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Flaps and Grafts
“….the application of anatomical knowledge
to restore form and function…”
Graft VS FlapWhat is the difference?
What is a Flap?
• 16th century Dutch word “flappe”
– ….something that hangs broad and loose , fastened only by one side..”
What is a Flap?
• A flap is a unit of tissue that may be transferred from a donor to a recipient site while maintaining its blood supply.– Flaps can be characterized by their component parts
• cutaneous, musculocutaneous, osseocutaneous
– Their relationship to the defect• local, regional, or distant
– Nature of the blood supply• random versus axial
– The movement placed on the flap• advancement, pivot, transposition, free, pedicled
• Rung 1: Healing by secondary intention
• Rung 2: Primary closure
• Rung 3: Delayed primary closure
• Rung 4: Split thickness graft
• Rung 5: FTSG
• Rung 6: tissue expansion
• Rung 7: Random flap
• Rung 8: Axial flap
• Rung 9: Free Flap
Reconstructive Elevator
• Get off at the right level
Composition of a flap
• Skin– Muscle
– Bone
– Omentum
– Composite
Composition of a flap
– Skin
• Muscle– Bone
– Omentum
– Composite
Composition of a flap
– Skin
– Muscle
• Bone– Omentum
– Composite
Composition of a flap
– Skin
– Muscle
– Bone
• Omentum– Composite
Composition of a flap
– Skin
– Muscle
– Bone
• Omentum / viscera– Composite
Composition of a flap
– Skin +/- fascia
– Muscle (+/- innervation)
– Bone
– Omentum / viscera
• Composite
Which flap when?
Goals of reconstruction
• Separating the physiological cavities – Eg brain, orbit, mouth, neck
• Protecting the neck vessels
• Obtaining a healed wound
• Restore function
• Restore swallowing
• No leaks
• Aesthetics
• Flaps reduce complications by:
– Obliterating dead space
– Recruiting healthy well-vascularized tissue into the region, which has commonly been irradiated and contaminated
– Tension free closure
– Interposing flap skin between irradiated wound edges
Pharyngeal defects
• Partial defects
– Pectoralis major flap with muscle and skin
– Radial forearm free flap
• Circumferential defects
– Tubed radial forearm flap or ALT flap
– Jejunum
Goals of reconstruction:
• A single stage, reliable reconstruction
• Prompt discharge from hospital
• Return of swallowing and speech function
• No salivary fistulas
Literature Review
• Nelligan (J PlastReconstrAesthet Surg. 2008) reported a fistula rate of:
– 13% for all fasciocutaneous flaps
• ALT flap 16.4%
• radial forearm free flap 14.4%.
– Jejunum 9.4%
• Charing Cross Study (Moradi et al)
– fistula rate: 2/43 (4.7%)
– stricture rate: 6/43 (14%)
Murray D, Novak C, Neligan P. Fasciocutaneous free flaps in pharyngolarngo-oesophageal reconstruction: A critical review of literature. J
PlastReconstrAesthet Surg. 2008
Voice Restoration (Charing Cross
series)• 22 of 42 received a
primary (TEP)• 14 of 42 received a
secondary TEP • 36/42 (85%) received
either a primary or secondary TEP
• Voice was reported as:– Good in 17 of 39– Fair in 11 of 39. – 28 of 39 (72%) used their
tracheoesophagealpuncture as their primary mode of communication
When to eat?
• No scientific evidence on the timing of oral intake
• Err on the side of caution if previous radiotherapy
• Day 10
Mandible reconstruction
• Osteoradionecrosis (ORN) is a condition of non-vital bone in a site of radiation injury
• Characterised by:– hypovascularity– hypocellularity– hypoxia
• ORN occurs when, in the process of otherwise normal turnover of bone, the degradative function exceeds new bone production
• Can be either spontaneous or the result of an insult
Facial reanimation
• Goal of treatment
– Rest symmetry
– Facial function
– Voluntary function
– Spontaneous movement
– Absence of synkinesis
Facial reanimation
• Static vs dynamic
• Static: Divide face into 1/3rds
– Upper:
– Middle:
– Lower:
Dynamic: free gracilis
Static: slings
Tongue reconstruction
• Depending on extent of defect and the status of the floor of mouth
• Generally use:
– Radial forearm free flap
– Ulnar forearm free flap
– ALT
Radial forearm free flap
Ulnar forearm free flap
Ulnar forearm free flap
Ulnar forearm free flap