reconstructive flap 101: basic principles, imaging, and beyond eede#: eede-88 e supsupin 1, i alava...

Reconstructive Flap 101: Basic Principles, Imaging, and Beyond

eEdE#: eEdE-88

E Supsupin1, I Alava2, D Freet3, E Bonfante1, S Garza1, Y Weinstock2

Institutions:

1University of Texas Houston Department of Diagnostic & Interventional Imaging,

Houston, TX,

2University of Texas Houston Department of Otorhinolaryngology, Head & Neck

Surgery, Houston, TX,

3University of Texas Houston Department of Plastic Surgery, Houston, TX

Author disclosures

None

Basics of flaps

Case illustrations (including imaging): Flaps for restitution of function Flaps for restitution of function and cosmesis Flap for cosmesis

Reconstructive flaps in head &neck surgery

A “Flap” can be defined as a piece of tissue that is moved from one part of the body to another part of

the body with a blood supply intact.

Define “Flap”

Flaps A flap is referred to as a “Pedicled” flap if its blood supply is

left intact at its origin when it is moved to the new site.

A flap is referred to as a “Free” flap if the blood supply of the donor tissue to be moved is severed from its origin and then re-connected to a new artery and vein at the recipient site.

A flap can be made of any type of tissue: bone, cartilage, fascia, subcutaneous tissue, skin, or any combination of these.

Flaps Flaps are required for reconstruction of large composite

defects resulting from trauma or cancer extirpation.

A flap is referred to as a “Free” flap if the blood supply of the donor tissue to be moved is severed from its origin and then re-connected to a new artery and vein at the recipient site.

A flap can be made of any type of tissue: bone, cartilage, fascia, subcutaneous tissue, skin, or any combination of these.

Flaps

Flaps can be used for cosmetic purposes, functional purposes, or a combination of both depending on the needs of the patient.

Flaps

Flaps can be used for cosmetic purposes, functional purposes, or a combination of both depending on the needs of the patient.

What are commonly used flaps for head and neck reconstruction?

Pectoralis major Latissimus dorsi Rectus Abdominis Radial Forearm Free Fibula Free Iliac Crest

Pectoralis major Is considered a “work horse” in head and neck

reconstruction

Can be used as a muscle-only flap or can include skin

Most commonly transferred as a pedicled flap based on the pectoral branch of the thoracoacromial arterial trunk

Can be used for intra-oral lining, head and neck skin resurfacing or tubed for creation of a neopharynx

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

Latissimus Dorsi

Can be used as a pedicled flap or free flap

Large bulky muscle or muscle and skin flap based on the thoracodorsal branch of the subscapular artery

In head and neck reconstruction, this flap is used to fill large defects.

Can provide a very large amount of skin if needed

Not commonly used secondary to its bulky nature

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

Rectus abdominis

Always used as a free flap

Muscle or muscle and skin flap based on the deep inferior epigastric artery

Used to fill large defects such as that of a total glossectomy

Disadvantage is abdominal wall weakness.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

Radial Forearm

This is a free flap based on the radial artery.

Thin fasciocutaneous (fascia and skin) flap that can be used for intra-oral lining, used to resurface a tongue defect or can be tubed to create a neo-pharynx

Donor site can be problematic (poor healing).

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

Anteriolateral thigh Free flap that is based on the descending branch of the lateral

circumflex femoral artery.

Fasciocutaneous flap that can be made very large for large complex defects.

Can be used for intra-oral lining, can be tubed for neo-pharynx, can be used for head and neck resurfacing, or can be a combination of any of these

Minimal donor site morbidity

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

Free Fibula

Free flap based on the peroneal artery that uses a portion of the fibula and sometimes the overlying skin of the leg for complex reconstruction of the mandible and intra-oral lining

An excellent source of a large amount of bone.

Minimal donor site morbidity

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.



From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

From:Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

Free Iliac Crest

Free flap that is based on the deep circumflex iliac artery.

Can be bone only or can be bone and skin

Used mostly for mandibular reconstruction. Skin can be used for intra-oral lining.

Donor site can be very painful.

Image: AO Foundation

Flap for subtotal glossectomy

Necrotic, malignant infiltrating mass in the left tongue/floor of mouth. Resection of the mass and free flap reconstruction was planned.

Neck dissection prior to extirpation of mass.Apron flap is lifted up (yellow arcs).

Flap for subtotal glossectomy

Tongue mass is resected.Apron flap is lifted up (yellow arcs).

Flap for subtotal glossectomy

Flap is harvested from the anterolateral thigh

Flap (bracket) with its vascular (arrows) pedicle is shown.

Flap for subtotal glossectomy

Free flap sawn into tongue stump and floor of mouth

Harvested flap from thigh

Immediate postoperative result

Flap for total glossectomy

Images taken Intraoperatively and 1 month after surgery

This case illustrates the use of free flap mainly for restoration of function.

Flap for layngopharyngectomy

This patient presented with advanced transglottic laryngeal squamous cell cancer that ruptured into the skin (brackets & circle). The mass has obliterated the upper airway requiring tracheostomy (red arrow). Total laryngopharyngectomy with Free flap reconstruction was planned.

Flap for layngopharyngectomy

Large flap harvested from anterolateral thigh for free flap reconstruction and creation of neopharynx

Flap for layngopharyngectomy

Defect after neck dissection and extirpation of mass

Flap for layngopharyngectomy

Creation of tube/neopharynx from free flap harvested from thigh

Flap for layngopharyngectomy

Creation of tube/neopharynx from free flap harvested from thigh

Uvula – yellow arrow

Flap for layngopharyngectomy

This case illustrates the use of free flap for creation of neopharynx and closure of a large soft tissue defect. Flap is employed both forrestitution of function and cosmesis.

Pectoralis flap

A diabetic woman with poor glycemic control who developed multicompartmental abscesses in the suprahyoid neck and necrotizing fasciitis (CT). Full thickness loss of tissue in the face and neck after debridement with exposed mandible (arrow). Flap reconstruction is required to close the defect.

Pectoralis flap

Pectoralis flap is used to fill the soft tissue defect.

Pectoralis flap - postop

Free flap used to fill the soft tissue defect in the left face and neck, and create the lining of the oral cavity. There is persistent enhancement in the masticator space on MR (circle) a year after surgery, with no clinical signs of active infection.

Pectoralis myocutaneous flap - postop

Postoperative CT showing the pectoralis myocutaneous flap (arrows). M – muscle F- FatIn this case the flap serve both purposes of restoration of function and cosmesis

MF

This patient presented with oral tongue mass, later proven to be squamous cell carcinoma. The plan was resection of the tongue mass including the mandible, with free flap reconstruction.

Total glossectomy and mandibular resection with free flap reconstruction

Resection of tongue and mandible

Total glossectomy and mandibular resection with free flap reconstruction

Courtesy of James Melville DDS

Specimen removed

Total glossectomy and mandibular resection with free flap reconstruction

Courtesy of James Melville DDS

Harvesting flap from thigh

After resection of tongue and mandible

Total glossectomy and mandibular resection with free flap reconstruction

Courtesy of James Melville DDS

Mandibular reconstruction with Titanium chain

Total glossectomy and mandibular resection with free flap reconstruction

Courtesy of James Melville DDS

Total glossectomy and mandibular resection with free flap reconstruction

Flap implantation

Courtesy of James Melville DDS

Immediate postoperative result – this case illustrates use of flap for both restoration of function and cosmesis

Total glossectomy and mandibular resection with free flap reconstruction

Courtesy of James Melville DDS

Preoperative CT with cosmeticdefect on the right (bracket)after prior parotidectomy 10 years earlier for adenoid cystic carcinoma. Free flapreconstruction was decidedafter a negative workup fordisease recurrence.

Flap harvested from the thigh

Neck dissection in preparation forfree flap reconstruction

Immediate postsurgical result

SCM – sternocleidomastoid muscleCCA – common carotid artery bifurcation

Example of free flap reconstruction for cosmesis

Example of free flap reconstruction for cosmesis

Before After

Summary

Reconstructive flaps in the head and neck are used for restitution of function or cosmesis, or both, depending on the needs of the patient.

Case illustrations are provided.

Bibliography of illustrations

Slides 11-14; 16-19; 21; 23-26; 28-31; 33-36; 38

Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.

Slide 36:

“Reconstruction: Harvesting.” AOfoundation.org. Web. 23 Mar. 2015.