REFERAT

Free Flap pada Wajah

Muhamad Sidik Hasanudin

Pembimbing Utama :
dr. Shinta Fitri Boesoirie, M.Kes., Sp.T.H.T.K.L(K)

Bagian Ilmu Kesehatan Telinga Hidung Tenggorok - Bedah Kepala Leher

Fakultas Kedokteran Universitas Padjadjaran
Rumah Sakit Dr. Hasan Sadikin-Bandung
2015
1

Pendahuluan

Mathes SJ, Levine J. Muscle Flaps and Their Blood Supply. Dalam: Thorne C, Grabb WC, Smith JW, Beasley RW,
penyunting. Grabb and Smith's Plastic Surgery.Edisi ke 6. Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins; 2007.
Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology--Head and Neck Surgery.Edisi ke 3. New York: Mcgraw-hill;
2011.

Pendahuluan

Seidenberg dkk (1959) Aplikasi pertama free flap

rekonstruksi esofagus servikal menggunakan jejunum.
Kaplan, 1973 rekonstruksi rongga mulut dengan free flap
pangkal paha,
Panje, 1974, rekonstruksi rongga mulut dengan free flap
deltopektoralis.

Mathes SJ, Levine J. Muscle Flaps and Their Blood Supply. Dalam: Thorne C, Grabb WC, Smith JW, Beasley RW,
penyunting. Grabb and Smith's Plastic Surgery.Edisi ke 6. Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins; 2007.
Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology--Head and Neck Surgery.Edisi ke 3. New York: Mcgraw-hill;
2011.

Epidemiologi

Hatcher JL, Bell EB, Browne JD, Waltonen JD. Disposition of elderly patients after head and neck reconstruction. JAMA Otolaryngol Head
Neck Surg. 2013;139(11):1236-41.
Trivedi NP, Trivedi P, Trivedi H, Trivedi S, Trivedi N. Microvascular free flap reconstruction for head and neck cancer in a resourceconstrained environment in rural India. Indian J Plast Surg. 2013;46(1):82-6.
Tarsitano A, Pizzigallo A, Fantini MP, Marchetti C. Can microsurgical reconstruction after oral cancer improve patient-reported health-related
quality of life? A 5-year experience. Journal of Medicine & The Person. 2008;6(1):14-9.
Salvatori P, Paradisi S, Calabrese L, Zani A, Cantu G, Cappiello J, et al. Patients' survival after free flap reconstructive surgery of head and
neck squamous cell carcinoma: a retrospective multicentre study. Acta Otorhinolaryngol Ital. 2014;34(2):99-104.

Anatomi
Kulit

Fisiologi Flap Kulit

Girod DA, Tsue TT. Free Tissue Transfer. Dalam: Flint PW, Cummings CW, penyunting. Cummings Otolaryngology Head &
Neck Surgery.Edisi ke 5. Philadelphia: Mosby/Elsevier; 2010

Zona Perfusi.

Memelihara fungsi sel dan kelangsungan hidupnya.

Sistem peredaran darah pada makrosirkulasi, kapiler,
interstisial, dan tingkat seluler.

Zona I - IV penting
Zona I - IV penting
untuk flap dapat
untuk flap dapat
bertahan hidup.
bertahan hidup.
Free Flap
DA, Tsue TT. Flap
Dalam: Flint PW, Cummings CW, penyunting. Cummings Otolaryngology Head &
GirodFree
Free Tissue Transfer.
Neck
manipulasi
Surgery.Edisi ke 5. Philadelphia:
zona
Mosby/Elsevier;
I 2010
manipulasi zona I

Wound
Healing

Faktor yang Mempengaruhi Luk

Usia.

Nutrisi

Infeksi

Sirkulasi

(hipovolemia)
dan

Oksigenasi.
Hematoma

Benda asing
Iskemia
Diabetes
Keadaan
Luka.
Obat
(steroid,
antikoagulan
, T,antibiotik
Brunicardi F, Andersen D, Billiar
Dunn D, Hunter J,
Matthews J, et al. Schwartz's Principles of Surgery,
Ninth Edition.Edisi ke 8. New York: McGraw-Hill
Education; 2009.

Klasifikasi Flap
Lokasi

lokal,
regional,
jauh
(distant)
FREE
FLAP

Suplai
vaskular

aksial
Random
Rotational
Transpositio
n
Advanceme
nt
Postauricula
r
interpolatio
n

Desain Flap dan

metode gerakan
jaringan

Pivotal flap
Rotational
Transposition
Interpolated
Advancement
Uni-or bipedicled
advancement
V-Y or Y-V
advancement
Island advancement
Hinge
Jewett B. Local Cutaneous Flaps and Graft. Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.

Pemilihan Jenis Flap

STSG (Split-thickness Skin

Graft),
FTSG (Split-thickness Skin
Graft),
PML (Pectoralis Major Lateral
Flap),
LAT (Latisimus),
SCAF (Subclavicula Anterior
Flap),
DP (Deltopectoral Flap),
ALT (Anterolateral Thigh
Flap),

Erovic BM, Lercher P. Manual of Head and Neck Reconstruction Using

Regional and Free Flaps.Edisi ke 1. Verlag-Wien: Springer Vienna; 2014.

10

Indikasi Rekonstruksi dengan

menggunakan Free Flap pada Kepala
dan Leher

Girod DA, Tsue TT. Free Tissue Transfer. Dalam: Flint PW, Cummings CW, penyunting. Cummings Otolaryngology Head &
Neck Surgery.Edisi ke 5. Philadelphia: Mosby/Elsevier; 2010.
11

Evaluasi Pre operatif

ukuran dan luas defek,

lokasi donor
jumlah dan jenis jaringan yang akan didapatkan,
persarafan,
keuntungan dari sisi fungsional,
angka keberhasilan,
lamanya operasi,
kemampuan operator, dan
faktor status kesehatan pasien secara menyeluruh

Girod DA, Tsue TT. Free Tissue Transfer. Dalam: Flint PW, Cummings CW, penyunting. Cummings Otolaryngology Head & Neck Surgery.Edisi ke 5.
Philadelphia: Mosby/Elsevier; 2010.
Yap LH, Butler CE. Principle of Microsurgery. Dalam: Thorne C, Grabb WC, Smith JW, Beasley RW, penyunting. Grabb and Smith's Plastic Surgery.Edisi
12
ke 6. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007.

Alat-alat untuk melakukan opersi operasi

mikrovaskular.
Burkey BB, Schmalbach CE, Coleman JR. Microvascular Flap. Dalam: Papel ID, penyunting. Facial Plastic and Reconstructive Surgery.Edisi ke 3. New
York: Thieme; 2011.

13

Penanganan Intraoperatif

Girod DA, Tsue TT. Free Tissue Transfer. Dalam: Flint PW, Cummings CW, penyunting. Cummings Otolaryngology Head & Neck Surgery.Edisi ke 5.
Philadelphia: Mosby/Elsevier; 2010.
Yap LH, Butler CE. Principle of Microsurgery. Dalam: Thorne C, Grabb WC, Smith JW, Beasley RW, penyunting. Grabb and Smith's Plastic Surgery.Edisi
ke 6. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007.
Gooneratne H, Lalabekyan B, Clarke S, Burdett E. Perioperative anaesthetic practice for head and neck free tissue transfer - a UK national survey.
14
Acta Anaesthesiologica

Operasi Mikrovaskular
Yap LH, Butler CE. Principle of Microsurgery. Dalam: Thorne C, Grabb WC, Smith JW, Beasley RW, penyunting. Grabb and
Smith's Plastic Surgery.Edisi ke 6. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007.

15

Prinsip-prinsip umum dari teknik bedah

mikrovaskular :

Jahitan tegak lurus menembus melalui tunika adventitia ke intima.

Hindari memegang atau memanipulasi tunika intima.
Hindari melewati beberapa jahitan.
Saat menarik jarum harus mengikuti lengkungan jarum dengan
sempurna.
Melebarkan dan memvisualisasikan bagian dalam pembuluh darah
menggunakan larutan saline yang telah diberikan heparin.
Gunakan forsep yang halus untuk membuka lumen pembuluh darah
Lakukan anastomosis sebelum reperfusi.
Lepaskan klem pada vena yang pertama.
Memeriksa anastomosis dengan menggunakan ekor benang yang
panjang.
Lakukan penjahitan tambahan bila terjadi kebocoran pada jahitan.
Hindari melakukan jahitan tambahan pada anastomosis yang rembes
Gunakan larutan saline hangat dan papaverine untuk menutupi
anastomosis setelah reperfusi untuk melebarkan pembuluh darah dan
relaksasi bila spasme.

Burkey BB, Schmalbach CE, Coleman JR. Microvascular Flap. Dalam: Papel ID, penyunting. Facial Plastic and Reconstructive
Surgery.Edisi ke 3. New York: Thieme; 2011.

16

Perawatan Pasca Operasi

Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology--Head and Neck Surgery. Edisi ke 3. New York: Mcgraw-hill; 2011.
Fujioka M. Factors Predicting Total Free Flap Loss after Microsurgical Reconstruction Following the Radical Ablation of Head and Neck
Cancers. ISRN Plastic Surgery. 2013;2013(1):1-5.
Suh JD, Kim BP, Abemayor E, Sercarz JA, Nabili V, Liu JH, et al. Reirradiation after salvage surgery and microvascular free flap
reconstruction for recurrent head and neck carcinoma. Otolaryngol Head Neck Surg. 2008;139(6):781-6.
Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. Head Neck Oncol.

17

Jenis Free Flap:

Jewett B. Local Cutaneous Flaps and Graft. Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck Surgery Otolaryngology.Edisi ke 5. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.

18

19

Free Flap yang Sering Digunakan pada Kepala

dan Leher

Flap
Artery
Vein
Flap Fasiokutaneous

Nerve

Rekonstruksi

Lengan
bawah
radial

Radialis

Vena radialis Saraf

atau sefalika kutaneous
antebrakialis
medial dan
lateral

Rongga mulut, lidah,

palatum, hidung, wajah,
scalp, bibir, faring, laring,
faringoesofageal

Lengan
bawah
ulnaris

Ulnaris

Vena ulnaris Saraf

atau sefalika kutaneous
antebrakialis
medial dan
lateral

Rongga mulut, lidah,

palatum, hidung, wajah,
scalp, bibir, faring, laring,
esofagus servikal

Lengan
atas
lateral

Radialis
kolateral
posterior

Radialis
Saraf
kolateral post kutaneous
posterior

Rongga mulut, lidah,

palatum, faring

Paha
lateral

Deep femoral Vena

femoralis

Kutaneous
femoralis
lateral

Rongga mulut, lidah,

palatum, faring

Skapular- Subskapular Subskapular Rongga mulut, lidah,

paraskapul
palatum, faring, wajah,
arGirod DA, Tsue TT. Free Tissue Transfer. Dalam: Flint PW, Cummings CW, penyunting. Cummings
bibir Otolaryngology Head &
20
Neck Surgery.Edisi ke 5. Philadelphia: Mosby/Elsevier; 2010.

Free Flap yang Sering Digunakan pada Kepala

dan Leher
(lanjutan...)
Flap
Artery
Vein
Nerve
Rekonstruksi
Flap Osteokutaneous
Fibula

Radius

Peroneal

Peroneal

Radialis

Radialis or
sefalika

Kutaneous
lateral

kutaneous
antebrakialis
medial dan
lateral

Skapula

Subskapular

Subskapular

Krista
iliaka

Sikumfleksus
iliaka
profunda

Sikumfleksus
iliaka
profunda

Rekonstruksi
mandibula
Rekonstruksi
mandibula dan midface
Rekonstruksi
mandibula dan midface
Rekonstruksi
mandibula dan midface

Flap lain-lain
Cabang
Cabang
Rekonstruksi
Jejunum
mesenterik
mesenterik
faringoesofageal
superior
superior
Omentum Gastroepiploic Gastroepiploic Scalp
Girod DA, Tsue TT. Free Tissue Transfer. Dalam: Flint PW, Cummings CW, penyunting. Cummings Otolaryngology Head &
21
TemporalSuperficial
Neck Surgery.Edisi Superficial
ke 5. Philadelphia: Mosby/Elsevier;
2010.
Tulang dan kartilago

Fasia dan Fasiokutaneus

Free Flap
Sering digunakan untuk merekonstruksi kepala dan leher.
Tipis, fasia yang lentur. memiliki potensi untuk memiliki
rekonstruksi saraf reanastomosis saraf kutaneus.
Umumnya digunakan untuk menutup defek intraoral,
faring, dan defek kulit kepala dan leher

Flap Radius Lengan Bawah (Radial Forearm Flap)

Flap Lengan Lateral (Lateral Arm Flap)
Flap Paha Leteral (Lateral Thigh Flap)
Flap Paha Anterolateral (Anterolateral Thigh Flap)
Flap Fasia Temporoparietal (Temporoparietal Fascial
Flap)

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

22

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

23

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

24

Karsinoma sel basal yang luas

meliputi maksila kiri dan hidung.
Penutupan defek menggunakan flap
lengan bawah lateral
Tamimy MS, Rashid M, Islam MZ, Sarwar S-u-R, Aman S, Aslam A. A comparison of free transfer of radial forearm and
anterolateral thigh flaps for head and neck reconstruction. European Journal of Plastic Surgery. 2009;32(2):95-102.

25

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

26

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

27

Karsinoma sel skuamosa yang luas pada mandibula kiri.

Dilakukan penutupan defek menggunakan flap paha
anterolateral

Tamimy MS, Rashid M, Islam MZ, Sarwar S-u-R, Aman S, Aslam A. A comparison of free transfer of radial forearm and
anterolateral thigh flaps for head and neck reconstruction. European Journal of Plastic Surgery. 2009;32(2):95-102.

28

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

29

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

30

Flap Fasia Temporoparietal

(Temporoparietal Fascial Flap)

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

31

Flapmuskulokutaneus
(Musculocutaneous Flap)

Flap Rektus
Abdominis

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

32

A.Flap rectus vertical.

B.Flap rectus abdominis
transversus bagian tengah
dan bawah.
C.Flap rectus
toracoumbilikal.
D.Flap gabunganr rectus
torakoumbilikal dan
vertical.

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

33

Karsinoma sel skuamosa aurikula, mandibula

dan skull base lateral. Free flap diambil dari
rektus abdominis.
34

Flap Latissimus
Dorsi

untuk merekonstruksi kulit kepala, tetapi kurang baik untuk

defek dengan ukuran besar

Flap Grasilis

Kegunaan utama
mengembalikan fungsi
fasial, dimana
revaskularisasi dan
reinervasi untuk
mengembalikan aktivitas
otot.

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

35

Composite Free Flap

Flap Fibular Osteokutaneus (Fibular
Osteocutaneous Flap)

Chepeha DB. Microvascular Free Flaps in Head and Neck

Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting.
Bailey's Head and Neck Surgery - Otolaryngology.Edisi ke 5. Phil

36

Flap osteokutaneous fibula pada rekonstruksi mandibula

Wehage IC, Fansa H. Complex reconstructions in head and neck cancer surgery: decision making. Head & Neck
Oncology. 2011;3(1):14-5.

37

Osteocutaneous and
Osteomusculocutaneous Iliac Crest Flaps

Chepeha DB. Microvascular Free Flaps in Head and Neck Reconstruction Dalam: Johnson JT, Rosen CA, Bailey BJ, penyunting. Bailey's Head and Neck
Surgery - Otolaryngology.Edisi ke 5. Phil

38

Simpulan

39

Terima kasih

40