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