Flaps in

otolaryngologyBALASUBRAMANIAN THIAGARAJAN

Ideal flap

"when a part of one's person is lost, it

should be replaced in kind, bone for

bone, muscle for muscle, hairless skin

for hairless skin, an eye for an eye, a tooth for a tooth."

Ralph Millard

Introduction

The term "flap" first originated during the 16th century from the Dutch

word "flappe" meaning a structure that hung broad and loose,

fastened only on one side.

Flaps are usually used to repair structural defects following surgery i.e.

for malignant conditions of head and neck.

History

600 B.C. Susrutha performed nasal reconstruction using cheek flap

1440 A.D. Forehead rhinoplasty (India).

Pivotal flaps was preferred during early days. This involves rotation

of the flap around its vascular pedicle.

Advancement flap (French surgeons). This involves transfer of skin

from adjacent area without rotation.

History (contd)

McGregor - Who introduced the forehead flap during 1963

Bakamjian - Who introduced the deltopectoral flap during 1965

Ariyan - Who pioneered the Pectoralis major myocutaneous flap in

1979

Daniel & Taylor - Who pioneered the free flap in 1973

Flap surgery - Principles

Principle I : Replace like with like. This will go a long way in Camouflaging the surgical defect.

Principle II: Reconstruction should be thought in terms of units. It was Millard who divided the human body into 7 main parts (head, neck, body and extremities). He subdivided each of these parts into units. Each unit is further divided into subunits. These units and subunits should be considered and studied before the process of reconstruction is begun.

The most important aspect of these units are their borders. These borders include creases, margins and hair lines. Adherence to these borders during reconstruction is very important. It is always better to convert a partial unit defect into a whole unit defect before grafting. This will enable better consmesis.

Principle III: There should be a pattern and a fall back option always at hand.

Principle IV: The graft should be sutured without any tension. The donor area should not suffer excessive tissue loss.

Definition of flap / graft

Flap is a unit of tissue that can be transferred from one site (donor) to another (recipient site) while maintaining its own blood supply. Flap is transferred with its

blood supply intact, whereas a graft is a transfer of tissue without its own blood

supply. Survival of graft depends entirely on the blood supply from the recipient

site.

Facial incision

Classification of flap

Flaps may be classified according to their:

1. Blood supply

2. Tissue to be transferred

3. Location of donor site

Blood supply

For any graft tissue to survive blood supply is a must. If the

blood supply is derived from unnamed blood vessels then it is

termed as "Random flap". Many local skin flaps fall in this

category. If blood supply to the flap is derived from named

vessel / vessels it is referred to as "Axial flap". Most muscle flaps

fall in this category

Types of axial flaps

Type I Axial flap: Has only one vascular pedicle e.g. Facia lata

Type II Axial flap: Has blood supply served by dominant and Minor

pedicles e.g. Gracilis flap

Type III Axial flap: Has blood supply served by two dominant

pedicles e.g. Gluteus maximus flap

Type IV Axial flap: Has blood supply via segmental blood vessels

e.g. Sartorious flap

Type V Axial flap: Derives blood supply from one dominant pedicle

and many segmental blood vessels e.g. Latissmus dorsi flap

Axial flaps (contd)

Classification – according to tissue

to be transferred

Skin

Fascia

Muscle

Bone

Viscera (colon, small intestine, omentum)

Composite – Fasciocutaneous, myocutaneous, Tendocutaneous

and osseocutaneous flaps

Classification - Location

Tissue could be transferred from an area adjacent to the defect. This

type of flap is known as local flap. They may be further subclassified

depending on its geometric design.

Pivotal flaps: are also known as geometric flaps. They include

rotation, transposition, and interpolation types.

Advancement flaps: This type include single pedicle / Bipedicle / V-

Y flaps

Tissue transferred from non contiguous site i.e. distant flaps. These

flaps could either be pedicled or free flaps. The pedicled flaps are

still attached to their blood supply, while free flaps are totally severed from their blood supply and are reattached to vessels at

the recipient site (microanastomosis).

Advancement flap (History)

Celsus of ancient Rome as the first to perform advancement flap

French surgeons in 1800 popularized this flap as sliding flaps

Used to cover skin defects close to an area of skin laxity

Initially it was commonly used in forehead, scalp, eyelid and upper

lip areas

Vascularity of advancement flaps

Critical blood supply – 1-2 ml / min / 100g of tissue is adequate.

Advancement flaps depend on random blood supply arising from

anastomoses within subdermal / dermal plexus

Flap length : width ratio in head and neck region is 4:1

Types of advancement flaps

Monopedicled flap

Bipedicled flap

V – Y flaps

Monopedicle flap

Usually rectangular and moves

forwards

Redundant tissue at the base of

the flap can be reduced by

creating Burow triangle

Bipedicle flap

Incisions are made on each side

of flap

These are random flaps (obtain

blood supply from capillaries

rather than named arteries

Commonly these flaps are

generally skin

V – Y Flap

V – shaped incision

Broad base of V is advanced into

the defect

Resultant defect is closed (Y

shaped closure)

If long flaps are needed delay

phenomenon can be made use

of. After raising the flap 1-3 weeks

time is given before advancing it.

Delay phenomenon works

because the choked blood vessels

open up if time is given.

Glabellar flap

Best suited for reconstruction of

defects involving the bridge or

upper half of the nose.

Axial flap

Blood supply – supratrochlear

artery / dorsal nasal branches

Upper portion of incision should be

carried up to the periosteum

Mobilisation around naso frontal

angle should be carried out by

blunt dissection. Supra trochlear

vessels should be preserved

Sliding rotation degloving nasal

flap

Helps to cover the lower half of

the front of the nasal cavity

The degloving flap is outlined in

such a fashion that the incision to

mobilize the flap is on the right-

hand side along the nasolabial

fold going up to the glabellar

region.

The apex of the flap is in the

midline, with symmetrical right and

left limbs

Blood supply is from the nasolabial

artery

Nasolabial flap

Axial flap

Blood supply – Nasolabial artery

Width to length ratio – 1:5

Useful in covering defects over

lower portion of nose and ala of

the nose

Inferiorly based nasolabial flap

Based on nasolabial artery

Logically suited because of its

blood supply

Suited for lateral aspect of lower

portion of nose reconstruction

Even though the defect to be

filled is circular its apex is made

triangular to facilitate primary

closure of donor site

Flap should be superficial to the

underlying facial musculature

Rhomboid flap

Geometric flap

Described by Limberg

Useful in pts with lax skin

Blood supply is from subdermal

plexus

Length to width ratio should not

exceed 2:1

Useful in reconstruction of lateral

nasal defects and cheek defects

Mustardé Advancement Rotation

Cheek Flap

1. Defects of infraorbital region / medial

part of cheek can be closed using

this cheek flap

2. Blood supply is from the terminal

branches of facial artery

3. Flap should be mobilized up to the

angle of the mandible to avoid

unnecessary tension to the flap

4. Superior aspect of incision is towards

the temple – prevents drooping of

lateral canthus of eye

Bilobed flap

Random flap

Can be used anywhere in the

body

Effective in covering defects over

zygoma and buccinators

Works best in pts with lax skin

First lobe fills the defect while the

second lobe fills up the defect

created by the first lobe

Cervical flap

Regional cutaneous flap

Useful to cover lower half of the

face and upper neck

Vascularity from subdermal

arterical plexus

Length to width ratio not to

exceed 3:1

Neck dissection if need be can be

performed via the same incision

Flap is to be elevated superficial to

platysma

Myocutaneous flaps

Includes skin, subcutaneous tissues

and muscles

Useful in sealing large defects

Classified according to their

vascular patterns and locations

1. Pectoralis major myocutaneous

flap

2. Deltopectoral flap

3. Radial forearm free flap

4. Temporalis flap

Pectoralis major myocutaneous

flap

Myocutaneous flap

Pectoral branch of

acromiothoracic artery

Enters the muscle just below

clavicle at the junction of middle

and outer thirds

Useful in reconstruction of oral

cavity, oropharynx, hypopharynx

and larynx

Pectoralis major myocutaneous

flap – elevation tips

1. The incision should be made above the nipple in male and below

the breast in the female patient.

2. Pedicle should be identified carefully to preserve the vascularity

of the flap

3. After repair of the defect rubber drains should be placed

Deltopectoral flap

Bakamjian in 1965

Axial flap

Supplied by perforating branches

of internal mammary artery

Can cover any site of the neck up

to the level of zygoma.

Advantage – Flap retraction

occurs from side to side and not

from end to end.

Deltopectoral flap (contd)

Flap is outlined in the anterior chest wall and shoulder

Dissection plane – deep to pectoral and deltoid muscle fascia

Muscle fibres should be seen as the flap is being elevated

Elevation of this flap should only be done up to 2cms lateral to the

sternal border taking care to avoid injury to perforating arteries

Donor site should be covered with split thickness skin graft

Radial forearm flap

Faciocutaneous flap based on

radial artery

Venous outflow is from the

superficial veins of forearm

Used to reconstruct oral cavity,

oropharynx and hypopharyx

This flap includes skin from the

anterior cubital fossa to the flexor

crease at the wrist. Skin should not

be elevated over the ulnar artery

Abbe Estlander flap

This flap is commonly used to

reconstruct defects involving lips

and commissures

Full thickness flap with skin /

muscle / mucous membrane are

used

The flap can be marked, rotated

and sutured leading to the

formation of new commissure

Temporoparietal flap

Based on superficial temporal

artery

Both anterior and posterior

branches of superficial temporal

artery should be included

Size of the flap should be the size

of temporalis muscle

The arch of the zygoma should be

fractured to deliver the flap into

the oral cavity

Donor site should be closed

primarily

Hadad Flap

Used for skull base reconstruction

Mucoperichondrial/periosteal flap

Based on nasoseptal artery

Commonly used for anterior skull

base reconstruction

Hadad flap - Indications

Skull base reconstruction after endonasal surgery

To prevent communication between brain and sinuses

To repair anterior skull base leak

Hadad flap - advantages

Robust blood supply

Superior arc of rotation

Provides enough area to cover entire anterior skull base

Can be safely stored in nasopharynx if the procedure needs to be

staged

Can be taken down and reused in revision cases