BRITISH MICROSURGICAL SOCIETY MEETING Free flaps in facial reconstruction 0. M. FENTON and B. J. MAYOU Department of Plastic Surgery, The Hospital for Sick Children and St Thomas’ Hospital, London 437 The versatility of free flaps in facial reconstruction is now well established. Their advantages over conventional cutaneous and myocutaneous flaps are their ability to be tailored to fit a defect precisely, incorporating a vascularised bone graft if required and their generally superior donor defects. A series of patients with large defects of the head and neck were shown to demonstrate different methods of free flap reconstruction and the applica- tion of these techniques to the reconstruction of hemi-facial microsomia and hemi-facial atrophy. Hemi-facial microsomia is classified as: (9 (ii) (iii) (iv) Type 1: requiring only a soft tissue augmentation. Type 2: requiring soft tissue plus an on-lay bone graft. Type 3: requiring an inter-position bone graft. Type 4: requiring a complete hemi-mandible replacement. Type 1 is corrected using a shaved scapular flap, the flap being designed to be placed upside down in the subcutaneous facial pocket such that the tough dermis may be secured to the zygoma and the inferior orbital margin to avoid the problem of slipping and also to allow the soft subcutaneous fat to be adjacent to the facial skin. It is suggested that in girls the scapular flap should be raised in a vertical plane so that the resulting scar can be concealed in the bra line. Where the defect extends above the zygoma, the scapular flap may not be large enough and it is then necessary to use omentum or possibly augment the scapular flap with a galeal flap. In all other types of hemi-facial microsomia, a deep circumflex iliac artery flap is used. The amount of bone required is carefully assessed pre-operatively using plaster of Paris models and plastic templates. In the more severe types of hemi-facial microsomia, mandibular and maxillary osteotomies are required. The deltoid free flap: anatomical studies and clinical experience K. A. MURRAY, M. T. REBOT, G. B. SINGH and R. C. RUSSELL Section of Plastic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada A deltoid free flap is a neurovascular fasciocuta- neous flap which is able to provide relatively thin sensate tissue for use in soft tissue reconstruction. This flap is based on a perforating branch of the posterior circumflex humeral artery and receives sensation via the lateral brachial cutaneous nerve, an inferior branch of the axillary nerve. This paper reviews the results of 20 anatomical studies in fresh cadavers. These included anatomical dissections, in situ and extracorporeal arterio- graphy and ink injection studies of the deltoid flap. A neurovascular pedicle 6 to 8 cm in length can be obtained when the flap is dissected to the posterior circumflex humeral artery, with a vessel diameter of 2 to 3 mm. Three clinical examples of soft tissue lower extremity reconstruction by sensate free tissue transfer are presented. These cases show the variable amount of skin that can be transferred due to the anastomotic channels between the primary and secondary vascular skin territories demonstrated by the anatomical studies. The length of the flaps ranged from 8 to 33 cm. The deltoid flap has the following advantages: (0 (ii) (iii) (iv) It is a thin, sensate, well vascularised fas- ciocutaneous flap. The pedicle length and vessel diameter are satisfactory. The amount of tissue available for transfer is extremely variable. The colour match is acceptable for soft tissue reconstruction. The disadvantages of the flap are the need to skin graft the donor site in all but the smallest flaps and the strong retraction required to expose the pedicle with its potential risk of axillary nerve damage.

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BRITISH MICROSURGICAL SOCIETY MEETING

Free flaps in facial reconstruction

0. M. FENTON and B. J. MAYOU

Department of Plastic Surgery, The Hospital for Sick Children and St Thomas’ Hospital, London

437

The versatility of free flaps in facial reconstruction is now well established. Their advantages over conventional cutaneous and myocutaneous flaps are their ability to be tailored to fit a defect precisely, incorporating a vascularised bone graft if required and their generally superior donor defects.

A series of patients with large defects of the head and neck were shown to demonstrate different methods of free flap reconstruction and the applica- tion of these techniques to the reconstruction of hemi-facial microsomia and hemi-facial atrophy.

Hemi-facial microsomia is classified as:

(ii)

(iii) (iv)

Type 1: requiring only a soft tissue augmentation. Type 2: requiring soft tissue plus an on-lay bone graft. Type 3: requiring an inter-position bone graft. Type 4: requiring a complete hemi-mandible replacement.

Type 1 is corrected using a shaved scapular flap, the flap being designed to be placed upside down in the subcutaneous facial pocket such that the tough dermis may be secured to the zygoma and the inferior orbital margin to avoid the problem of slipping and also to allow the soft subcutaneous fat to be adjacent to the facial skin. It is suggested that in girls the scapular flap should be raised in a vertical plane so that the resulting scar can be concealed in the bra line. Where the defect extends above the zygoma, the scapular flap may not be large enough and it is then necessary to use omentum or possibly augment the scapular flap with a galeal flap. In all other types of hemi-facial microsomia, a deep circumflex iliac artery flap is used. The amount of bone required is carefully assessed pre-operatively using plaster of Paris models and plastic templates. In the more severe types of hemi-facial microsomia, mandibular and maxillary osteotomies are required.

The deltoid free flap: anatomical studies and clinical experience

K. A. MURRAY, M. T. REBOT, G. B. SINGH and R. C. RUSSELL

Section of Plastic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada

A deltoid free flap is a neurovascular fasciocuta- neous flap which is able to provide relatively thin sensate tissue for use in soft tissue reconstruction. This flap is based on a perforating branch of the posterior circumflex humeral artery and receives sensation via the lateral brachial cutaneous nerve, an inferior branch of the axillary nerve.

This paper reviews the results of 20 anatomical studies in fresh cadavers. These included anatomical dissections, in situ and extracorporeal arterio- graphy and ink injection studies of the deltoid flap. A neurovascular pedicle 6 to 8 cm in length can be obtained when the flap is dissected to the posterior circumflex humeral artery, with a vessel diameter of 2 to 3 mm.

Three clinical examples of soft tissue lower extremity reconstruction by sensate free tissue transfer are presented. These cases show the variable amount of skin that can be transferred due to

the anastomotic channels between the primary and secondary vascular skin territories demonstrated by the anatomical studies. The length of the flaps ranged from 8 to 33 cm.

The deltoid flap has the following advantages:

(ii)

(iii)

(iv)

It is a thin, sensate, well vascularised fas- ciocutaneous flap. The pedicle length and vessel diameter are satisfactory. The amount of tissue available for transfer is extremely variable. The colour match is acceptable for soft tissue reconstruction.

The disadvantages of the flap are the need to skin graft the donor site in all but the smallest flaps and the strong retraction required to expose the pedicle with its potential risk of axillary nerve damage.