reliant on blood supply of recipient site but flaps takes their blood supply with them