local and regnl prts 2 (nxpowerlite) / orthodontic courses by indian dental academy

Local and Regional Flaps In Head and Neck Cancer INDIAN DENTAL ACADEMY

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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

Ariyan 1970


Anatomy

Origin Vessels Function


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



Superior and lateral thoracic arteries - additional pedicles

Overlying skin additionally supplied by intercostal perforators

3 subunits each with its own vascular & motor supply


functions

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 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 Sharzer et al. - harvesting a vertically

oriented "parasternal” skin paddle that extended across the sternum to the opposite internal mammary perforators.


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 Deal with Excessive Bulk


Methods to Achieve Two Epithelial Surfaces for Reconstruction of Compound Defects


“Gemini” flaps


POTENTIAL PITFALLS

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

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



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



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



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



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


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



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



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



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

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.


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

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 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

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

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

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

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

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



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

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 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

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 VERTICAL TREPIZIUS

PLATYSAMA DELTO PECTROL

ORAL MUCOSA mnd intactCentrl mnd defectsLateral mnd - male - female

1st

1st 2nd

2nd

1st

1st

EXT FACIAL DEFECT Mand intact Mand defect

3rd

2nd2nd 1st

1st

2nd


Thank you

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local and regnl prts 2 (nxpowerlite) / orthodontic courses by indian dental academy

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