local flaps in ent
TRANSCRIPT
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Dr. Ajay ManickamJunior Resident ENT & Head Neck SurgeryR.G. Kar Medical College
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Simple injury/ surgical
Repairable ….??? Many defects can be
directly closed if small & enough tissue available locally
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If the defect becomes larger...... Ablative cancer surgery
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Larger defects 1. Grafts2. Local flaps3. Pedicled flaps4. Free flaps5. Combination
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These are parallel to natural skin wrinkles Surgical incision placed parallely Least tension as skin contraction is at its
greatest
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Ellipse three times as long as its wide If ellipse is too short dog ear deformity
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Eye lid Helical rims of ear Lips Not only skin – composite tissue - closed in layers1. Lips – mucosa, orbicularis
oris, skin2. Ear – cartilage and skin
both anterior & posterior3. Eyelids – conjunctiva,
tarsal plate, orbicularisoculi and skin
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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
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Split thickness – part of dermis
Full thickness – all of dermis
Composite – skin & another tissue
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Graft origin1. Auto graft – same person2. Isograft – identical twin3. Allograft –same species4. Xenograft – diff species5. Alloplastic - synthetic
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SPLIT THICKNESS
More likely to take Contracts more Pigment abnormal Limited sensory recovery
FULL THICKNESS
High risk for graft loss Less Better colour match Better sensory recovery
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Imbibition – plasma – 48 hours Inosculation - Graft revascularization – graft
anastomosis Neovascularization – atleast a month
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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
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Simple flap lesions in nasal tip
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Kind of advancement flap modified
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Lower eyelid reconstruction Bipedicled flap – receives blood supply from
both ends
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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
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Pivot flap Rhomboid needs to be 120 & 60 degree So that scar becomes parallel
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Pivot flap – axial transposition flap
Flap lengh 3 times the length of base
Primary defect closed directly
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Two transposition flaps Defects in tip of nose
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Large flaps that rotate into primary defect
Flap circumference should be atleast 8 times
Repairs defect of scalp or cheek
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Based on named arterial pedicle runs within skin superficial to the underlying muscle layer parallel to the skin overlying
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Forehead flapNasolabial flapSubmental island flapFacial artery myomucosal flapTemporo parietal fascial flap
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Mc gregor Cutaneous axial
median forehead flap – supra trochlear artery
Cheek , External nose
Forehead flap contracts excessively
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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
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Reconstruction of facial skin or intra oral lining
Supplied by facial artery branches
Can be tunneledunder mandible through submentaland submandibular space for oral reconstruction / tranposed onto face for soft tissue coverage
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Pribaz Oral mucosa
and buccinatormuscle branches of facial artery
Small mucosal defects of the oral cavity, mucosa of lip, tongue, palate
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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.
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Deltopectoral flap Myocutaneous and muscle only axial distant
flaps 1. Pectoralis major2. Lattissimus dorsi3. Sternomastoid4. Trapezius5. Platysma
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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
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Ariyan described it in 1970 pectoral branch of acromio thoracic artery Large skin territory – can be harvested in
supine position
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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
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