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Grafts and Flaps in the Head and Neck

Grafts and Flaps in the Head and Neck. Dr. Supreet Singh Nayyar, AFMC For more presentations, visit www.nayyarENT.com. Goals of Reconstruction. Safety Functional rehabilitation Aesthetic rehabilitation. Preoperative planning . Nature of defect Clinical stage and prognosis

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Grafts and Flaps in the Head and Neck

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  1. Grafts and Flaps in the Head and Neck Dr. Supreet Singh Nayyar, AFMC For more presentations, visit www.nayyarENT.com www.nayyarENT.com

  2. Goals of Reconstruction • Safety • Functional rehabilitation • Aesthetic rehabilitation www.nayyarENT.com

  3. Preoperative planning • Nature of defect • Clinical stage and prognosis • Patient factors • Available flap donor sites • Compliance, expectations & psychosocial needs • Clinical experience and skill of surgeon www.nayyarENT.com

  4. Timing of Reconstruction • Optimally performed in one stage • Optimal conditions present on resection • Defect is widely exposed • Tissue requirements accurately assessed • Potential recipient vessels for anastomosis dissected out • Surgical margins cleared by frozen section • Delayed reconstruction and secondary procedures www.nayyarENT.com

  5. Reconstructive ladder www.nayyarENT.com

  6. Grafts • Types • Skin grafts • Split thickness skin graft (STSG) • Full thickness skin graft (FTSG) • Composite full thickness skin & cartilage graft • Pinch graft • Fat grafts • Fascial grafts • Dermal grafts • Mucosal grafts • Nerve grafts www.nayyarENT.com

  7. Skin Grafts • Physiology • Serum imbibition • Revascularization • Inosculation • Neovascularization • Organization www.nayyarENT.com

  8. Skin grafts • Split thickness skin graft • Epidermis with portion of dermis • Thin – 0.005 – 0.012 inches • Moderate – 0.012 – 0.018 • Thick – 0.018 – 0.028 • Immobilization is critical • Anterior thigh – preferred site www.nayyarENT.com

  9. Skin grafts • Full thickness skin graft • Epidermis and entire dermis • Thick and don’t contract • Covers the contours well • Good colour matching • Slow revascularization and low take rates • Commonly used after excision of cutaneous malignancies • Common donor sites • Primary closure of donor site www.nayyarENT.com

  10. Flaps • Classification • Blood Supply • Axial • Random • Free • Location • Local • Regional • Distal free www.nayyarENT.com

  11. Flaps • Classification • Type of tissue • Mucosal • Fasciocutaneous • Myocutaneous • Osteocutaneous • Visceral www.nayyarENT.com

  12. Skin and Fasciocutaneous Flaps • Multiple descriptions of flaps • Z-plasty • All limbs must be equal • Gains length at expense of width • V-Y advancement • Recruitment technique for tissue deficiency www.nayyarENT.com

  13. Skin and Fasciocutaneous Flaps • Rotational • Need wide arch of rotation to fill small defect • Back cut increases arc of rotation (decreases vascularity) • Advancement www.nayyarENT.com

  14. Skin and Fasciocutaneous Flaps • Transposition • Need to close the “wake” • Scalp flap • Rhomboid • Bi-lobed • Make first flap 2/3 defect and second 1/2 of first www.nayyarENT.com

  15. www.nayyarENT.com

  16. Local flaps • Effective reconstructive alternatives for small and medium sized defects • Use determined by: • Size and location of defect • Properties of available tissue • Vascular supply • Advantages • Best match of color and texture • Less morbidity www.nayyarENT.com

  17. Local flaps • Mucosal flaps • Palatal • Tongue • Buccal • Skin and muscle flaps • Forehead flap • Nasolabial flap • Temporal flap • Temporoparietal flap www.nayyarENT.com

  18. Local flaps • Nasolabial flap • Up to 25sq cm is provided for oral lining • Vascular supply • Labial artery • One / Two stage www.nayyarENT.com

  19. Local flaps • Nasolabial flap • Uses • Anterior oral defects • Floor of mouth defects • Coverage of exposed mandible • Advantages • Minimal donor site morbidity • Excellent cosmesis www.nayyarENT.com

  20. Local flaps • Temporal Flap • Vascular supply • Deep Temporal artery • Uses • Tissue defects of orbit and lateral face • Palatal defects • Reanimation of unilateral facial paralysis • Complications • Injury to temporal branch of VII Nerve • Fibrosis of RMT • Distortion of facial contour www.nayyarENT.com

  21. Temporoparietal flap Pedicled or free fascial flap Vascular supply Posterior branch of superficial temporal artery and vein Local flaps www.nayyarENT.com

  22. Local flaps • Temporoparietal flap • Uses • Resurfacing the orbit, lateral oral defects, mid face defects • Auricular reconstruction • Composite flap for reconstruction of orbit & zygoma • Advantages • Well hidden donor site • Minimal morbidity • Disadvantages • Risk of injury to temporal branch of VII N • Auriculotemporal nerve is sacrificed causing temporal numbness • Alopecia www.nayyarENT.com

  23. Regional flaps • Pedicled flaps • Classification • Fasciocutaneous • Myocutaneous • Muscle • Selection • Location and size of defect • Intrinsic properties of flap www.nayyarENT.com

  24. Bakamjian – 1965 Fasciocutaneous flap Axial pattern Vascular supply 2nd and 3rd perforating branches of internal mammary artery Deltopectoral flap www.nayyarENT.com

  25. Deltopectoral flap • Use • Resurfacing cutaneous neck defects • Facial, oral, pharyngeal defects • Advantages • Technically easy • Low morbidity • Disadvantages • Unreliable distal random portion • Lack of bulk • Skin graft for donor site • Two stage procedure www.nayyarENT.com

  26. Ariyan – 1979 “Work horse flap” Blood supply Pectoral branch of Thoracoacromialartery Skin island - perforators Pectoralis Major Flap www.nayyarENT.com

  27. Pectoralis Major Flap • Modifications • Bipaddled • Osteomyocutaneous • Uses • Oral cavity and pharyngeal defects • Mandibular defects • Cutaneous defects of neck • Protection of great vessels • Obliteration of dead space after mediastinaldissection • Reconstruction of pharynx after pharyngectomy www.nayyarENT.com

  28. Pectoralis Major Flap • Advantages • Good vascular supply • Large skin paddle • Versatile • Easy to harvest • Single stage • Supine position • Primary closure of donor site • Low incidence of complications www.nayyarENT.com

  29. Pectoralis Major Flap • Disadvantages • Less reliable for cephalic defects of face and scalp • Effect of gravity • Excessive bulk • Transposition of hair • Complications • Flap necrosis – total / partial • Donor site complications • Haematoma • Wound dehiscence www.nayyarENT.com

  30. Trapezius flap • Conley - 1972 • Vascular supply • Perforating branches of posterior intercostal arteries www.nayyarENT.com

  31. Trapezius flap • Use – ipsilateral skin and pharyngeal defects • Advantages • Simple dissection • Not prone to wound separation due to gravity • Not in radiated field • Pedicle not threatened during neck dissection • Disadvantages • Limited length • STSG for donor site • Modifications • Lateral Island flap • Lower Island flap www.nayyarENT.com

  32. Free flaps • Daniel and Taylor – 1973 • Characters defining free flap transfer: • Anatomical site & characteristics of flap • Texture , color , contour, vascular pedicle , innervation • Requirement of bone • Morbidity of donor site www.nayyarENT.com

  33. Free flaps • Advantages • Superior restoration of function and aesthetics • One stage • Superior vascular supply • Greater variety and versatility of donor site • 93 – 96% success rate www.nayyarENT.com

  34. Free flaps • Disadvantages • Complexity of technique • Increased surgical time • Different color & contour from recipient site • Multidisciplinary effort • Morbid in patients with poor surgical risk www.nayyarENT.com

  35. Recipient vessels • Arteries • Superficial temporal system – scalp and upper face • Facial artery—midface and cervical region (atherosclerosis common) • Superior thyroid or lingual artery—lower cervical region • Other: thyrocervical trunk, external carotid, common carotid www.nayyarENT.com

  36. Recipient vessels • Veins • External jugular • Branches of internal jugular (common facial) • Internal jugular • Retrograde (superficial temporal, thyroid) • Transverse cervical, occipital (very small) www.nayyarENT.com

  37. Chinese flap - 1981 Harvested from volar aspect of forearm Vascular supply Radial artery & its venaecomitantes Osteocutaneous flap based on periosteal perforators Sensory innervation Antebrachialcutaneous nerves Allen’s test Radial Forearm Flap www.nayyarENT.com

  38. Radial Forearm Flap www.nayyarENT.com

  39. Radial Forearm Flap • Uses • Oral & oropharyngeal defects • Hypopharyngeal& cervical esophagus reconstruction • Resurfacing of scalp & face • Advantages • Thin, pliable, hairless • Long vascular pedicle, large sized vessels • Sensate • Abundant subcutaneous fat for protection & contouring • Can be used as a osteocutaneous flap • Simultaneous two team approach in supine position www.nayyarENT.com

  40. Radial Forearm Flap • Disadvantages • STSG for donor site • Color & texture match is only fair • Vascular compromise of hand • Numbness of hand • Incomplete healing of STSG due to exposure of tendons • Osteocutaneous flap • Restricts dental restoration • Pathological fracture of radius www.nayyarENT.com

  41. Taylor & co workers – 1975 Osteomyocutaneous flap Vascular supply Peroneal artery with 2 venaecomitantes Sensory innervation Lateral sural nerve Fibula Flap www.nayyarENT.com

  42. Fibula Flap • Uses • Mandibular reconstruction • Palatomaxillary reconstruction • Advantages • Exceptional bone length • Thick bone allows fixation plates & screws • Dental rehabilitation • Sensate • Primary closure of donor site with minimal morbidity • Simultaneous two team harvest in supine position www.nayyarENT.com

  43. Fibula Flap • Disadvantages • Limitations imposed by soft tissue component • Poor arc of rotation of skin island • Presence of atherosclerosis or congenital anomalies are a contraindication • Potential donor site complications • Injury to peroneal nerve – foot drop • Instability of knee and ankle joints www.nayyarENT.com

  44. Types Myocutaneous Myofascial Muscle Vascular supply Deep inferior epigastric artery and vein Precaution Preservation of anterior rectus sheath below the arcuate line to prevent hernia formation Rectus Abdominis Flap www.nayyarENT.com

  45. Rectus Abdominis Flap • Uses • Large skull base defects • Total glossectomy • Orbitomaxillary defects www.nayyarENT.com

  46. Rectus Abdominis Flap • Advantages • Long vascular pedicle with large diameter • Flexibility in design of paddles • Minimal donor site morbidity with primary closure • Suture placement during in setting of flap allows watertight closure and dead space obliteration in oral cavity and skull base • Simultaneous two team approach in supine position • Disadvantages • Excessive bulk in obese patients • Segmental nerve supply prevents effective re innervation • Poor color match of skin www.nayyarENT.com

  47. Visceral flaps • Types • Pedicled • Gastric transposition • Colon interposition • Free • Jejunal • Gastro - omental www.nayyarENT.com

  48. Causes for flap failure • Anastamotic failure • Venous stasis • Thrombosis • Hypovolemia, low blood flow states • Injury to endothelium • Error in suture placement • Vascular spasm • Haematoma formation • Infection • Previous irradiation • Age, tobacco smoking, diabetes mellitus www.nayyarENT.com

  49. Assessment of flap viability • Clinical • Color • Temperature • Capillary refill • Bleeding www.nayyarENT.com

  50. Assessment of flap viability • Monitoring devices • Transcutaneous PO2 monitoring • Surface temperature monitoring • Implantable thermocouple probes • Dermoflourometry • Surface doppler USG • Laser doppler flowmetry • IV flourescin • Photopletysmography • Electrical impedance pletysmography • Implantable microcatheters • Radionucleotide scanning www.nayyarENT.com

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