COCLIA 99:Grafts and Flaps in

Head & Neck Surgery

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Skin Overview

• Epidermis– stratified squamous

epithelium– no blood vessels:

receives nutrients by diffusion

Skin Overview

• Dermis– 2 layers: papillary &

reticular– reticular dermis: larger

blood vessels, epidermal appendages

– intradermal epithelial structures (sebaceous & sweat glands, hair follicles) are lined with epithelial cells with the potential for division and differentiation

STSG vs. FTSG

• STSG– Entire epidermis and a dermal component of variable thickness

• thin (0.005-0.012 inches)• intermediate (0.012-0.018 inches)• thick (0.018-0.030 inches)

– Thicker STSG requires more favorable conditions because of the greater amount of tissue requiring revascularization

– Much broader range of application than FTSG

• FTSG– Entire epidermis and dermis– Retains more characteristics of normal skin (color, texture, thickness) – Undergoes less contraction while healing– Limited to relatively small, uncontaminated, well-vascularized wounds

• Describe the three stages of survival for a STSG…

The Three Stages

• 3 stages– Imbibition (“to drink”): absorbs nutrients from

underlying recipient bed; initial 2-3 days– Inosculation (“to kiss”): blood vessels in the skin

graft grow to meet the blood vessels in the recipient bed; days 4-6

– Neovascularization: new blood vessels form bridging the graft to the recipient bed; days 6-7

• What factors are important in graft survival?

Survival Factors

• Good– Nutrition and oxygenation delivery– Removal of waste products

• Bad– Mobility of graft– Infection – Fluid collection beneath graft

• How are STSG and FTSG harvested?

STSG Harvesting

• Dermatome– Uniform thickness (set width and

thickness)

– Fast

– Must be familiar with equipment

– 15 blade scalpel simulates 0.015 inches

• Free hand with scalpel– Variable thickness

– Irregular edges

FTSG Harvesting

• Free hand with scalpel

• Enlarge by 3-5%– Compensates for immediate primary contraction

• MUST trim off all residual adipose tissue– Relatively avascular

• What is the point of meshing?

STSG Meshing

• Allows expansion up to 9 times the donor site

• Purposes– Cover large surface area– Recipient site is irregularly

contoured

• The larger the size mesh the more fragile the graft

• How is “pie-crusting” different from meshing?

Pie-Crusting

• Multiple stab wounds through the graft– Made with scalpel or scissors

• Allows egress of wound fluid

• Does not expand surface area

• How can you manage the donor graft site (STSG and FTSG)?

STSG Donor Site

• Options– Semi-occlusive dressings (Op-Site, Tegaderm)

• Shown to be superior: transparent, sterile, moist

– Semi-open dressings (Vaseline gauze, Xeroform)• Might damage new fragile epithelial layer when

removed

– No dressing

• Healing – begins within 24 hours of harvesting– directly proportional to the number of epithelial appendages– inversely proportional to the thickness of graft

FTSG Donor Site

• Usually closed primarily

• Can cover with STSG (rarely done)

Flap Classification

• by arrangement of their blood supply– random, arterial

• by the method of transfer– advancement, pivotal, hinged

• by configuration– rhomboid, bilobed

• by location – local, regional, distant

• What is the difference between random and axial pattern flaps?

• Give examples of each type

Random Pattern Flaps

• Do not have named arterial or venous vessels

• Rely on blood flow through dermal and subdermal plexus

• Eventually connects with perforating vessels (neovascularization)

• Limited in length and width

Random Pattern Flaps

• Advancement flap

• Rotation advancement flap

• Rhomboid flap

Axial Pattern Flaps

• Rely on blood supply from named direct cutaneous arteries and veins – Runs along longitudinal flap axis – Runs in subcutaneous tissue superficial to muscle

• Flap blood supply secure for at least length of blood vessels

• Can further lengthen flap with tacking on random pattern flap at distal end

Axial Pattern Flaps

• Nasolabial flap – angular

• Median or paramedian forehead flaps– supratrochlear

• Lateral forehead flap– superficial temporal

• What is a Burow’s triangle?

Burow’s Triangle

• A triangle of skin can be excised from the base of a flap to aid in closure

• Effective for correcting dog ears

Flap Classification

• by arrangement of their blood supply– random, arterial

• by the method of transfer– advancement, pivotal, hinged

• by configuration– rhomboid, bilobed

• by location – local, regional, distant

• Discuss these flaps:– advancement– transposition – rotation– interpolation

Advancement Flap

• The flap’s leading edge moves into the defect

• Flap movement is longitudinal rather than rotational

• Burow’s triangles can be excised from the base of the flap to aid in closure

Transposition Flap

• Movement of adjacent skin from an area of excess to the area of deficiency

• Moves laterally about a pivot point into an adjacent defect

• Usually rectangular configuration

• Donor site can be closed primarily

• Examples: rhomboid flap, Z-plasty

Rotation Flap

• Moves adjacent tissue rotated in an arc around a pivot point

• Relies on perforators that course superficially to supply the dermal and subdermal plexuses

• Length of the flap's perimeter should be at least 4 times the width of the defect

Interpolation Flaps

• Rotates about a pivot point into a nearby but not adjacent defect

• Usually linear configuration• Pedicle passes above or

below a skin bridge• Base is located at some

distance from the defect• Flap is subsequently

detached in a second surgical procedure

Flap Classification

• by arrangement of their blood supply– random, arterial

• by the method of transfer– advancement, pivotal, hinged

• by configuration– rhomboid, bilobed

• by location – local, regional, distant

Rhomboid Flap

• Pedicle width controls the amount of circulation within the dermal-subdermal plexus

• Closed with a choice of 4 different flaps

• Line of tension is greatest at donor site

• Point of greatest tension is at “C”

Rhomboid Flap

Bilobed Flap

• Each lobe of the flap is tethered to a cutaneous pedicle

• Two important variables: flap length, flap angle

• 1st lobe is designed to be equal to the width of the original defect

• 2nd lobe is constructed with an elliptical tip to facilitate side-to-side closure of the tertiary defect

• What is the safe length-to-width ratio of a flap?

Length-to-Width Ratio

• 3:1 used as a rough guideline only• Face is very vascular• Random pattern pedicled flap blood supply originates

from nearest cutaneous arterial perforator at the base• Surviving length: determined by the perfusion

pressure of the feeding vessels and the intravascular resistance

• Increasing the width of a flap’s base does not increase the survivng length of the flap

Flap Classification

• by arrangement of their blood supply– random, arterial

• by the method of transfer– advancement, pivotal, hinged

• by configuration– rhomboid, bilobed

• by location – local, regional, distant

• Describe some common regional flaps used in head and neck reconstruction

• Give the blood supply for each

Common Regional Flaps

• Pectoralis major

• Deltopectoral

• Latissimus dorsi

Pectoralis Major

• Myocutaneous flap• Pectoral branch of the

thoracoacromial artery • Advantages: bulk,

reliability, one-stage procedure

• Disadvantages: bulk, insensate, tend to tether adjacent mobile structures

• Can reach as high as the nasopharynx

Deltopectoral

• Faciocutaneous flap

• Perforating branches of mainly the first four intercostal arteries

• Skin graft is needed to reconstruct part of the donor site

Latissimus Dorsi

• Thoracodorsal artery

• Useful to line large defects (sizable, bulk)

• Disadvantage: potential for kinking of the feeding vessels at the shoulder

Nasolabial Fold Reconstruction

• Maintain nasolabial crease

• Do not distort lip or nasal alae

• Rhomboid flap

• Bilobed flap

• Advancement flap

Nasolabial Flap

• Medial cheek tissue located lateral to the nasolabial crease

• Random blood supply from branches of the facial artery

• Based either superiorly or inferiorly

• Superiorly based: lower two thirds of the nose (nasal dorsum, alae, tip)

• Inferiorly based: upper lip, floor of nose, columella

Medial Canthus Reconstruction

• Rhomboid flap

• Bilobed flap

• Modified glabellar flap

• Eyelid myocutaneous flap

Indian Forehead Flap

• Midline forehead flap

• Blood supply: paired supratrochlear vessels

• Incision: hairline to nasofrontal angle, penetrated to periosteum

• 3 weeks: pedicle divided