Flaps in otolaryngology
- 2. Ideal flap "when a part of one's person is lost, it should be replaced in kind, bone for bone, muscle for muscle, hairless skin for hairless skin, an eye for an eye, a tooth for a tooth." Ralph Millard
- 3. Introduction The term "flap" first originated during the 16th century from the Dutch word "flappe" meaning a structure that hung broad and loose, fastened only on one side. Flaps are usually used to repair structural defects following surgery i.e. for malignant conditions of head and neck.
- 4. History 600 B.C. Susrutha performed nasal reconstruction using cheek flap 1440 A.D. Forehead rhinoplasty (India). Pivotal flaps was preferred during early days. This involves rotation of the flap around its vascular pedicle. Advancement flap (French surgeons). This involves transfer of skin from adjacent area without rotation.
- 5. History (contd) McGregor - Who introduced the forehead flap during 1963 Bakamjian - Who introduced the deltopectoral flap during 1965 Ariyan - Who pioneered the Pectoralis major myocutaneous flap in 1979 Daniel & Taylor - Who pioneered the free flap in 1973
- 6. Flap surgery - Principles Principle I : Replace like with like. This will go a long way in Camouflaging the surgical defect. Principle II: Reconstruction should be thought in terms of units. It was Millard who divided the human body into 7 main parts (head, neck, body and extremities). He subdivided each of these parts into units. Each unit is further divided into subunits. These units and subunits should be considered and studied before the process of reconstruction is begun. The most important aspect of these units are their borders. These borders include creases, margins and hair lines. Adherence to these borders during reconstruction is very important. It is always better to convert a partial unit defect into a whole unit defect before grafting. This will enable better consmesis. Principle III: There should be a pattern and a fall back option always at hand. Principle IV: The graft should be sutured without any tension. The donor area should not suffer excessive tissue loss.
- 7. Definition of flap / graft Flap is a unit of tissue that can be transferred from one site (donor) to another (recipient site) while maintaining its own blood supply. Flap is transferred with its blood supply intact, whereas a graft is a transfer of tissue without its own blood supply. Survival of graft depends entirely on the blood supply from the recipient site.
- 9. Classification of flap Flaps may be classified according to their: 1. Blood supply 2. Tissue to be transferred 3. Location of donor site
- 10. Blood supply For any graft tissue to survive blood supply is a must. If the blood supply is derived from unnamed blood vessels then it is termed as "Random flap". Many local skin flaps fall in this category. If blood supply to the flap is derived from named vessel / vessels it is referred to as "Axial flap". Most muscle flaps fall in this category
- 11. Types of axial flaps Type I Axial flap: Has only one vascular pedicle e.g. Facia lata Type II Axial flap: Has blood supply served by dominant and Minor pedicles e.g. Gracilis flap Type III Axial flap: Has blood supply served by two dominant pedicles e.g. Gluteus maximus flap Type IV Axial flap: Has blood supply via segmental blood vessels e.g. Sartorious flap Type V Axial flap: Derives blood supply from one dominant pedicle and many segmental blood vessels e.g. Latissmus dorsi flap
- 13. Classification – according to tissue to be transferred Skin Fascia Muscle Bone Viscera (colon, small intestine, omentum) Composite – Fasciocutaneous, myocutaneous, Tendocutaneous and osseocutaneous flaps
- 14. Classification - Location Tissue could be transferred from an area adjacent to the defect. This type of flap is known as local flap. They may be further subclassified depending on its geometric design. Pivotal flaps: are also known as geometric flaps. They include rotation, transposition, and interpolation types. Advancement flaps: This type include single pedicle / Bipedicle / V- Y flaps Tissue transferred from non contiguous site i.e. distant flaps. These flaps could either be pedicled or free flaps. The pedicled flaps are still attached to their blood supply, while free flaps are totally severed from their blood supply and are reattached to vessels at the recipient site (microanastomosis).
- 15. Advancement flap (History) Celsus of ancient Rome as the first to perform advancement flap French surgeons in 1800 popularized this flap as sliding flaps Used to cover skin defects close to an area of skin laxity Initially it was commonly used in forehead, scalp, eyelid and upper lip areas
- 16. Vascularity of advancement flaps Critical blood supply – 1-2 ml / min / 100g of tissue is adequate. Advancement flaps depend on random blood supply arising from anastomoses within subdermal / dermal plexus Flap length : width ratio in head and neck region is 4:1
- 17. Types of advancement flaps Monopedicled flap Bipedicled flap V – Y flaps
- 18. Monopedicle flap Usually rectangular and moves forwards Redundant tissue at the base of the flap can be reduced by creating Burow triangle
- 19. Bipedicle flap Incisions are made on each side of flap These are random flaps (obtain blood supply from capillaries rather than named arteries Commonly these flaps are generally skin
- 20. V – Y Flap V – shaped incision Broad base of V is advanced into the defect Resultant defect is closed (Y shaped closure) If long flaps are needed delay phenomenon can be made use of. After raising the flap 1-3 weeks time is given before advancing it. Delay phenomenon works because the choked blood vessels open up if time is given.
- 21. Glabellar flap Best suited for reconstruction of defects involving the bridge or upper half of the nose. Axial flap Blood supply – supratrochlear artery / dorsal nasal branches Upper portion of incision should be carried up to the periosteum Mobilisation around naso frontal angle should be carried out by blunt dissection. Supra trochlear vessels should be preserved
- 22. Sliding rotation degloving nasal flap Helps to cover the lower half of the front of the nasal cavity The degloving flap is outlined in such a fashion that the incision to mobilize the flap is on the right- hand side along the nasolabial fold going up to the glabellar region. The apex of the flap is in the midline, with symmetrical right and left limbs Blood supply is from the nasolabial artery
- 23. Nasolabial flap Axial flap Blood supply – Nasolabial artery Width to length ratio – 1:5 Useful in covering defects over lower portion of nose and ala of the nose
- 24. Inferiorly based nasolabial flap Based on nasolabial artery Logically suited because of its blood supply Suited for lateral aspect of lower portion of nose reconstruction Even though the defect to be filled is circular its apex is made triangular to facilitate primary closure of donor site Flap should be superficial to the underlying facial musculature
- 25. Rhomboid flap Geometric flap Described by Limberg Useful in pts with lax skin Blood supply is from subdermal plexus Length to width ratio should not exceed 2:1 Useful in reconstruction of lateral nasal defects and cheek defects
- 26. Mustardé Advancement Rotation Cheek Flap 1. Defects of infraorbital region / medial part of cheek can be closed using this cheek flap 2. Blood supply is from the terminal branches of facial artery 3. Flap should be mobilized up to the angle of the mandible to avoid unnecessary tension to the flap 4. Superior aspect of incision is towards the temple – prevents drooping of lateral canthus of eye
- 27. Bilobed flap Random flap Can be used anywhere in the body Effective in covering defects over zygoma and buccinators Works best in pts with lax skin First lobe fills the defect while the second lobe fills up the defect created by the first lobe
- 28. Cervical flap Regional cutaneous flap Useful to cover lower half of the face and upper neck Vascularity from subdermal arterical plexus Length to width ratio not to exceed 3:1 Neck dissection if need be can be performed via the same incision Flap is to be elevated superficial to platysma
- 29. Myocutaneous flaps Includes skin, subcutaneous tissues and muscles Useful in sealing large defects Classified according to their vascular patterns and locations 1. Pectoralis major myocutaneous flap 2. Deltopectoral flap 3. Radial forearm free flap 4. Temporalis flap
- 30. Pectoralis major myocutaneous flap Myocutaneous flap Pectoral branch of acromiothoracic artery Enters the muscle just below clavicle at the junction of middle and outer thirds Useful in reconstruction of oral cavity, oropharynx, hypopharynx and larynx
- 31. Pectoralis major myocutaneous flap – elevation tips 1. The incision should be made above the nipple in male and below the breast in the female patient. 2. Pedicle should be identified carefully to preserve the vascularity of the flap 3. After repair of the defect rubber drains should be placed
- 32. Deltopectoral flap Bakamjian in 1965 Axial flap Supplied by perforating branches of internal mammary artery Can cover any site of the neck up to the level of zygoma. Advantage – Flap retraction occurs from side to side and not from end to end.
- 33. Deltopectoral flap (contd) Flap is outlined in the anterior chest wall and shoulder Dissection plane – deep to pectoral and deltoid muscle fascia Muscle fibres should be seen as the flap is being elevated Elevation of this flap should only be done up to 2cms lateral to the sternal border taking care to avoid injury to perforating arteries Donor site should be covered with split thickness skin graft
- 34. Radial forearm flap Faciocutaneous flap based on radial artery Venous outflow is from the superficial veins of forearm Used to reconstruct oral cavity, oropharynx and hypopharyx This flap includes skin from the anterior cubital fossa to the flexor crease at the wrist. Skin should not be elevated over the ulnar artery
- 35. Abbe Estlander flap This flap is commonly used to reconstruct defects involving lips and commissures Full thickness flap with skin / muscle / mucous membrane are used The flap can be marked, rotated and sutured leading to the formation of new commissure
- 36. Temporoparietal flap Based on superficial temporal artery Both anterior and posterior branches of superficial temporal artery should be included Size of the flap should be the size of temporalis muscle The arch of the zygoma should be fractured to deliver the flap into the oral cavity Donor site should be closed primarily
- 37. Hadad Flap Used for skull base reconstruction Mucoperichondrial/periosteal flap Based on nasoseptal artery Commonly used for anterior skull base reconstruction
- 38. Hadad flap - Indications Skull base reconstruction after endonasal surgery To prevent communication between brain and sinuses To repair anterior skull base leak
- 39. Hadad flap - advantages Robust blood supply Superior arc of rotation Provides enough area to cover entire anterior skull base Can be safely stored in nasopharynx if the procedure needs to be staged Can be taken down and reused in revision cases