Local Flaps used

in
Head & Neck Reconstruction

Local flaps
 Dr V.RA MKUMAR
 CONSULTANT DENTA L&FACIOMAXILLAR Y
SURGE ON
 REG NO:4118- TAMILNADU-INDIA(ASIA)
Principles techniques of wound closure
(reconstructive ladder)
What is ……

Flap:
In its basic form is a tongue of tissue
consisting of the entire thickness of skin
and variable amount of subcutaneous
tissue, which is transferred from one site
to another.

(McGregor)
 Local / Regional flaps – Goals
(Kinnerw & Jeter)
1. Adequate color match
2. Adequate thickness – avoid protrusions or
deficiencies
3. Preservation of clinically perceivable
sensory innervation
4. Sufficient laxity – avoid retraction or
deranged function
5. Resultant suture lines of either primary or
secondary defects are restricted to
anatomic units and fall within natural skin
lines.
Delay of Flap: surgical outlining - before
actual transfer -improve circulation.
(1- 2 weeks)

2 basic schools
1. Delay improves nutrient blood flow
2. Delay increases the tolerance of the
cells to ischemia, allowing them to
survive at a lower flow rate.
Planning in Reverse : used when a local flaps
jumps over skin and in distant flaps.

( a piece of fabric to represent it the flap is

taken in reverse through various stages of
the mock transfer to ensure that the real
flap is large enough and long enough to
reach its destination without kinking or
undue tension at any stage of transfer)
Classification of flaps

1. Based on movement
Local flaps:
Advancement (single / bipedicle, V-Y)
Pivotal : Rotation
Transposition
Interpolation
Distant flaps
Direct
Tube
Microvascular (free)
Local Flap:

skin flap taken from an area close to the wound.

E.g. a wound on the lip may be repaired by a

flap from the adjacent cheek.

Regional Flap:

skin flap is not from the adjacent area, but is

from the same region of the body.

E.g. a wound on the tip of nose might be repaired with

a flap from the forehead.
Distant Flap:

- When a flap is from a different part of

the body.
- Any flap taken from below the lower
border of the mandible is considered a
distant flap.
A local flap repair is usually
done in one operation, whereas
regional and distant flaps need two or
more operations.
Free Flap:

This is a distant flap, but the whole

procedure is done in one stage by
repairing the donor and recipient
blood vessels by microsurgery.
2. Based on blood supply:
Axial
Random

Daniel (1973) blood supply to skin:

Musculocutaneous arteries
random arteries
myocutaneous

Septocutaneous arteries
fasciocutaneous
arterial

Septocutaneous arteries
 Musculocutaneous system: Vascular system penetrating the
underlying muscles and then continues to supply the skin.

Random cutaneous: it is composed of skin and subcutaneous fat with

multiple musculocutaneous arteries at the base.

Myocutaneous flap: it is composed of skin, subcutaneous fat and

muscle with its blood supply coming from muscular arteries
plus numerous terminal musculocutaneous arteries.
Septocutaneous system: vascular system reaching the skin
through septa between muscles. (groin & DP flaps)
 3. Based on composition

Skin (cutaneous)
Visceral ( colon, omentum)
Muscle
Mucosal

Composite
Fasciocutaneous
Myocutaneous
Osseocutaneous
Tendocutaneous
Sensory/innervated flaps
Osseo-myo-cutaneous
Based on vascular pedicle types
In muscles

Mathes and Nahai (1979)

Type I: one vascular pedicle

Type II: dominant pedicle (s) + minor pedicles
Type III: two dominant pedicles
Type IV: Segmental vascular pedicles
Type V: dominant pedicle + secondary segmental pedicles
Areas of skin availability exploited most commonly
for facial local flap transfer

Palpation & PINCH Test

Advancement flaps
flap moves in a straight path without any lateral
movement into the primary defect.
(Burrows Triangle’s)
sites – forehead, brow, cheek.

Single advancement flap:

movement is entirely in one direction.
 Bilateral advancement flap:

When large tissue is required.

Same technique & principle.

used:
forehead, mustache area
and posterior neck.
 A to T flap:

variant of bilateral advancement flap

Useful for
defects at the periphery of the face
around the nasal ala and upper lip

dog–ear almost always forms

Disadvantages:
number of scars- created with the three limbs and Burow’s triangle
and with the three point closure
 V-y advancement flap: (Herbert flap)

A V shaped flap is moved into a defect with primary

closure of the donor area leaving a final Y shaped
suture line.
It is pedicled from the underlying subcutaneous
tissue rather than the surrounding skin.

Ideal for Lesion in

the cheek
and alar base
 Burow’s triangular flap

Variation of advancement flap

cover those areas on the face where there are

anatomical structures on one side of the defect
that should not be pulled or stretched.

repair of upper lip or over the lateral eyebrow,

Point C moves to point B

&
point D moves to point F
Panthographic expansion:

variation of the advancement

instead of the flap being advanced as a rectangle,

the limbs of the flap are designed at 120º with back cuts at the
bottom so that it looks like an inverted tumbler.

The flap is then advanced so that the donor site closes primarily.

This technique is particularly useful on the cheek and neck.

 Pivot flaps:

Derives its name from the pivot point at the base of the flap
as well as its arc of rotation .

When flap moves laterally into the primary defect - transposition

flap

when it is rotated into the defect - rotation flap

isosceles triangle- triangulation of the defect

Pivot point

Is the axis around which the transfer takes place.

Flap is designed so that the distance from the pivot

point to each part of the flap before transfer is
atleast equal to the distance to be expected after
transfer

pivot point is on the side of the flap away from

the direction of movement of the flap.
Rotation flaps: it is semicircular flap that rotates about a pivot point
to fill the defect.

Place the arc closest to the defect higher than the defect itself,
to reach the most distal point of the defect

Should be 5-8 times the width of the defect

Simple rotation flap

Ideally suited on a convex surface

cheek
Submandibular area
Bilateral rotation flap
 Transposition flaps
Classic form - a rectangle or near square which is raised
and moved laterally into a triangular defect

In a correctly designed flap, the distance from the pivot point to A

equals the distance to B and the transfer is carried without tension

sites of choice
retroauricular area
submandibular area A
perioral area for upper and
lower lip reconstructions.
scalp B
not to rotate more than 90º

More acute –less dog ear

Transposition flap
Methods for correction of “dog ear”
 Limberg’s flap:

combination of flap rotation and

transposition

BD=DE=EF
EF at angle of 60º &
Parallel to one side

Disadvantages:
Excess tension

Anatomic landmark displacement because the tissue used to resurface

the rhomboid defect is borrowed from single area.
Rotation pucker at Point C

Best in temple region between the eyebrows and anterior hair line
Limberg’s flap
 Dufourmental flap:

variation of a rhomboid flap

Need not convert into 60º rhomboid

Such flaps are designed for closure of

square & rectangular defects.

Adv:
less closure tension

Disadv:
rotation puckering at point C
Double ‘Z’ rhomboid flap: by Cuono

Advantage over Limberg flap:

Excessive tension is reduced by using

two flaps

anatomic landmark displacement in

minimized because tissue used to
resurface the rhomboid defect is
borrowed from two areas.

Rotation pucker seen with Limberg flap is avoided and the

resultant scar forms an elongated ‘Z’ plasty.
 First by Esser in 1918
Bilobed flap: popularized by Zimany

reconstruct nasal and facial defects and even full thickness cheek
defects.

Tension free closure of original and secondary defects.

90º is the optimal angle between the first and second flap

Maximum distortion occurs around

the flap bases and the second donor
lobe closure sites

Disadvantages:
Rotation pucker
 S’‘ plasty: Schrudder

First by Szymanowski

modification of transposition flap

Difference between transposition and S- plasty

Proximity of the flap base to the defect.

It is positioned tangential to the wound margin
leaving a ‘V’ shaped flap between them.

Intermediate flap created between the flap and the defect.

60 degree between the flap and the
defect will avoid ‘dog ear’

1/5th to 1/6th higher

½ or ¾ the defect
width
Interpolation flaps:

An interpolation flap is from a nearby, but not immediately

adjacent donor Site and transposed either above or below
the intervening skin to the Recipient defect

Types:

Cutaneous: requires two stage procedure but more reliable

Subcutaneous
Island

Ex: Median forehead flap

Nasolabial flap
 LOCAL FLAPS
Buccal fat flap / Syssarcosis :
Masticatory space

average volume of the fat is 9.6ml (8.4 to 11.9)

cover defects of up to 4cm

blood supply from branches of facial, transverse facial

and internal maxillary arteries.

epithelization within 2-3 wks

 Uses:
Oro-antral & oro-nasal communications

reconstruction of ablative defects of the

maxilla and cheek, hard and soft palate, retro-molar
and pterygo-mandibular regions, as
An interpositional graft in OSMF

Advantages:
Easy
Donor site complications rare

Disadvantages:
Facial asymmetry is a possible complication
Buccal Pad Fat
Buccal pad of fat
 Tongue flaps

First by Gersuny
Eiselberg popularized in 1901

Blood supply: lingual artery

advantages:
reliance on an excellent blood supply

low morbidity

Can be used in irradiated patients

Used to cover defects in cheek, floor of the mouth, soft palate and
hard palate, alveolus, oroantral fistulas and vermillion
and lip reconstruction
Classification of tongue flaps:

Flaps from dorsum of tongue

Posteriorly based dorsal tongue flap
Anteriorly based dorsal tongue flap
Transverse based dorsal tongue flap

Flaps from lingual tip

Perimeter flap
Unipedicle and bipedicle
Dorsoventrally disposed flaps

Flaps from ventral surface of tongue

 Posteriorly based dorsal tongue flap

Uses:

To repair a defect of moderate size in the

retromolar trigone, tonsillar fossa of the
ipsilateral side

To cover a posterior mucosal defect in cheek

minimum thickness of the flap

should be 8mm
Tongue flap-posterolaterally based
 Anteriorly based dorsal tongue flap

Uses: to repair defects in the

anterior cheek,
lip,
anterior floor of the mouth,
anterolateral floor of the mouth and
palate
Transverse based dorsal tongue flap

to repair anterior floor of the mouth and lower lip

Perimeter flap

unipedicled or bipedicled

for repair of vermillion border of either lip

Upper and lower lip reconstruction
Dorsoventrally disposed flaps

Flaps reflected ventrally on a anterior base:

Used for lining in lower lip reconstruction

Flaps reflected dorsally on a posterior base.

Used for lining in upper lip reconstruction

Flaps from ventral surface of tongue

cover defect on anterior floor

of the mouth
 Nasolabial flap:

Sushruta in 600 BC
popularized by Esser and Ganzer

reconstruction of facial skin defects of the upper lip,

nose and cheek following extirpation of skin cancers.

superiorly based nasolabial flap- closure of the oro antral

fistulae.

The bilateral inferiorly based nasolabial flap has utility in the

reconstruction of the anterior defects of the floor of the mouth.

Defect in the anterior face, nose and upper lip, floor of the mouth
OAF
Adv:
It provides thin, local tissue for coverage of small defects.
It may be also be deepitheliazed at the base
for one stage procedure.

Disadv:
Limited donor tissue
Facial scarring
Second surgical procedure might me needed
Difficult to use in the floor of the mouth if
the patient is not edentulous
Transfer of beard in male patients
 Inferiorly based Superiorly based

For reconstruction in the

anterior floor of the mouth
Case photos-Nasolabial flap
 Forehead flap: McGregor.

Blood supply
superficial temporal artery and posterior auricular artery.

Hemiforehead flap or total forehead flap

Long enough to reach any part of the ipsilateral face
Butterfly shape is used to repair of
defects of the posterior tongue to
allow Mobility, the other wing
closing the defect in the cheek.
The distal extension provides cover
and seal.

The narrow flap repairs central and

alveolar defects

The repair following total

glossectomy should be in the
form of a shield
Advantages:

Near to the oral cavity

Hairless
Tissue is firm and holds sutures well
Excellent blood supply
Thin and suitable for intraoral lining

Disadvantages:

Noticeable donor defect

Need to divide the pedicle and close the
oral fistula at a second operation
Bleeding
Flap necrosis can occur
Glabellar Flap

- Axial pattern flap

- Based on supra-trochlear
artery

uses:
-nasal reconstruction
-cheek defects

disadvantages:
-donor site morbidity
-limited amount of tissue
 Temporalis flap:

Golovine in 1898

Type III

Temporoparietal fascia - superficial temporal artery

Temporalis muscle - anterior and posterior deep temporal br. Max. art
Uses:
 Useful for obliterating skull base,
maxillofacial and orbital defects.
 It is also used in cranialisation procedure
 Reanimation of the face
 Used to close CSF leaks & dural tears
secondary to trauma & cancer surgeries.
 Used for midface augmentation for
hypoplasia secondary to trauma &
congenital anomalies.
Advantages:
 Close to the oral cavity
 Good arc of rotation
 Reliable and well tolerated
 Thin flap
 Problems from the loss of muscle function
are minimal
Disadvantages:
 Cosmetic deformity in donor site
 Traction paresis of Facial nerve
Temporalis flap
 Narayanan bilobed flap

Uses:
Useful for obliterating skull base, maxillofacial and orbital defects.
It is also used in cranialisation procedure
Reanimation of the face

Advantages:
Close to the oral cavity
Good arc of rotation
Reliable and well tolerated
Thin flap

Disadvantages:
Cosmetic deformity in donor site
Facial nerve paresis
Cervicofacial flap:

•Ideal for Aged patient

•Defects of 4x4 to 6x7 cm.

•based laterally

•It involves lower cheek and upper neck

•useful, well tolerated flap for closing cheek defects with or without
an associated neck dissection.

•maxillary artery, vein and their branches-blood supply

Intra –oral flaps

Palatal flaps (Ashley)

Buccal advancement flaps

-Rehrman’s
-Moczair buccal sliding trapezoidal flap.
(is slid to use the papilla of the adjacent tooth
to rotate into the defect)
Intraoral flaps (buccal)
Bipedicled flap
Ashley palatal flap
Modified palatal flap
Thank U