1. IN HEAD &NECK RECONSTRUCTION
LOCAL & Regional FLAPS
IN HEAD &NECK RECONSTRUCTION
Dr.Wafaa Khalil

2. Definition : A flap is a unit of tissue that is transferred from donor site to recipient site while maintaining its own blood supply. Missing tissue most often results from either trauma or oncologic surgery. Commonly there is a wide range of options for repairing a given defect, including healing by secondary intention, primary closure, placement of a skin graft, or mobilization of local or regional tissue.

3. Flaps Uses Replace tissue loss due to trauma or surgical excision
Provide skin coverage through which surgery can be carried on latter
Provide padding over bony prominences
Bring in better blood supply to poorly vascularized bed
Improve sensation to an area (sensate flap)
Bring in specialized tissue for reconstruction such
as bone or functioning muscle

4. BASED ON LOCATION OF DONOR SITE
LOCAL FLAP: Flap transferred from an area adjacent tothe defect.
REGIONAL FLAP: Flap recruited from different area of the same part of the body.
DISTANT FLAP : Flap transferred from an noncontiguous anatomic site.

5. CLASSIFICATION OF LOCAL FLAPS
BLOOD SUPPLY
METHOD OF MOVEMENT
COMPOSITION

6. Local flaps can be classified based on their blood supply
Random flaps
Axial flaps
1. Free flaps
2. Island axial pattern flap

7. Random flaps
Random flaps are supplied by the dermal and subdermal plexus alone
Its the common type of flap used for reconstructing facial defects
length to width ratio of up to 2 : 1 in the face without risk of flap loss or skin necrosis.

8. Axial flaps
Derive their blood supply from a direct cutaneous artery or named blood vessel .
Examples :Nasolabial flap (angular artery) , Forehead flap(supratrochlear artery).
The surviving length of an axial pattern flap is entirely related to the length of the included artery.

9. Axial flaps
Pedicle flaps are supplied by large named arteries that supply the skin paddle through muscular perforating vessels.
Free flap: is a tissue harvested from a remote region and have the vascular connection which transfer and reestablished at the recipient site.

11. CLASSIFIACATION OF LOCAL FLAP BASED ON THE METHOD OF MOVEMENT
LOCAL FLAPS
CLASSIFIACATION OF LOCAL FLAP BASED ON THE METHOD OF MOVEMENT
ADVANCEMENT FLAP
PIVOT FLAP
(ROTATION FLAP)
INTERPOLATION FLAP

12. LOCAL FLAPS Advantages Best local cosmetic tissue match
Often a simple procedure
Local or regional anaesthesia option
Disadvantages
Possible local tissue shortage
Scarring may exacerbate the condition
Surgeon may compromise local resection

13. sites – forehead, brow, cheek.
Advancement flaps are mobilized along a linear axis without any lateral movement into the primary defect.
(Burrows Triangle’s)
sites – forehead, brow, cheek.
movement is entirely in one direction.
A, Advancement flap for closure of forehead defect. B, Closure of defect with incision lines placed in natural forehead crease A B

15. V-y advancement flap: (Herbert flap)
A V shaped flap is moved into a defect with primary closure of the donor area leaving a final Y shaped suture line. 
It is pedicled from the underlying subcutaneous tissue rather than the surrounding skin.
Ideal for Lesion in
the cheek
and alar base

17. Rotation flaps pivot around a point at the base of the flap.C
A, Axial frontonasal flap for repair of a nasal defect. B, Elevation of the flap with thorough undermining. C, Closure of the defect

18. Interpolated flaps are those flaps that are mobilize either over or beneath a complete bridge of intact skin via a pedicle. A B C D
Transpotion flap
A, Outline for a rhombic flap. B, Resection of the lesion. C, The flap is transposed into the defect. D, Postoperative result with the incisions placed in the relaxed skin tension lines

19. Interpolated flaps A B CC D E F
A, Nasal defect after excision of squamous cell carcinoma lesion. B, Use of Doppler ultrasonography to locate the supratrochlear artery. C, The forehead flap has been elevated. D, The flap is turned 180° and sutured into place. E, The pedicle is divided 2 to 3 weeks later. F, Postoperative result

20. Local flap based on composition
Skin (cutaneous)
Visceral ( colon, omentum)
Muscle
Mucosal
Composite
Fasciocutaneous
Myocutaneous
Osseocutaneous
Tendocutaneous
Sensory/innervated flaps
Osseo-myo-cutaneous

21. Local / Regional flaps – Goals (Kinnerw & Jeter)
1. Adequate color match
2. Adequate thickness – avoid protrusions or deficiencies
3. Preservation of clinically perceivable sensory innervation
4. Sufficient laxity – avoid retraction or deranged function
5. Resultant suture lines of either primary or secondary defects are restricted to anatomic units and fall within natural skin lines.

22. REGIONAL FLAPS
Defined as those flaps that are located near a defect but are not in the immediate proximity.
They are frequently harvested from the neck, chest, or axilla.
Classified as axial, however most flaps have random pattern at their distal ends
Utilized to cover large defects which require bulk
Examples : 1. PMMF (Pectoralis Major Myocutaneous flap) 2. DPF (deltopectoral flap) 3. Trapezius flap

23. REGIONAL FLAPS Advantages of regional flaps
large amount of soft tissue and skin available.
Disadvantages of regional flaps
poor color and texture match
excessive bulkiness of the flap
donor site morbidity.

25. Deltopectoral Flap

28. Postoperative Care Pain reliever Wound care antibiotic ointment
Sutures removed at 5-7 days
Revision if required - 6 months

29. Complications Infection Dehiscence Vascular insufficiency due to
Mechanical tension
Kinking
compression
Hematoma/seroma
Failure/necrosis

30. Causes of flap failure
poor anatomical knowledge when raising the flap (such that the blood supply is deficient from the start)
flap inset with too much tension
local sepsis or a septicaemic patient
the dressing applied too tightly around the pedicle;

31. THANK YOU