Local and regional flaps in head & neck cancer /certified fixed orthodontic courses by Indian dental academy

Local and Regional Flaps In
Head and Neck Cancer
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


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PECTORALIS MAJOR MYOCUTANEOUS FLAP
TEMPORALIS FLAP
STERNOCLIEDOMASTOID FLAP
MASSETER FLAP
DELTOPECTORAL FLAP
TRAPEZIUS FLAP
LATISSIMUS DORSI FLAP
CONCLUSION
REFFERENCES


PECTORALIS MAJOR MYOCUTANEOUS
FLAP
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Ariyan 1970


Anatomy
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Origin
Vessels
Function


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large fan-shaped muscle that covers much of the
anterior thoracic wall. To a variable extent, it overlies
the pectoralis minor, subclavius, serratus anterior,
and intercostal muscles.
origins -three portions.
1 cephalad -medial third of the clavicle.
2 central,-sternocostal-sternum &cartilages of
the first six ribs
3 aponeurosis of the external oblique, is
variable in size.

vessels


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Superior and lateral
thoracic arteries additional pedicles
Overlying skin
additionally supplied by
intercostal perforators
3 subunits each with its
own vascular & motor
supply


functions
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adduct and medially rotate the arm
It becomes active in internal rotation of the arm only
when working against resistance.
upper muscle fibers help to flex the arm to the
horizontal level; the lower fibers assist in arm
extension.
Contraction helps to extend the arm to the individual's
side, but it plays no role in hyperextension beyond that
point.
loss of the dynamic activity of the pectoralis major
appears to be well tolerated
Much of the adductor activity is compensated for by
the powerful, latissimus dorsi muscle, which makes up
the posterior axillary fold.


Types



ADVANTAGES
 One stage
 Generous portion of skin & soft tissue(400cm2)
 Consistent blood supply – highly reliable
 Adequate arc of rotation for facial defects
 Donor site can be closed primarily
 Two skin islands on the same muscle paddle
 Protects the carotid artery
 Technically, the flap is ease to elevate


DISADVANTAGES
 Arc of rotation limited for oromaxillary defects
 It can be too bulky
 There is distortion of symmetry at the donor
site
 Shoulder function is impaired
 Distal skin of the flap is not reliable


Methods to Improve the Arc of
Rotation
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Ariyan's -incorporated a long segment of skin that
extended from the clavicle to the caudal extent of
the muscle.
Distal skin paddle placed over the caudal extent of
the muscle
Maghee- skin paddle extended over rectus
abdominus
Lee and Lore -removal of a segment of the clavicle
to gain up to 3 cm of length.
Wilson et al. -tunneling the muscle pedicle deep to
the clavicle in a subperiosteal plane .

Methods to Deal with Excessive Bulk
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Sharzer et al. - harvesting a vertically
oriented "parasternal” skin paddle that
extended across the sternum to the opposite
internal mammary perforators.


Methods to Deal with Excessive Bulk
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Murakami et al. -eliminating the skin paddle
entirely.
two-stage procedure
a split-thickness skin graft was placed
over the muscle  3 to 4 weeks later harvest
the muscle-skin graft unit.
Maintain nerve supply or not


Methods to Achieve Two Epithelial Surfaces for
Reconstruction of Compound Defects


“Gemini” flaps


POTENTIAL PITFALLS
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Incidence of total flap necrosis was reported
to be 1.0%, 1.5%, 3%, and 7%.
Partial flap necrosis- 14%-30%
Pedicle compression
In male patients may lead to problems with
excessive hair growth in the oral cavity or
pharynx


TEMPORALIS MUSCLE FLAP
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Golovine 1898 - orbital
exenteration
Gilles - reanimation of
paralyzed face
Fan - shaped muscle
arising from temporal fossa
& the superior temporal line
The muscle is bipennate,
with an additional superficial
origin from the temporalis
fascia


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Main blood supply - anterior &
posterior deep temporal artery
Anterior deep temporal artery &
Posterior deep temporal enter the
muscle approximately 1cm
anterior & 1.7cm posterior to
coronoid process respectively
This vascular anatomy allows
splitting of muscle into anterior &
posterior flap


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Mobilized flap consists of
fascia, muscle, & pericranium
Two distinct fascial layers, the
superficial & deep temporal
fascia
Superficial temporal fascia is a
thin, highly vascular layer of
moderately dense Connective
tissue
The absence of vascularity
between this two layers


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Hemicoronal flap provides excellent access
Incision ends above the superior temporal line
Dissections proceeds down to the deep temporal fascia until the
entire muscle is exposed
Dissection in this plane protects the temporal branch of facial
nerve
Reflection of the muscle of the temporal bone should be performed
in a strict subperiosteal plane
Rotation can be improved by dividing ZA & base of the coronoid


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If the muscle is split in coronal plane posterior
portion of muscle is transposed anteriorly
Donor site - secondarily reconstructed by
alloplastic implants
Alopecia avoided by careful placement of
coronal incision parallel to hair shaft
Bradley & Brock hank - flap does not require
skin grafting & rapid mucolization occur

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It is relatively short (3 to 5 cm) and thin (2 to
3mm) and has a contraction capability of 1 to
1.5 cm
flap has a rotational radius of 8 cm
it is possible to cover defects of the mastoid,
cheek, pharynx, and palate.


ADVANTAGES
 Ease of elevation
 Reliable blood supply
 Proximity
 Camouflage of incision
with in hair line
 Muscle support graft &
alloplast well

DISADVANTAGES
 Sensory disturbances
 Potential facial nerve
injury
 Temporal hallowing


STERNOCLEDOMASTOID
MYOCUTANEOUS FLAP


STERNOCLEDOMASTOID MYOCUTANEOUS FLAP

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Long strap muscle
Muscular origin Tendinous
origin
Insertion
Branch of spinal accessory
nerve
Dominant blood supply –
branches of occipital artery
& its draining vein
Middle third of the muscle
Inferior third of the muscle



REPORTED INDICATIONS
 Provision of epithelial lining for mucosal
reconstruction
 Closure of orocutaneous fistulas
 Release of scar contracture in submandibular &
angle region
 Provision of additional vascularized tissue around a
bone graft when the tissue bed has been heavily
irradiated



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Superior blood supply
6 x 8 cm paddle of skin
Skin paddle should be kept
overlying the muscle above
the level of clavicle
Skin paddle is tacked down
to the muscle fascia
Muscle dissected &
elevated by incising the
fascia



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Inferior blood supply
Branches of superior
thyroid artery are noted
to enter the anterior
aspect of muscle at the
level of carotid
bifurcation


MASSETER FLAP
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Lexer and Eden in 1911
Short, flat, thick quadrangular
muscle
Superior belly - downwards &
backwards
Deep belly - vertically & slightly
forwards
Massetric nerve & artery
Hemimandiblectemy. suturing
the masseter to the hyoid bone
to assist in laryngeal elevation
during swallowing.


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Does not restore emotional mimetic
movements
Muscle eliminated in extensive ablative
surgery
Limited in size & volume
Does not have skin paddle
Restricted arc of rotation


DELTOPECTORAL FLAP
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First axial pattern skin flap
The base of flap is parasternal includes the first three
or four perforating branches of internal mammary
artery, second perforator is largest
Artery as rich anastomosis, accompanied by Vein
It extend laterally over the upper chest at the level of
clavicle on to the deltoid muscle & shoulder
Width 8 - 12 cm, Length 18 - 22 cm
reverse of deltopectoral flap - Thoracoacromial flap


DELTOPECTORAL FLAP
ADVANTAGES
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High biologic
dependability
Readily accessible
Arc of rotation 45 - 135
May be used in male,
female & children
Hairless skin


DELTOPECTORAL FLAP
DISADVANTAGES
 Donor site require skin grafting
 Moderate amount of scarring & deformity is
unacceptable in women
 Physiologic disadvantage in malnourished patient or
post operative irradiation
 Flap should not be used if previous scarring on
donor area


DELTOPECTORAL FLAP
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Superior incision is placed just below the clavicle
inferior one run parallel to it
Flap raised from lateral extent medially
Incision is carried down through the pectoral fascia
Plane of dissection is sub fascial
Dissection proceeds up to 2 cm of lateral border of
sternum
Back cut on medial aspect - improve the flap rotation
90% success rate

PLATYSMA FLAP
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Extremely thin band like & variable muscle
forming superficial boundary of neck
Arises from clavicle superiorly continues with
the attachment to the mandible
Submental branch of the facial artery
Flap size
Muscle - 10 x 10 cm to 10 x 20 cm
skin paddle - 3 x 6 cm to 6 x 20 cm

PLATYSMA FLAP
ADVANTAGES
 Proximity & Regionality
 Thin & delicate
 Reliable when vascu-lar criteria adhered
 Arc of rotation - 180
 No donor site disability

DISADVANTAGES
 Lack of bulk
 Hair bearing in male
 Reliability 85%
 Complication like skin
loss & fistula


TRAPEZIUS FLAP
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Mutter 1842
Originally described as
superior based cutaneous
flap
Flat & triangular and cover
the superoposterior aspect of
the neck & shoulder
Dominant pedicle, the
transverse cervical artery
Functions to rotate the
scapula & to elevate, rotate &
adduct upper arm
10 x 20 cm in size

TRAPEZIUS FLAP
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Lateral positioning of patient
to elevate flap
Ideally suited for radical
parotidectomy
Limited to small defects in
oral cavity
Generous amount of soft
tissue & large portion of
skin island
90 – 95 % of success


TRAPEZIUS FLAP
ADVANTAGES
 Flap is versatile
 Regionality of flap
 Strong vascular security
 Supplies considerable bulk
 Arc of rotation 90 – 180 degree
 One stage procedure
 Minimum deficit at donor area


TRAPEZIUS FLAP
DISADVANTAGES
 Venous system difficult to preserve
 Vascular supply in general difficult to preserve
 Can present with excessive bulk
 Cannot be easily tubed
 Moderate shoulder drop postoperatively


LATISSIMUS DORSI MYOCUTANEOUS FLAP

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Distant flap, provides largest possible skin paddle,
involves the most complex donor site dissection,
and arc of rotation extremely versatile
Donor site skin paddle measures 40 by 25 cm & still
allows primary closure
The latissimus dorsi is very broad muscle of the
back with a fascial origin from T7 to T12, from the
lumbar & sacral vertebrae, from posterior crest of
the ilium & also minor origination from the last four
ribs


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Insertion on the intertubercular groove of the
humerus
Extend, adduct, & medially rotate the arm
Major pedicle is thoracodorsal artery, a
terminal branch of the subscapular artery
Perforators enter the muscle medially along
the spine – secondary supply



ADVANTAGES
 Size – largest flap in
the body
 Flap location
 Arc of rotation - 180
 Large, reliable
unicentric
neurovascular pedicle
 Donor area
 90% success rate


DISADVANTAGES
 Repositioning of the patient
 Skin paddle is thick & has strong attachment
to the underlying muscle
 Considerable bulk – postoperative sagging &
pendulosity
 Donor area may need skin graft
 It is in competition with other very suitable
flaps

conclusion
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Success in reconstruction of the craniofacial
region by local and regional flaps requires
knowledge ,careful preop planning, skilled
tecqniques, and meticulous care after
operation
The goal is to return the patient as closely as
possible to the preop aesthetic and functional
level


Thank you

REFERENCES
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Oral and Maxillofacial surgery clinics of North America November
1993
Flaps in Head and Neck Surgery 1989 John Conley and Carl Patow
Oral cancer Jatin P shah
GRABB’S Encyclopedia of flaps Volume 1
Maxillofacial Surgery Vol. 1 Peter Ward Booth
Atlas of Regional and Free Flaps for head and neck reconstruction
Mark L. Urken
Plastic surgery –McCarthy.vol-1
Fonseca –OMFS Vol-7
Mastery in plastic and reconstructive surgery-Mimis Cohen


REFERENCES
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Oral and Maxillofacial surgery clinics of North
America NOVEMBER 1993
Flaps in Head and Neck Surgery 1989
John
Conley and Carl Patow
Oral cancer Jatin P shah
GRABB’S Encyclopedia of flaps
Maxillofacial Surgery Vol. 1 Peter Ward Booth


Defect

PMMC

ORAL
MUCOSA
mnd intact
Centrl mnd
defects
Lateral mnd
- male
- female

EXT FACIAL
DEFECT
Mand intact
Mand defect

VERTICAL
TREPIZIUS

PLATYSAMA

DELTO
PECTROL

1st
1st

1st
2nd

3rd
2nd

2nd
1st

2nd
1st


1st
2nd

Thank you
For more details please visit


Local and regional flaps in head & neck cancer /certified fixed orthodontic courses by Indian dental academy

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Local and regional flaps in head & neck cancer /certified fixed orthodontic courses by Indian dental academy