extra oral flap

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Classification of Flaps:

Blood supply (vascular anatomy) Method of Transfer Tissue type

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Classification of Flaps: I- Blood supply (vascular anatomy) A-Random B- Axial -Random: Has no specific arterial – venous system and depends for their blood supply on the sub-dermal plexus Length : Width of 2:1Limitationslimited Rotation arcProximity to the zone of injuryDecreased bacterial resistance *

Random pattern flap

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-Axial flap

Has a definite arterial – venous system (direct cutaneous artery in its longitudinal axis). They can be raised at least to the length of their supplying blood vessels No delay required e.g.Lateral forehead Deltopectoral If it is attached only by its vascular pedicle then it is called island flap *

Axial pattern flap

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II Method of Transfer

Local Adjacent to the zone of injury/defect Regional Near, but not adjacent to zone of injury/defect Distant Distant from the zone of injury/defect
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1-LOCAL FLAPSA-advancement : e.g. V-Y advanc., rectangular advanc.B-Move around a fixed point :- rotation: the defect is traingulated, back cut can decrease tension- transposition: rotated flap transposes a normal tis. e.g. Rhomboid flap2-DISTANT FLAPS: flaps that involves movement over a considerable distance from the defect site-Pedicled : flaps whose arc of rotation allows them to reach the head and neck without division of their original blood supply -Microvascular transfer ( free flap): flap completely detached from donor area and its artery & vein are anastomosed to those of the recipient site 
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LOCAL FLAPS Advancement flaps Slide directly into defect Single-pedicle (mono-pedicle) Double-pedicle (bi-pedicle)
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Advancement flaps V-Y flaps

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Advancement flaps Rectangular

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Rotation flapsSemicicular – pivot pointBackcutBurow’s triangle *

Transposition flaps Rotated laterally Fills adjacent defect Bilobed Z-plasty Rhomboid (Limberg) Dufourmentel
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Transposition: Z-Plasty All limbs equal Int. angles equal Length gained proportional to angle
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Method of Transfer - Regional
Rotate into defect NOT adjacent to donor site
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Method of Transfer – Distant Direct flaps: donor site Free Flaps

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III-Tissue type Cutaneous Muscle and Musculocutaneous Fascial and Fasciocutaneous Vascularized bone flaps Abdominal viscera
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Cutaneous (skin) flaps I-Nasolabial flap Superiorly based or inferiorly based on branches of the facial and angular arteries. Defects of the lower lip, floor of mouth, buccal vestibule. Inferiorly based flaps to anterior floor of mouth 5 mm below the medial canthus to oral commissure Tunneled through cheek mucosa Disadvantages: Hair bearing in male
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II-Forehead flap1-lat. forehead flap: based on superficial temporal art. Disadvantages: -poor esthetic, -2 stages 2-central forehead flap: Based on supratrochlear art.Lat. Forehead flap may be used for intra- oral defects such as cheek, alveolus, max., tongue, floor of mouth by passing deep to the zygomatic arch
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Lateral forehead flap

III-Deltopectoral flap: AxialBased on internal mammary artrey Can b e used for lower lip & intraoral defectsDonor site needs split skin graft
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Deltopectoral flap

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Tissue Composition – Muscle Flaps Reliable vasculature Easily obliterates dead space

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Mathes and Nahai classification of muscle flaps based on vascular pattern

Type I: One Vascular Pedicle Type II: Dominant Vascular Pedicle(s) and Minor Vascular Pedicle(s) Type III: 2 Dominant Pedicles Type IV: Segmental Vascular Pedicles Type V: Dominant Vascular Pedicle and Secondary Segmental Pedicles

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Dominant pedicle  entire flap will liveMinor pedicle  cannot support entire flapSegmental pedicle  will support flap if dominant divided *

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Myocutaneous flaps e.g. pectoralis major flap

Based on thoracoacromial axis from the first part of axillary art. Can reach up to the level of the zygomatic arch Intraorally can reach soft palate easily Can be used as osteomyocutaneous fap
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Pectoralis major flap
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Tissue Composition – Fascia/Fasciocutaneous Skin with underlying fascia Pedicled or free Preserve muscle Thin and pliable Can be sensate
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Tissue Composition – Vascularized Bone Vascularized through endosteal and periosteal sources Undergoes primary bone healing Withstand radiation Large bone defects Fibula (peroneal) Iliac crest (deep circumflex) Scapula (circumflex scapula) Radius (radial)
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Reconstruction of lip-fan flap: for large defects. Mainly for lower lip.Disadv. -Tip has tendency to necrose-roudening of mouth corner-Abbe flap (lip switch) the defect sh. not be larger than 1/3 of the donor lip. Mainly used for lower lip defects. When it involves the commissure then it is called Estlander flap
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Abbe flap

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Abbe flap

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Abbe Estlander flap

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- Nasolabial flap-karapandzic flap: innervated myocutaneous flap for lower lip by separating orbicularis oris muscle from supporting muscle of mastication of expression maintaining blood & nerve supply
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Flap Monitoring – Clinical Exam “GOLD STANDARD”Temperature (body temp)Color (Pink)Capillary refill (~2sec)Point bleeding (red)Firmness (soft) *

Flap Monitoring

Arterial Insufficiency Cool Pallid Decreased capillary refill softer Slow bleeding
Venous Insufficiency Warmer Blue/purple Increased cap refill Brisk dark blood Tense, swollen
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