LOCAL FLAPS, RECONSTRUCTION

1. Dr.Ajay Manickam
Junior Resident ENT & Head Neck Surgery
R.G. Kar Medical College

2.  Simple injury/
surgical
 Repairable ….???
 Many defects can be
directly closed if
small & enough
tissue available
locally

3.  If the defect becomes larger......
 Ablative cancer surgery

4.  Larger defects
1. Grafts
2. Local flaps
3. Pedicled flaps
4. Free flaps
5. Combination

5.  These are parallel to natural skin wrinkles
 Surgical incision placed parallely
 Least tension as skin contraction is at its
greatest

6.  Ellipse three times as long as its wide
 If ellipse is too short dog ear deformity

7.  Eye lid
 Helical rims of ear
 Lips
Not only skin – composite
tissue - closed in layers
1. Lips – mucosa, orbicularis
oris, skin
2. Ear – cartilage and skin
both anterior & posterior
3. Eyelids – conjunctiva,
tarsal plate, orbicularis
oculi and skin

8.  1817 – Sir Astley Cooper
 1871 – Lawson – elective
full thickness graft
 1872- Ollier – split skin
graft
 1929 – Brown & Blair –
differentiated full
thickness and split
thickness skin grafts
advantages &
disadvantages

9.  Split thickness – part
of dermis
 Full thickness – all of
dermis
 Composite – skin &
another tissue

10. Graft origin
1. Auto graft – same person
2. Isograft – identical twin
3. Allograft –same species
4. Xenograft – diff species
5. Alloplastic - synthetic

11. SPLITTHICKNESS
 More likely to take
 Contracts more
 Pigment abnormal
 Limited sensory recovery
FULLTHICKNESS
 High risk for graft loss
 Less
 Better colour match
 Better sensory recovery

12.  Imbibition – plasma – 48 hours
 Inosculation - Graft revascularization – graft
anastomosis
 Neovascularization – atleast a month

13.  Relies on skin elasticity
 Modified in a number of ways – burow
triangle
 Simple
Rintalla flap
 Modified
V-Y flap (axial flap)
 Bipedicled flap
Tripier flap

14.  Simple flap lesions in nasal tip

15.  Kind of advancement flap modified

16.  Lower eyelid reconstruction
 Bipedicled flap – receives blood supply from
both ends

17.  Moves around a pivot point – transposition
flap or rotation flap
 Rhomboid flaps – transposition flaps – donor
defect closed directly
 Flag or banner flaps – transposition flaps –
donor site closed directly
 Bilobed flaps – two transposition flaps

18.  Pivot flap
 Rhomboid needs to be 120 & 60 degree
 So that scar becomes parallel

19.  Pivot flap – axial
transposition flap
 Flap lengh 3 times the
length of base
 Primary defect closed
directly

20.  Two transposition flaps
 Defects in tip of nose

21.  Large flaps that rotate into primary
defect
 Flap circumference should be atleast 8
times
 Repairs defect of scalp or cheek

23.  Based on named arterial pedicle runs within
skin superficial to the underlying muscle layer
parallel to the skin overlying

24. Forehead flap
Nasolabial flap
Submental island flap
Facial artery myomucosal flap
Temporo parietal fascial flap

25.  Mc gregor
 Cutaneous axial
median forehead
flap – supra
trochlear artery
 Cheek , External
nose
 Forehead flap
contracts
excessively

26.  Susruta 600 Bc – defects around face – anterior oral
cavity
 Based on distal branches of the facial artery
 Extremely reliable based inferiorly
 Anterior floor of mouth , gingiva – simple & effective

27.  Reconstruction of
facial skin or intra
oral lining
 Supplied by facial
artery branches
 Can be tunneled
under mandible
through submental
and submandibular
space for oral
reconstruction /
tranposed onto face
for soft tissue
coverage

28.  Pribaz
 Oral mucosa
and buccinator
muscle
branches of
facial artery
 Small mucosal
defects of the
oral cavity,
mucosa of lip,
tongue, palate

29.  Golovine
 Free facial flap for
reconstruction of head &
neck
 Superficial temporal
artery – external carotid
artery
 Teardrop, elliptical shape
 Orbital reconstruction,
auricular reconstruction,
palate reconstruction,
buccal mucosal
reconstruction.

30.  Deltopectoral flap
 Myocutaneous and muscle only axial distant
flaps
1. Pectoralis major
2. Lattissimus dorsi
3. Sternomastoid
4. Trapezius
5. Platysma

31.  Bakamjian and littlewood 1964
 Upper 3 perforating internal mammary artery
branches
 Single stage reconstruction – anterior neck skin
 Two stage reconstruction – over neck structures to
resurface distant sites

32.  Ariyan described it in 1970
 pectoral branch of acromio thoracic artery
 Large skin territory – can be harvested in
supine position

33.  Local flaps & regional flaps plays an
important role in head & neck reconstruction
 When using local flaps in the head & neck
preoperative planning of the flap is prime
importance
 Grafts are reliant on blood supply of recipient
site but flaps takes their blood supply with
them