Local flaps Dr V.RAMKUMAR CONSULTANT DENTAL&FACIOMAXILLARY

SURGEON REG NO:4118-TAMILNADU-INDIA(ASIA)

Principles techniques of wound closure

What is ……

Flap : It is defined as a tongue of tissue consisting of entire thickness of skin and variable thickness of subcutaneous tissue which is transferred from one site to another and is based on its own blood supply.

Local / Regional flaps – Goals (Kinnerw & Jeter)

1. Adequate color match2. Adequate thickness – avoid protrusions or

deficiencies3. Preservation of clinically perceivable

sensory innervation4. Sufficient laxity – avoid retraction or

deranged function5. Resultant suture lines of either primary or

secondary defects are restricted to anatomic units and fall within natural skin lines.

Delay of Flap: surgical outlining - before actual transfer -improve circulation.

(1- 2 weeks)

2 basic schools1. Delay improves nutrient blood flow2. Delay increases the tolerance of the

cells to ischemia, allowing them to survive at a lower flow rate.

1. Based on movement Local flaps:

Advancement (single / bipedicle, V-Y)Pivotal : Rotation

Transposition Interpolation

Distant flapsDirect TubeMicrovascular (free)

Classification of flaps

Local Flap:

skin flap taken from an area close to the wound.

E.g. a wound on the lip may be repaired by a flap from the adjacent cheek.

Regional Flap:

skin flap is not from the adjacent area, but is from the same region of the body.

E.g. a wound on the tip of nose might be repaired with a flap from the forehead.

- When a flap is from a different part of the body.

- Any flap taken from below the lower border of the mandible is considered a distant flap.

A local flap repair is usually done in one operation, whereas regional and distant flaps need two or more operations.

Distant Flap:

Free Flap:

This is a distant flap, but the whole procedure is done in one stage by repairing the donor and recipient blood vessels by microsurgery.

2. Based on blood supply:

Axial Random

Daniel (1973) blood supply to skin:

Musculocutaneous arteriesrandom arteriesmyocutaneous

Septocutaneous arteriesfasciocutaneous arterial

Septocutaneous arteries

Musculocutaneous system: Vascular system penetrating the underlying muscles and then continues to supply the skin.

Random cutaneous: it is composed of skin and subcutaneous fat with multiple musculocutaneous arteries at the base.

Myocutaneous flap: it is composed of skin, subcutaneous fat and muscle with its blood supply coming from muscular arteries plus numerous terminal musculocutaneous arteries.

Septocutaneous system: vascular system reaching the skin through septa between muscles. (groin & DP flaps)

3. Based on composition

Skin (cutaneous)Visceral ( colon, omentum)Muscle Mucosal

CompositeFasciocutaneous Myocutaneous Osseocutaneous Tendocutaneous Sensory/innervated flaps Osseo-myo-cutaneous

Type I: one vascular pedicleType II: dominant pedicle (s) + minor pediclesType III: two dominant pediclesType IV: Segmental vascular pediclesType V: dominant pedicle + secondary segmental pedicles

Based on vascular pedicle typesIn muscles

Mathes and Nahai (1979)

Areas of skin availability exploited most commonly for facial local flap transfer

Palpation & PINCH Test

Advancement flaps

flap moves in a straight path without any lateral movement into the primary defect.(Burrows Triangle’s)

sites – forehead, brow, cheek.

Single advancement flap:movement is entirely in one direction.

Bilateral advancement flap:

When large tissue is required.Same technique & principle.

used: forehead, mustache area

and posterior neck.

variant of bilateral advancement flap

Useful fordefects at the periphery of the face around the nasal ala and upper lip

dog–ear almost always forms Disadvantages:number of scars- created with the three limbs and Burow’s triangle and with the three point closure

A to T flap:

V-y advancement flap: (Herbert flap)

A V shaped flap is moved into a defect with primary closure of the donor area leaving a final Y shaped suture line. 

It is pedicled from the underlying subcutaneous tissue rather than the surrounding skin.

Ideal for Lesion in the cheek and alar base

Variation of advancement flap

cover those areas on the face where there are anatomical structures on one side of the defect that should not be pulled or stretched.

repair of upper lip or over the lateral eyebrow,

Point C moves to point B & point D moves to point F

Burow’s triangular flap

Panthographic expansion:

variation of the advancement

instead of the flap being advanced as a rectangle, the limbs of the flap are designed at 120º with back cuts at the bottom so that it looks like an inverted tumbler.

The flap is then advanced so that the donor site closes primarily. This technique is particularly useful on the cheek and neck.

Pivot flaps:

Derives its name from the pivot point at the base of the flap as well as its arc of rotation .

When flap moves laterally into the primary defect - transposition flap

when it is rotated into the defect - rotation flap

isosceles triangle- triangulation of the defect

Pivot point

Is the axis around which the transfer takes place. Flap is designed so that the distance from the pivot point to each part of the flap before transfer is atleast equal to the distance to be expected after

transfer

pivot point is on the side of the flap away from the direction of movement of the flap.

Rotation flaps: it is semicircular flap that rotates about a pivot point to fill the defect.

Place the arc closest to the defect higher than the defect itself, to reach the most distal point of the defect

Should be 5-8 times the width of the defect

Simple rotation flap

Ideally suited on a convex surfacecheekSubmandibular area

Bilateral rotation flap

Classic form - a rectangle or near square which is raised and moved laterally into a triangular defect

In a correctly designed flap, the distance from the pivot point to A equals the distance to B and the transfer is carried without tension

sites of choice retroauricular area submandibular area perioral area for upper and lower lip reconstructions.scalp

Transposition flaps

A

B

not to rotate more than 90º

More acute –less dog ear

Methods for correction of “dog ear”

Limberg’s flap:

combination of flap rotation and transposition

Disadvantages:Excess tension

Anatomic landmark displacement because the tissue used to resurface the rhomboid defect is borrowed from single area.

Rotation pucker at Point C

Best in temple region between the eyebrows and anterior hair line

BD=DE=EFEF at angle of 60º &Parallel to one side

Dufourmental flap:

variation of a rhomboid flap

Need not convert into 60º rhomboid

Such flaps are designed for closure of square & rectangular defects.

Adv: less closure tension

Disadv: rotation puckering at point C

Double ‘Z’ rhomboid flap: by Cuono

Advantage over Limberg flap:

Excessive tension is reduced by using two flaps

anatomic landmark displacement in minimized because tissue used to resurface the rhomboid defect is borrowed from two areas.

Rotation pucker seen with Limberg flap is avoided and the resultant scar forms an elongated ‘Z’ plasty.

Bilobed flap: First by Esser in 1918popularized by Zimany

reconstruct nasal and facial defects and even full thickness cheek defects.

Tension free closure of original and secondary defects.

90º is the optimal angle between the first and second flap

Maximum distortion occurs around the flap bases and the second donor lobe closure sites

Disadvantages: Rotation pucker

‘

modification of transposition flap

Difference between transposition and S- plasty

Proximity of the flap base to the defect. It is positioned tangential to the wound margin leaving a ‘V’ shaped flap between them.

Intermediate flap created between the flap and the defect.

First by Szymanowski

S’ plasty: Schrudder

60 degree between the flap and the defect will avoid ‘dog ear’

1/5th to 1/6th higher

½ or ¾ the defectwidth

Interpolation flaps:

An interpolation flap is from a nearby, but not immediately adjacent donor Site and transposed either above or below the intervening skin to the Recipient defect

Types:

Cutaneous: requires two stage procedure but more reliableSubcutaneous Island

Ex: Median forehead flapNasolabial flap

LOCAL FLAPSBuccal fat flap / Syssarcosis :

Masticatory space

average volume of the fat is 9.6ml (8.4 to 11.9)

cover defects of up to 4cm

blood supply from branches of facial, transverse facial and internal maxillary arteries.

epithelization within 2-3 wks

Uses:Oro-antral & oro-nasal communications

reconstruction of ablative defects of the maxilla and cheek, hard and soft palate, retro-molar and pterygo-mandibular regions, as An interpositional graft in OSMF

Advantages: Easy

Donor site complications rare Disadvantages:

Facial asymmetry is a possible complication

Buccal Pad Fat

First by Gersuny Eiselberg popularized in 1901

Blood supply: lingual artery

advantages: reliance on an excellent blood supply

low morbidity

Can be used in irradiated patients

Used to cover defects in cheek, floor of the mouth, soft palate and hard palate, alveolus, oroantral fistulas and vermillion and lip reconstruction

Tongue flaps

Classification of tongue flaps:

Flaps from dorsum of tonguePosteriorly based dorsal tongue flapAnteriorly based dorsal tongue flapTransverse based dorsal tongue flap

Flaps from lingual tipPerimeter flap

Unipedicle and bipedicleDorsoventrally disposed flaps

Flaps from ventral surface of tongue

Posteriorly based dorsal tongue flap

Uses:

To repair a defect of moderate size in the retromolar trigone, tonsillar fossa of the ipsilateral side

To cover a posterior mucosal defect in cheek

minimum thickness of the flap should be 8mm

Anteriorly based dorsal tongue flap

Uses: to repair defects in the

anterior cheek,lip, anterior floor of the mouth, anterolateral floor of the mouth and palate

Transverse based dorsal tongue flap

to repair anterior floor of the mouth and lower lip

Perimeter flap

unipedicled or bipedicled

for repair of vermillion border of either lipUpper and lower lip reconstruction

Dorsoventrally disposed flaps

Flaps from ventral surface of tongue

Flaps reflected dorsally on a posterior base. Used for lining in upper lip reconstruction

Flaps reflected ventrally on a anterior base:Used for lining in lower lip reconstruction

cover defect on anterior floor of the mouth

Nasolabial flap:

Sushruta in 600 BCpopularized by Esser and Ganzer

reconstruction of facial skin defects of the upper lip, nose and cheek following extirpation of skin cancers.

superiorly based nasolabial flap- closure of the oro antral fistulae.

The bilateral inferiorly based nasolabial flap has utility in the reconstruction of the anterior defects of the floor of the mouth.

Defect in the anterior face, nose and upper lip, floor of the mouth OAF

Adv:It provides thin, local tissue for coverage of small defects. It may also be deepitheliazed at the base for one stage procedure.

Disadv:Limited donor tissueFacial scarringSecond surgical procedure might me neededDifficult to use in the floor of the mouth if the patient is not edentulousTransfer of beard in male patients

Inferiorly based Superiorly based

For reconstruction in the anterior floor of the mouth

Forehead flap: McGregor.

Blood supply superficial temporal artery and posterior auricular artery.

Hemiforehead flap or total forehead flap

Long enough to reach any part of the ipsilateral face

Butterfly shape is used to repair of defects of the posterior tongue to allow Mobility, the other wing closing the defect in the cheek. The distal extension provides cover and seal.

The narrow flap repairs central and alveolar defects

The repair following total glossectomy should be in the form of a shield

Advantages:

Near to the oral cavityHairlessTissue is firm and holds sutures wellExcellent blood supplyThin and suitable for intraoral lining

Disadvantages:

Noticeable donor defectNeed to divide the pedicle and close the oral fistula at a second operationBleeding Flap necrosis can occur

Glabellar Flap

- Axial pattern flap- Based on supra-trochlear artery

uses:-nasal reconstruction-cheek defects

disadvantages:-donor site morbidity-limited amount of tissue

Intra –oral flaps

Palatal flaps (Ashley)

Buccal advancement flaps -Rehrman’s -Moczair buccal sliding trapezoidal flap. (is slid to use the papilla of the adjacent tooth

to rotate into the defect)

Intraoral flaps (buccal)

Bipedicled flap

Ashley palatal flap

RECONSTRUCTION OF LIP

GILLIES principle

Any anatomic reconstruction should attempt to restore

‘lip with lip & cheek with cheek’

Vermillion loss replacement

Mucosal-advancement possible in forwards ,sideways or as

vascularised island Mucosa from contra-lateral lip Mucosal grafts from palate Tongue flap Mucosa from inner cheek

Lower lip reconstruction

Central defects

-Smaller defects

- V excision- W plasty- advancement (muco-muscular)

- Larger defects

-Schuchardt flap (1954)-Stair case technique(1974)-Abbe flap (1898)

Lower lip reconstruction

-Bernard modification (1853)

-Freeman modification (1958)-Webster modification (1960)-Meyer-Abul-Failat technique (1982)-Naso-labial flap-Standard fan flap-Neurovascular fan flap (Karapandzic)-Modified fan flap

Commissural defects

Abbe-Estlander flap V excision & primary closure

Upper lip reconstruction

Central defects

Smaller defects- V excision- W plasty- Peri-alar crescents & cheek advancement- Burrows Triangles (Rhomboid flap)

Upper lip reconstruction

Larger defects

- Abbe flap- Cheek advancement flap- Distant – scalp, neck, free flap

V excision & W plasty

The defect is designed in the shape of the V & primary closure is done.

The V shaped defect can be designed in the shape of W and can be closed primarily.

Schuchardt flap

40 - 50 % defects. Advancement rotational flap of cheek Barrel shaped excision extended around the

labio-mental fold to submental region on each side.

Crescents –removed.

Staircase technique ( Johanson, 1974)

Up to 60 % defects. Central & lateral defects 2-4 steps. Width -1/2 defect & height 8mm. Rectangular shaped defect ( full thickness)

Abbe flap (1898)

V shaped flap raised on a narrow pedicle containing inferior labial vessels and rotated 180o into the opposite lip

In philtral area V can be converted into W. Pedicle divided in 2 weeks.

Double ABBE Flap

Bernard modification (1853)

Tumor removed as wedge in central region Incision extend outward from commissures Full-thickness triangles removed lateral to

upper lip (advance bilateral lower cheek flaps)

Freeman modification (1958)

Only skin & subcutaneous tissue is excised rather than full-thickness lateral triangles

Incisions were extended more laterally to confirm to graceful lines of nasolabial fold.

Webster modification (1960)

‘physiologic flap’ Also hold good for

complete upper lip reconstruction

Tumor excised in quadrilateral shape

Flaps of buccal mucosa provide new vermillion.

Lower cheek flap extended as in schuchardt flap

Vertical lines may be interrupted by Z-plasty

Meyer- Abul- Failat technique (1982)

Recent modification of Bernard. 80 % -central defects Tumor excised as trapezoidal (full-thickness) Upper lip Abbe flap – peri-alar crescents Lower skin incised as schuchardt flap Mucosal lining raised inferior to stensons duct.

Standard fan flap (Gillies & Millard, 1957)

Correction of lower lip if the defects are less than 60% to 80%

Rectangular shaped defect. Incision- full thickness –lip & cheek and passes

round the angle of mouth to upper lip –then continued as a back-cut to the vicinity of the vermillion border

Totally denervated

Neurovascular Fan Flap (Karpandzic flap,1974)

Nerves & blood vessels –intact.Design reduces the amount of advancement (no

back cut)Incision-carried as in standard flap, extending till

alar base.Drawbacks:MicrostomiaCircum-oral scar.

Modified fan flap (Mc Gregor, 1983)

When resection extends till angle & when ½ lip is involved.

Defect – square. A vertical full thickness cheek flap is designed

adjacent to defect. Pedicle provides a static pivot point around

which the rectangular flap rotates. At the completion, the angle of the mouth

remains in its original position. Denervated. Can be used for total lower lip reconstruction.

Modified fan flap

Abbe-Estlander flap (Lip switch technique)

Two stage procedure Commissural defects V shaped flap with medial pedicle is raised

and rotated 180o to the defect in the opposite lip.

The pedicle becomes the new angle of the mouth

V excision & primary closure (angle)

When the defect is in the angle alone, a small lesion may be managed with a straight V excision passing directly laterally from the angle with direct closure

Peri-alar crescents & cheek advancement (Webster, 1955)

Uses nasolabial area of availabity Incision is made around the alar base,

extending along the groove between nose and cheek for approximately 1.5 cm.

Lateral to this incision a deep crescent of tissue is removed, the cheek is mobilized off the maxilla – and lip & cheek are advanced medially

Advancement closes the peri-alar defect and reduces the width of defect, on occasion closing it completely.

Peri-alar crescents & cheek advancement

Flaps used in eye reconstruction

1. Bucket handle / TRIPIER flap2. Half Tripier flap3. Superiorly based naso-labial flap4. Forehead flap

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