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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
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
Ariyan 1970
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Anatomy
Origin Vessels Function
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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.
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vessels
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
Superior and lateral thoracic arteries - additional pedicles
Overlying skin additionally supplied by intercostal perforators
3 subunits each with its own vascular & motor supply
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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.
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
Types
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
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
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PECTORALIS MAJOR MYOCUTANEOUS FLAP
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
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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 .
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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.
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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
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Methods to Achieve Two Epithelial Surfaces for Reconstruction of Compound Defects
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“Gemini” flaps
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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
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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
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TEMPORALIS MUSCLE FLAP
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
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TEMPORALIS MUSCLE 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
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TEMPORALIS MUSCLE FLAP
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
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TEMPORALIS MUSCLE FLAP
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
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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.
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TEMPORALIS MUSCLE FLAP
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
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
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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
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
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
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
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
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STERNOCLEDOMASTOID MYOCUTANEOUS FLAP
Inferior blood supply Branches of superior
thyroid artery are noted to enter the anterior aspect of muscle at the level of carotid bifurcation
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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.
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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
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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
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DELTOPECTORAL FLAP
ADVANTAGES High biologic
dependability Readily accessible Arc of rotation 45 - 135 May be used in male,
female & children Hairless skin
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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
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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
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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
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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
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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
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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
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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
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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
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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
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LATISSIMUS DORSI MYOCUTANEOUS FLAP
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
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LATISSIMUS DORSI MYOCUTANEOUS FLAP
ADVANTAGES Size – largest flap in
the body Flap location Arc of rotation - 180 Large, reliable
unicentric neurovascular pedicle
Donor area 90% success rate
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LATISSIMUS DORSI MYOCUTANEOUS FLAP
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
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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
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Thank you
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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
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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
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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
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