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Principles of Local, Regional d Mi V l fl iand Micro-Vascular flaps in H&N Reconstruction&
Khalid Hussain AL-QahtaniQMD,MSc,FRCS(c)Assistant ProfessorAssistant Professor
Consultant of OtolaryngologyAd H d & N k O lAdvance Head & Neck Oncology ,
Thyroid & Parathyroid,Microvascular Reconstruction,and Skull Base Surgery
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Reconstructive ladderReconstructive ladder
• Primary closurePrimary closure• Heal by secondary intention
Ski fti• Skin grafting• Local flaps• Regional flaps• Free tissue transferFree tissue transfer
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Reconstructive ladderReconstructive ladder
• Primary closurePrimary closure• Heal by secondary intention
Ski fti• Skin grafting• Local flaps• Regional flaps• Free tissue transferFree tissue transfer
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Local FlapsLocal Flaps
• Advantages:Advantages:– Use of local tissue w/ better donor site match– One stage (usually)One stage (usually)– Low donor site morbidity
• Disadvantages:Disadvantages:– Random pattern blood supply w/ limited length– Distortion surrounding structures w/ donor siteDistortion surrounding structures w/ donor site
closure in some cases– Not enough bulk for deep defectsg p
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Local FlapsLocal Flaps– Rotational
– Transpositionp• Rhomboid, Duformental, Bilobed
– Interpolated
– Advancement
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RotationalRotational• Triangular Defect g
Adjacent to Flap• Rotates in Arc about
Pivot Point – curvilinearPivot Point curvilinear movement
• Flap Shortens as RotatedB ’ T i l t B• Burow’s Triangle at Base of Flap
• Advantage – allows gclosure of large lesion by recruiting lax skin over a greater distanceg
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TranspositionRhomboid Flap
• Classic rhomboid flap is designed to fit aClassic rhomboid flap is designed to fit a rhombic defect with two 60-degree and two 120-degree anglestwo 120 degree angles
• For each rhomboid defect, four possible flap orientations may be used for closureflap orientations may be used for closure
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Rhomboid FlapRhomboid Flap
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Dufourmental FlapDufourmental Flap• Variant of the rhomboid. • For defects that don’t correspond to 60, 120-degree p , g
dimensions. • Imaginary lines extended from diameter and on side. • Angle created by these two line then bisected by a line of• Angle created by these two line then bisected by a line of
same length as a side of defect. • Back cut is then made parallel to long axis. Flap then
t t drotated
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Bilobed flapBilobed flap
• Double rotation flap Work best for noseWork best for noseDouble rotation flap in tandem with a single pedicle
Work best for nose Work best for nose where tissue where tissue borrowed from paraborrowed from parasingle pedicle.
• Distributes tension over two flaps;
borrowed from para borrowed from para nasal area. nasal area.
over two flaps; each rotated about 90 deg90-deg.
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Transposition FlapsTransposition Flaps
Bilobed FlapBilobed Flap
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Transposition Flaps
Dorsal Nasal Flap (of Rieger)
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Interpolated FlapInterpolated Flap
MELOLABIAL FLAPS
Superiorly Based Inferiorly Based
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Interpolated FlapsInterpolated Flaps
Paramedian Forehead Flap
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Advancement FlapsAdvancement Flaps
• Linear MovementLinear Movement
B ’ T i l t B• Burow’s Triangles at Base
• Length:Width Ratio 2:1
• Good for Forehead and Brow
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Advancement FlapsAdvancement Flaps
Double Advancement
Single Advancement
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Advancement FlapsAdvancement Flaps
V Y Advancement flapV – Y Advancement flap
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Reconstructive ladderReconstructive ladder
• Primary closurePrimary closure• Heal by secondary intention
Ski fti• Skin grafting• Local flaps• Regional flaps• Free tissue transferFree tissue transfer
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REGIONAL FLAPSREGIONAL FLAPS
• Advantages/Uses:– Bulky– Quick and easy to
• Disadvantages:– BulkyQuick and easy to
harvest– Single stage– Minimal donor site
– Downward Pull of Flap– Atrophy
morbidity– Required one surgical
team
– Arc of Rotation Limiting– Distal Flap Necrosis
– Large Tongue Base/TG Defects
– Carotid Coverage
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REGIONAL FLAPSREGIONAL FLAPS
• Deltopectoral flapDeltopectoral flap• Pectoralis major musculocutaneous flap
(PMMF)(PMMF)• Latissimus dorsi flap (LDMF)• Sternocleidomastoid flap (SCMF)• Trapezius flap• Trapezius flap• Serratus anterior flap
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Deltopectoral flapDeltopectoral flap
• Three main vascular contributions:1st four perforating branches of–1st four perforating branches of internal mammary arteryTh i l t li–Thoracoacromial artery supplies upper midportion of deltopectoral flflap
–Perforating vessels from deltoid muscle
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Pectoralis major musculocutaneous flap (PMMF)
-Thoracoacromial major pedicle
S d t l-Secondary segmental parasternal perforators from i t linternal mammary artery
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Latissimus dorsi flap (LDMF)Th d l t b hThoracodorsal artery branches
• Advantages:L i
• Disadvantages:P iti i–Large size
–Wide –Positioning–Intricate
excursion–Donor site
dissection–Complexity of
morbidity negligible
p ytunneling
g g
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Sternocleidomastoid flap (SCMF)Sternocleidomastoid flap (SCMF)• Moderately useful
P ti l fl l i 50% f ti t• Partial flap loss in 50% of patients• Most reliable when based on the
i it l t d t i d kioccipital artery and retained skin bridgeA f t ti d t i d b th• Arc of rotation determined by the course of the spinal accessory nerve within the musclewithin the muscle
• Improved vascularity with preservation of superior thyroid artery and veinof superior thyroid artery and vein
• Can include clavicle in the flap
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Trapezius flapTrapezius flap
–Three main vascular sources:»Transverse cervical artery (TCA)»Transverse cervical artery (TCA)»Dorsal scapular artery (DSA)
P t i i t t l t i l»Posterior intercostal arterial branches
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Serratus anterior flapSerratus anterior flap
• Fasciocutaneous extension ofFasciocutaneous extension of serratus anterior muscle from 6th to 8th
ribsribs• Long pedicle 15-20 cm
Rib b i l d d• Rib can be included• Latissimus dorsi flap can be included
in same pedicle–Can cover large soft tissue defectsg
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Reconstructive ladderReconstructive ladder
• Primary closurePrimary closure• Heal by secondary intention
Ski fti• Skin grafting• Local flaps• Regional flaps• Free tissue transferFree tissue transfer
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Free tissue transferFree tissue transfer– High success ratesg– Superior aesthetic and functional results– Allows for reconstruction of defects that could not be
repaired in other waysrepaired in other ways– Advantages
• Vascular pedicle anastomosed to most appropriate recipient• Ease of flap insetting and orientation• Closure of massive defects feasible• Provide epithelium, subcutaneous tissue, muscle, nerve, and
bbone• Option of restoration of sensation
– Sensory nerve harvest
% f– 95% flap survival– Complication rate approximately 20%
• Salivary fistula 12%
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Free tissue transferFree tissue transfer
• Fascial and Fasciocutaneous FlapsFascial and Fasciocutaneous Flaps
M l d M l t Fl• Muscle and Musculocutaneous Flaps
• Composite Free Flaps
• Visceral Flaps
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Fascial and Fasciocutaneous FlapsFascial and Fasciocutaneous Flaps
• 1 Radial forearm1. Radial forearm
2 A t L t l thi h• 2. Antro Lateral thigh
• 3. Lateral arm
• 4. Temporoparietal fascial
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Radial Forearm Free Flap
• “work horse of the head and neck surgeon”
• Arterial source– Radial artery
• Venous Source– Paired vena
commitantes and/or cephalic veincephalic vein
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Radial Forearm Free FlapRadial Forearm Free Flap
• Advantages: • Disadvantages:g– Thin, pliable skin with long,
large pedicle– Easy positioning
g– Loss of hand– Poorly aesthetic donor site
Requires skin graftEasy positioning– Potential for sensate flap– Potential for unusual
shapes
– Requires skin graft– Potential for pathologic
fracturesL f h d f tishapes
– Potential for vascularized boneE f ti
– Loss of hand function
– Ease of preoperative evaluation
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Superficial palmar arch, Allen's test
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Anterolateral Thigh FlapAnterolateral Thigh Flap
• Thick flap based on the 3rd perforator ofThick flap based on the 3 perforator of the profunda femoris system
• Potential for large flaps (25 X 14cm)
• Reinnervation via lateral femoral cut. nerve
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Anterolateral Thigh FlapAnterolateral Thigh Flap
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Muscle and Musculocutaneous FlFlaps
• 1 Rectus Abdominis1. Rectus Abdominis
2 L ti i D i• 2. Latissimus Dorsi
• 3. Gracilis Flap
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Rectus Abdominus Free Flap
• Arterial supply based on deep inferior epigastric artery
• Venous supply form vena commitantes joining external iliacjoining external iliac vein
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Rectus Abdominus Free FlapRectus Abdominus Free Flap
• Advantages: • Disadvantages:g– Easy positioning and
harvest– Constant anatomy
Disadvantages:– Often bulky– No sensation potentialConstant anatomy
– Long (8-10 cm) and large caliber vessel (avg 3.4 mm)Donor site closed primarily
p– Potential for hernia
formation if dissection below arcuate line– Donor site closed primarily
– Large flap obtained– Anterior rectus sheath
d bl
below arcuate line
durable
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Latissimus Dorsi Free Flap
• Arterial supply based on th d l tthoracodorsal artery
• Venous drainage from thoracodorsalfrom thoracodorsal vein
• Motor nerve innervation potential with thoracodorsal nervenerve
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Latissimus Dorsi Free FlapLatissimus Dorsi Free Flap
• Advantages: • Disadvantages:g– Large flap with long pedicle
( artery 2-3 mm, vein 3-5 mm, length: 7-10 cm)
Disadvantages:– Difficult positioning
and two team harvest– 2nd largest skin paddle– Possibility for “axillary
megaflap”M lti l ki ddl
• 30-45% LD
– Postoperative seroma formation– Multiple skin paddles
– Low donor site morbidity– Possibility of muscle
reinnervation via
formation– Bulky flap
• Unable to tubereinnervation via thoracodorsal nerve
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Composite Free FlapsComposite Free Flaps
• 1 Fibular osteocutaneous flap• 1. Fibular osteocutaneous flap• 2. Osteocutaneous iliac crest flap
3 O f• 3. Osteomusculoctaneous iliac crest flap• 4. Fasciocutaneous scapular and
parascapular flap• 5. Osteofasciocutaneous scapular and p
parascapular flap
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Fibular Free FlapFibular Free Flap
• Arterial supply –Arterial supply peroneal artery
• Venous supply – venaVenous supply vena commitantes
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Fibular Free FlapFibular Free Flap
• Advantages: • Disadvantages:g– Longest and strongest
bone stock (25 cm of bone)– Pedicle 12 cm
g– High incidence of
peripheral vascular disease– Small cutaneous paddle
– Can be a sensate flap• Lateral sural n.
– Low donor site morbidity
Small cutaneous paddle– Decreased ankle strength
and toe flexionSmall risk chronic ankle– Easy positioning
– Excellent periosteal blood supply (contouring)
– Small risk chronic ankle pain
– Requires invasive study for preop evaluation– Support osseointegrated
implantspreop. evaluation
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• Fibula is outlinedSki ddl t d j ti f iddl• Skin paddle centered over junction of middle and distal third to encompass dominant septoperforatorsseptoperforators
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•Leave 6 cm of proximal and distal fibulaea e 6 c o p o a a d d sta bu a
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Scapular/Parascapular Free Flap• Arterial supplyArterial supply
– Circumflex scapular• Venous SupplyVenous Supply
– Vena commitantes
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Scapular/Parascapular Free FlapScapular/Parascapular Free Flap
• Advantages: • Disadvantages:Advantages:– Large skin paddle– Easy to harvest
Disadvantages:– Thick skin– Difficult positioningy
– Low donor site morbidity (closes primarily)
p g
primarily)– Availability for bone
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Visceral FlapsVisceral Flaps
• 1 Jejunum1. Jejunum
2 O t• 2. Omentum
• 3. Gastroomentum
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Functional ObjectivesFunctional Objectives
– Restore sensation– Maintain oral continenceMaintain oral continence– Facilitate swallowing– Prevent aspirationp– Preserve speech– Protect vital structures– Achieve primary wound healing– Obtain cosmesis
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Planning and TechniquePlanning and Technique
• Patient Factors:Patient Factors:– Age– Malnutrition
– Peripheral Vascular DiseaseMalnutrition
– Diabetes Mellitus– Hypertension
– Hyperlipidemia– Smoking
Immunosuppression– Immunosuppression– XRT
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Planning and TechniquePlanning and Technique
• Surgical Factors:Surgical Factors:– Rough handling
– Damage to axial vessels
– Tension
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Characteristics of “ideal” free flaps f H & N ifor H & N reconstruction
– Length and caliber of vessels adequateg q
– Innervation with sensory or motor nerves f iblfeasible
Functional recovery of resected structure(s)– Functional recovery of resected structure(s) facilitated
– Cosmetic potential excellent
– Donor site morbidity minimal
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Recipient vesselsRecipient vessels
• Arteries– Superficial temporal system
scalp and upper face–scalp and upper face– Facial artery—midface and
cervical region ( h l i )(atherosclerosis common)
– Superior thyroid or lingual artery—lower cervical regiony g
– Other: thyrocervical trunk, external carotid, common carotidcarotid
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Recipient vesselsRecipient vessels
• Veins– External jugular– Branches of internal jugular
(common facial)– Internal jugular– Retrograde (superficial
temporal thyroid)temporal, thyroid)– Transverse cervical, occipital
(very small)(very small)
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Potential ProblemsPotential Problems
• Donor Site:Donor Site:– Hemorrhage
Wound breakdown– Wound breakdown– Nerve damage
Scarring– Scarring– Functional deficits
C ti d f iti– Cosmetic deformities
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Potential ProblemsPotential Problems
• Recipient Site:Recipient Site:– Immediate
– Early
– Late
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Immediate ComplicationsImmediate Complications
• Anastomotic leakAnastomotic leak
A t ti f il• Anastomotic failure
• Flap compression
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Anastomotic failureAnastomotic failure• 93-95% success rate expected
• Venous thrombosis:Arterial thrombosis 4:1, ateriovenous loop, tobacco use significant factors
• Venous occlusion, Delayed reconstruction, Hematoma significant factors in breast free tissue grecon.
• Age, prior irradiation, DM (well-controlled), method g , p , ( ),of anastomosis, timing, vein graft, and specific arteries/veins not felt to contribute to failure rate
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Early ComplicationsEarly Complications
• Anastomotic occlucionAnastomotic occlucion• Vascular thrombosis
Fl d• Flap edema• Secondary hemorrhage• Infection
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Late ComplicationsLate Complications
• InfectionInfection• Dehiscence
Fi t l• Fistula• Poor cosmesis• Loss of function
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Viability = PerfusionViability Perfusion
• Problems outside the vessel wallProblems outside the vessel wall
P bl ith th l ll• Problems with the vessel wall
• Problems within the vessel wall
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External to Vessel WallExternal to Vessel Wall
• mechanical compression from neighboringmechanical compression from neighboring anatomic structures:
Tight skin flaps– Tight skin flaps
Edema– Edema
H t– Hematoma
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Intrinsic to Vessel WallIntrinsic to Vessel Wall
• Disruption of endotheliumDisruption of endothelium– Release of thromboplastin and formation of
thrombusthrombus
• Vessel wall spasm• Vessel wall spasm– Restricts blood flow
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Treatement for anastomotic failureTreatement for anastomotic failure
• Revision of anastomoses
• Exploration of woundp
• Streptokinase, ASA,Heparinp , , p
• Wound care