SEMINAR ON

FLAPS IN MAXILLOFACIAL RECONSTRUCTION

Presented by Dr. Jaspreet Kaur Bhasin Department of Oral and Maxillofacial Surgery,
National Dental College, Derabassi. PUNJAB.

Contents : 1. Introduction 2. Free skin grafts 3. Skin flapsFlaps definition, history and classification 4. Designing of the flap 5. Planning considerations 6. Commonly used local and regional flaps in the reconstruction of maxillofacial defects 7. References

Split-skin grafts are further subdivided into thin. pilosebaceous follicle or sweat gland apparatus. and split-skin grafts. leaves behind no epidermal structure in the donor area from which resurfacing can take place. The presence of circulating blood in a graft can be demonstrated approximately 48 hours postapplication. The various processes which result in its reattachment and revascularisation are collectively called take. Donor area of a split-skin graft requires no care other than that usually accorded any raw surface. When the defect is too large or for other reasons is unsuitable for direct suture. the initial adhesion provided by the fibrin cloth converts into a more effective definitive attachment of fibrous tissue and provides within 4 days an anchorage which allows the grafted area to be handled safely if reasonable care is taken. The skin and/or mucosal defects created sometimes include in addition a segment of mandible too. of is cut with a special instrument ± the Humby Knife or the Dermatome.such a graft can remain viable for a limited period and depends on the ambient temperature. Free Skin Grafts Free skin graft they consist of the entire thickness of the epidermis and a variable amount of dermis. or a free flap. containing a proportion only. So . the potential methods of reconstruction are by the use of a free skin graft. Gradually .Introduction ± The defects both of the skin and the mucous membrane which follow excision of malignant tumours. from which the donor site can resurface. containing the entire thickness of the dermis. . in most instances by direct suture. closure by direct suture is used when the defect is small enough and is otherwise suitable. The whole skin graft. the split-skin graft leaves adnexal remnants. and thick. While so detached . medium. a skin flap. once cut. the donor area of a whole skin graft has to be closed. The process of take : The graft initial adheres to its new bed by fibrin and its immediate nutritional requirements appear to be met by diffusion from the plasma which exudes from the bed providing a so-called plasmatic circulation. The whole skin graft is cut with a scalpel while the split-skin graft. They are designated according to their dermal component as whole skin grafts.reinforced by the outgrowth of capillary buds from the recipient area. This limits the size of the whole skin graft by direct suture. extensive defects are split-skin grafted. a composite flap.

The number of cut capillary ends exposed when a thick split-skin graft is cut is smaller than with a thin graft and the full thickness graft has even fewer. its behaviours varies in different sites. 1. Cartilage covered with perichondrium.the more suitable the particular surface is for grafting. Thin grafts are generally easier to get to take than thick grafts. left ungrafted. Bare cartilage cannot be relied upon to take a graft. Conditions for take. the neighbouring bone of the maxilla. the blood supply of the surrounding tissues may be sufficeintly profuse to allow the graft to bridge the avascular area and cover it successfully (nasal defect reconstruction). are so vascular that they all accept grafts extremely readily. The Graft bed The bed must have a rich enough blood supply to vascularise the graft as rapidly as possible and be capable also of providing the necessary fibrin anchorage. 2.-This is achieved by outgrowth of capillary buds and the more rapid the process . The graft Variations in graft thickness relate to the thickness of the dermal component and this influences their vascularity .being less vascular in its deeper part. the characteristics of the graft itself.The speed and effectiveness with which blood supply and fibrous adhesion are provided are determined by the qualities of the bed. The most frequent cause of separation is hematoma acting as a block to link-up of the out-growing capillaries. the circumorbital bony buttresses are all capable of taking grafts in descending order of case. and the conditions under which the graft is applied to the bed. If the area is small. Bare bone. the walls of the orbit. Rapid vascularisation is all important. Capillary outgrowth is also the key factor in the production of granulation tissue. takes a graft without difficulty as does also bone covered with perisoteum. The surgeon can assess the suitability of a surface by considering the speed with which it would be expected to granulate. The graft has therefore to be in the closest possible contact with the bed. The hard palate. The soft tissue of the face. . Vascularisation. At the same time the graft has to lie immobile on the bed until it is firmly attached. The bare cortical bone of the outer table of the skull vault and the bare bone of the mandible both lack sufficient vascularity to take a graft successfully. muscle. whether of nose or ear.dermis in general . fascia and fat.

cotton waste and polyurethane foam. but wiping with gauze or the careless use of the suction nozzle is to be discouraged as it is likely to start fresh bleeding. and with the graft overlapping the defect in a split-graft.. When grafting is carried out primarily. in the second. edge to edge in a full thickness graft. Clinical methods of grafting. Keep the volume of tissue ligated or burned as small as possible. The pressure is merely a means of providing immobility of the graft and holding it in contact with the bed. helps also to achieve haemostasis by maintaining the two in contact. cotton wool moistened with saline or liquid paraffin. They are advisable even if the graft is split-skin when the defect is in an area which is inherently mobile. merely protected from being rubbed off. In the first. but in both sites two distinct techniques are used. The graft is sutured to the margins of the defect. pressure methods. The raw surface may be irrigated with saline to wash off any cloth. THE SKIN SURFACE Pressure methods The pressure is exerted by a bolus applied directly to the graft further pressure is usually also applied by added dressings. without dressing of any kind. Various bolus materials are used ± flavine wool.Complete haemostasis is desirable before any surface is grafted and the various steps of the excisional procedure. Pressure methods are preferable when the graft is small in area and are invariable when it is full thickness in type. Exposed grafting The graft is laid on the defect. -The methods depend on whether the graft is being applied on the skin surface or inside the mouth and/or sino-nasal cavity. Further dressing are provided by crepe bandage and/or Elastoplast. the graft is left exposed without pressure. The sutures fixing the graft to the margins are left long and tied over a bolus dressing. pressure is applied to the graft. .3. apart from helping to create immobility for the graft and its bed. It should be free of pathogens. Any air trapped under it is pressed out and the skin is allowed to overlap the defect margins. and allowed to attach by fibrin adhesion alone. Preparation of a surface of grafting.

As soon as the site is clean . Skin Flaps Flap Definition. Application of the graft to the defect is postponed for several days. The most important single point of technique is to make sure that the surface of the defect is not allowed to dry out. They are sensitive to the nitroimidazole antimicrobials. Antibiotics in intra-oral grafting Squamous carcinoma in the oral cavity has been found to harbour anaerobic bacteria. Flaps come in many different shapes and forms. This is far from easy and for this reason delayed exposed grafting is more usual. A skin flap in its basic form is a tongue of tissue consisting of the entire thickness of the skin plus a variable amount of the underlying subcutaneous tissue. A 5mm thick layer of tulle gras sheeting is used. The transfer usually leaves a secondary defect which is either closed by direct suture or covered with a free skin graft. . control of all bleeding points must be rigorous since pressure is not available to help haemostasis. fat. and Classification A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply. 2-5 days is an average but the time is not critical.. sealed container and stored in a refrigerator until required. such as Metronidazole or Tinidazole. Its occlusive properties prevent the surface from drying out and it can be removed with a minimum of discomfort 24 ± 28 hours later. the skin in the interval being stored in the refrigerator. Storage of skin The graft is wrapped in gauze moistened with saline.If exposed grafting is being used primarily. The time lag between excision and grafting allows bleeding to stop completely and the waiting period is used to free the wound of all residual blood clot. It is transferred in order to reconstruct a primary defect and is inset into this defect. They range from simple advancements of skin to composites of many different types of tissue. placed in a sterile.the graft can be applied. History. A storage temperature of 4oC is likely to give the longest survival. or fascia. They may include skin. bone. muscle. It can be avoided by making sure that an occlusive dressing is applied to the defect as soon as it has been made. These composites need not consist only of soft tissue.

or both to supply the overlying tissue. fastened only by one side. and osseocutaneous (bone and skin) flaps. The most recent advancement in flap surgery came in the 1990s with the introduction of perforator flaps.further classified by Mathes and Nahai as: y One vascular pedicle (eg.How does a flap differ from a graft? A flap is transferred with its blood supply intact. which transport skin to an adjacent area while rotating the skin about its pedicle (blood supply). Subsequent surgical flap evolution occurred in phases. when surgeons reported using axial pattern flaps (flaps with named blood supplies). tensor fascia lata) y Dominant pedicle(s) and minor pedicle(s) (eg. Distant pedicle flaps. This was a breakthrough in the understanding of flap surgery that eventually led to the birth of free tissue transfer. the number of different tissue types used increased significantly with the development of fasiocutaneous(fascia and skin) flaps (which are less bulky than muscle flaps). osseous (bone) flaps. pedicled flaps were used extensively. The history of flap surgery dates as far back as 600 BC. also were reported in Italian literature during the Renaissance period. Classification of flaps 1. which has now become the criterion standard in breast reconstruction. when Sushruta Samita described nasal reconstruction using a cheek flap. and a graft is a transfer of tissue without its own blood supply. Some reports suggest flap surgeries were being performed before the birth of Christ. survival of the graft depends entirely on the blood supply from the recipient site. In the 1980s. which transfer tissue to a remote site. Therefore. In the 1970s. These flaps are supplied by small vessels (previously thought too small to sustain a flap) that typically arise from a named blood supply and penetrate muscle. gracilis) . a distinction was made between axial and random flaps (unnamed blood supply) and muscle and musculocutaneous (muscle and skin) flaps. The surgical procedures described during the early years involved the use of pivotal flaps. During the First and Second World Wars. The next period occurred in the 1950s and 1960s. History of flap surgery The term flap originated in the 16th century from the Dutch word flappe. The origins of forehead rhinoplasty may be traced back to approximately 1440 AD in India. Blood supply I. Random (no named blood vessel) II. muscle septae. Axial (named blood vessel) . An example of this is the deep inferior epigastric perforator (DIEP) flap. which transfer skin from an adjacent area without rotation. The French were the first to describe advancement flaps. meaning something that hung broad and loose.

lateral to the angle of mouth and the alar base. Two dominant pedicles (eg.from the facial artery . Random Pattern flap Flap has no pre-existing bias in its vascular pattern and this lack places stringent limits on its dimensions particularly on the ratio between its length and breadth. Above the zygomatic arch vascular anatomy is different. The degree of stringency depends to a considerable extent on the richness of its subdermal vascular pattern. the posterior auricular and occipital vessels behind the ear.there is a very rich subdermal plexus in the fatty layer between the skin and the muscles of facial expression. the zygomatic arches.the vessels run horizontally in the dense connective tissue layer between skin and galea with no significant deep vascular connections.y y y 1. 2. are conccentrated mainly at the level of these land marks. . This system running along its length makes it possible to construct a flap at least as long as the territory of its axial artery with minimal regard for considerations of breadth. The branches that pass upwards towards the inner canthal region. sartorius) One dominant pedicle and secondary segmental pedicles (eg. each dividing into anterior and posterior branches. The arteries and veins are in a line encircling the head at the level of the supraorbital ridges. They can be regarded as random. In the scalp proper . the supraorbital and supratrochlear vessels on the medial side of each supra-orbital ridge. Below the level of the zygomatic arch . The vessels which cross this line are the superficial temporal artery and vein just in front of the ear. The success of such flaps relates to two factors ± the virtual absence of deep vascular connections and the calibre of the vessels themselves in the plexuses. Facial flaps are raised deep to the subdermal plexus and they largely rely on its richness. in the forehead the situation is similar with frontalis muscle replacing the galea and a looser background of connective tissue. latissimus dorsi) Axial pattern flap Flap is constructed around a pre-existing anatomically recognized arteriovenous system. gluteus maximus) Segmental vascular pedicles (eg. the mastoid area on each side and the highest nuchal line on the occipital bone. fed from deeper vessels which emerge from between the facial muscles and In the nasolabial area .

tendocutaneous (eg. bone. Configuration Flaps are often referred to by their geometric configuration. radial forearm flap). whereas regional flaps refer to those flaps recruited from different areas of the same part of the body. colon. muscle. 3. Distant flaps are harvested from different parts of the body. fascia. y Advancement flaps-single pedicle advancement flap . o Composite flaps include fasciocutaneous (eg. dorsalis pedis flap). Location of donor site-local flaps -regional flaps -distant flaps Local flaps imply use of tissue adjacent to the defect. Examples of these flaps include bilobed.2. Method of Transfer The most common method of classifying flaps is based on the method of transfer. rhombic. 4. transverse rectus abdominis muscle [TRAM] flap). myocutaneous (eg. small intestine.V-Y. Flaps composed of one type of tissue include skin (cutaneous). omentum) flaps. dorsalis pedis flap with deep peroneal nerve). and sensory/innervated flaps (eg. fibula flap). and visceral (eg. osseocutaneous (eg. and Z-plasty 5.flap -Bipedicle flap . Tissue content y y Cutaneous Composite Faciocutaneous Myocutaneous osseocutaneous o Flaps may be composed of just one type of tissue or several different types of tissue.

 The characteristics of the defect and adjacent tissue must be analyzed. Transposition flap refers to one that is mobilized toward an adjacent defect over an incomplete bridge of skin.rotation flap -transposition flap(bilobed and rhomboid flap) -interpolation flap (Z-plasty) Advancement flaps are mobilized along a linear axis toward the defect .  Potential flap designs should be drawn on the skin surface being careful to avoid those designs that obliterate or distort anatomic landmarks. Examples of transposition flaps include rhombic flaps and bilobed flaps . elasticity. and location are evaluated as well as the availability and characteristics of adjacent or regional tissue. Rotation flaps pivot around a point at the base of the flap . Microvascular free tissue transfer from a different part of the body relies on reanastomosis of the vascular pedicle. depth.y Pivotal flaps.  Determine the mobility of adjacent structures and identify those anatomic landmarks that must not be distorted. . Interposition flaps differ from transposition flaps in that the incomplete bridge of adjacent skin is also elevated and mobilized. Although most flaps are moved by a combination of rotation and advancement into the defect. An example of an interposition flap is a Z-plasty. it is important to avoid secondary deformities that distort important facial landmarks or affect function.  The orientation of the RSTLs and esthetic units should by analyzed closely.  Avoid obliterating critical anatomic lines that are essential for normal function and appearance.  The defect size. These include color.  The final location of the resultant scar should be anticipated by previsualizing suture lines and choosing flaps that place the lines in normal creases. Interpolated flaps are those flaps that are mobilized either over or beneath a complete bridge of intact skin via a pedicle. Designing the Flap  A stepwise approach can be helpful in selecting and designing a flap. When designing a flap. the major mechanism of tissue transfer is used to classify a given flap. These flaps often require a secondary surgery for pedicle division.  The secondary defect that is created as the tissue is transferred into the primary defect must be able to be closed easily. and texture of the missing tissue.

 Avoid traumatizing the vascular supply by twisting or kinking the base of the flap. It is then that the need for a flap arises. flaps have become established for routine use in head and neck malignancy without prior preparation and transferred in a single stage. There is . scarring. LOCAL FLAPS If a tumour occurs in a site where skin is lax and available. or ectropion. Surgeon needs to be aware which area of availability he is exploiting so that he can assess whether or not the area is present in the particular patient and how abundant the skin is. Proper surgical technique involves gentle handling of the tissue by grasping the skin margins with skin hooks or fine-toothed tissue forceps. It is because area of availability exist in the face that the secondary defect which result from the transfer of such local flaps can be closed by direct suture and do not require to be grafted. If the tumour occurs where skin is not available. Planning in reverse is used when the flap is jumping over intact tissue and is not a straightforward transposed flap.  It is important to adequately mobilize and extend the flap. So both local and distant.  Deep pexing sutures minimize tension on the flap and eliminate dead space. The method is used most often in planning transposed or rotation flaps. which should be of adequate size to remain in place without tension to minimize the chance of dehiscence.. The flap must be designed so that the distance from the pivot point to each part of the flap before transfer is at least equal to the distance to be expected after transfer.  Excessive tension on the flap may decrease blood flow and cause flap necrosis. Detailed planning often used usually involves making use of the pivot point of the flap or of the method of planning in reverse. Planning considerations In cancer of the head and neck. This ensures that no part of the flap is under unacceptable tension. flaps are less often needed since suture of the defect sufficies.  Meticulous hemostasis should be achieved prior to final suturing so that a hematoma does not develop beneath the flap. the precise characteristics of the resection are rarely known with absolute certainty and time to prepare a flap is seldom available.

To close the defect by the movement of one side of the triangle across to the other. The area of availability which are exploited most frequently are the mandibulomasseteric . When the flap is a transposed one. flap and defect together making a half circle. The movement of tissue as a local flap can be by advancement.its idealised form is as the large arc of a circle of which the triangular primary defect is a small arc. particularly towards the mid-line has a limited availability. the forehead and temple. It is rotated or moved laterally into the defect. cheek. The absence of a secondary defect in the rotation flap. lower eyelid. The initial step with the rotation flap and the transposed flap in its basic form is the conversion of the primary defect into the shape of an isoscale triangle. The method has an extremely limited role. is approximately at the centre of the curve of the flap. the temple area beyond the lateral canthus. the nasolabial fold. Rotation flaps require a reasonably flat surface and are consequently raised on the cheek and submandibular area. or transposition. there is a triangular secondary defect left which corresponds to the triangle of the primary defect. and the scalp. To a lesser degree. It is the presence of wrinkles which indicates tissue availability. Advancement creates a triangular dog-ear of redundant tissue at the base of the flap on each side and excision of these completes the procedure. raised and advanced to cover a rectangular primary defect which adjoins its distal end. The rotations flap Since the flap is being rotated to its destination . involving tissue movement laterally. or its reduction to a small area compared with the primary defect. Even in the face there is always a continuing tendency for the tissue to revert to their original site as a result of differential tissue pull. rotation. The triangle is outlined beyond the clearance limit of the tumour. The advancement principle makes use of a single pedicled rectangular flap. the glabellar area. With the flap rotated there is a difference in the lengths of the two sides of the defect being sutured together and closure is achieved with a degree of differential tension. the forehead. The pivot point of the flap. is possible only because of the presence of skin laxity. is so great that it is regularly used in this capacity. Forehead has only its convenience and effectiveness as a source of hairless skin to cover defect of the middle third of the face ± nose. The larger the flap in relation to the defect the less the difference in length and the less the differential tension. The scalp fortunately also . Evidence of this is the dog ear which develops at the apex of the triangular defect when the flap is transferred and the fact that the bulk of the laxity taken up during transfer is at the other extremity of the flap. The flap is constructed on the skin adjoining one of the equal sides of the traingle.much greater availability of skin in most elderly patients.

At the defects which the flaps are designed to fill are usually comparatively small. Forehead flaps are most often used to cover defects below the level of the eyes and this makes it possible to inset only the distal segment of the flap at the initial transfer. Forehead flap is capable of coping with the presence of a raw surface over much of its length. This can be partly countered by bevelling the margin of the flap or alternatively. During the three weeks before it is divided the bridge segment spontaneously tubes itself to some extent by wound contraction on its deep surface and by marginal epithelialization . A dog ear may be excised from the redundant tissue outside the flap. A back-cut can be made along the diameter line of the circle of the flap until the tension has been sufficiently reduced. When a split skin graft has been required. The cosmetic disability. There is a tightness on the flap side of the suture line and a redundancy on its outer side. When a back cut is considered it must be remembered that it is reducing the vascular cross section of the flap. which is raised and moved laterally into the primary defect. leaves a secondary triangular defect which is at least equal in area to the primary defect. The transposed flap: In its µclassic¶ form this flap is a rectangle. usually near square.tolerates closure under tension better than almost any other skin area. usually from the end furthest away from the primary defect to equate the two sides of the suture line. A further variation is to jump over intact tissue in moving to its destination. the wound edge tend to invert unless removal of the scar . One of the two steps can be taken: 1. if the raw surface seems undully extensive a split skin graft is applied to the raw surface as an exposed graft. acts as a significant bar to the widespread used in the head and neck. the grafting be postponed for 10 days or so to allow a build up of granulations. In most flaps outside the neck and head a free bridge segment is tubed but not in forehead flaps. In suturing it back. Most of the secondary defects can be closed by direct suture. representing the discrepancy in a lengths of the two sides. in facial flaps generally. The graft in its early appearance tends often to form a depression on the forehead particularly if the frontalis muscle has been included in the flap. The secondary defect can be convered with a split skin graft. on occasion as much as 4:1. because of the compressing effect it would have on the blood vessels of the flap. graft only the area of the ultimate secondary defect. Flaps are routinely raised which are very much longer than their breadth. When the rotation flap is actually being transferred differential suturing is used. The general rigidity of any flap which includes galea would make tubing undesirable. If the bridge segment is being returned to the forehead all marginal epithelialization should be excised. or indeed. The fibrous tissue predominantly along the axis of the flap causing it to tube should be excised. 2. Its role confined to the hair bearing scalp in the head and neck generally the transposed flap is modified. previously triangulated in preparation for it.

as it enhances the motion of the muscles. a difficult plane to achieve consistently since it is not a natural one but must be created surgically. less with the inferior pedicle and often nil with the mid line pedicle. When the secondary defect has been closed by direct suture. Another variation is the flap which runs vertically from the zygomatic arch instead of curving across the forehead. In passing from the distal segment to the bridge segment it is usual to deepen the plane immediately to the standard surgical one just superficial to the pericranium to make sure that the maximum of axial vasculature is included this is liable to destroy the nerve supply to the forehead muscle medial to it but this has to be accepted. or directly by dissection at the margin of a surgical resection in the posterior maxilla. Vertical mattress sutures are sometimes required to counter the inversion. the average volume of the buccal fat pad was 9. The flap is carefully mobilized by blunt dissection. The fat pad is typically encased within a thin fascial envelope which aids in . It is in intimate contact with the facial nerve. the bridge segment can either be discarded or returned to its original site. transverse facial and internal maxillary arteries.and excision of spread epithelium are both scrupulous and even this does not entirely eliminate the tendency.3-11. parotid duct and the muscles of mastication.6 ml (8. and is termed a syssarcosis. using as its axial vessel the posterior branch of the superficial temporal artery instead of the more usual anterior branch. The distal segment is often raised between muscle and skin. The extent of the palsy is greatest with the lateral pedicle.9 ml). Variations in hair distribution the presence of baldness extend the possible variations in flap. Use of the fat pad as a free graft has been reported by Neder. It receives arterial blood supply from branches of the facial. It is delivered into the defect passively once adequate mobility is obtained. The buccal fat pad lies within the masticatory spaces. Commonly used Local maxillofacial defects : and regional flaps in the reconstruction of LOCAL/RANDOM PATTERM FLAPS: Buccal fat: The first reported utilization of the buccal fat pad as a pedicled flap was by Egyedi on the successful closure of oral antral and/or oral nasal communications following resection. Technique: It is assessed via a mucosal incision in the maxillary vestibule in the second molar region .

The flap is raised in the subcutaneous fat plane and then tunneled through an incision in the buccal mucosa. Second procedure for the division of the pedicle is not usually required. The fat is sutured into position with absorbable sutures. A defect of 4 cm can usually be covered adequately. Anteriorly based are useful for vermilion or floor of mouth repair. retromolar or lateral floor of mouth defects. Technique: A finger shaped flap is marked our on the lateral surface of tongue from the circumvallate papillae to 1-2 cm behind the tongue tip. The superiorly based flap can be transferred to an intraoral location for the closure of oral antral fistulae. The disadvantages are: limited donor tissue. facial scarring and a second surgical procedure is extremely difficult to use in dentate patients. A posteriorly based flap is helpful in the reconstruction of defects of the tonsillar. The flap is raised with a combination of blunt and sharp dissection through the tongue muscle.this dissection. approximately one third of the tongue can be used. Nasolabial: It is used for the reconstruction of facial skin defects of the upper lip. The donor site is closed primarily in a layered fashion. best results are obtained if the tongue tip is not violated. It can also be utilized to provide increased soft tissue bulk over reconstruction bars. It is adequately vascularized to allow its transfer to cover defects of the maxilla and cheeks. The pedicle requires division at 2-3 weeks to allow inserting of the flap and closure of the orocutaneous tunnel. Tongue: They can be based anteriorly. In elderly. The bilateral inferiorly based flap has utility in the reconstruction of anterior defects of the floor of mouth. nose and check following extirpation of skin cancers. dorsally. posteriorly or bipedicled dorsally. the most common utilization is the reconstruction of the posterior maxilla and soft palate and has also been utilized in conjunction with free bone grafting. . Partial necrosis has been reported in irradiated tissue and can also result from inappropriate tension. Following ablative surgical procedures. A bipedicled dorsally based tongue flap has been described for replacement of the vermilion. The authors allow the fat pad to heal secondarily and rapid mucosalization takes place within weeks. a flap of 5 cm width can be harvested. The donor site exhibits slight edema for the first few weeks. The blood supply is derived from branches of the facial artery. Dorsally based is most useful for closure of residual cleft fistulae of the hard palate. if it is transferred too great a distance. Technique: It requires the development of finger shaped flaps in the redundant tissue of the nasolabial fold.

Cutaneous perforating arteries pierce the platysma muscle and form extensive branches in the subdermal plane. redundant uvula who have undergone a resection of the posterior hard palate or part of the soft palate. Uvula: The uvula shows great variation in size between individuals. AXIAL PATTERN/FLAPS FASCIAL/FASCIOCUTANEOUS: Submental The submental artery arises from the facial artery 5-6. The submental vein runs with the artery.5 cm in width. These vessels are coagulated. It is easily identified in a groove on the medial surface of the submandibular gland. platysma and digastric muscles are present. The tongue flap remains. the uvula provides an easily harvested source of muscle and mucosa. It passes anteriorly between the gland and the mylohyoid muscle giving off multiple branches. foe example buccal fat pad and can be used to provide mucosa for the oral and nasal surfaces of the hard palate as well. its average diameter is 2.3-3.2 mm. further decreasing mobility. The skin teritory ranges from a 4 x 7 cm to a maximum of 15 x 7 cm. In cases of patients with field changes the surgeon runs the risk of transferring tissue to the site of the ablative operation that has potential for malignant degeneration. Usually used to cover other flaps.multiple small bleeders will be encountered. Additional muscular branches to the mylohyoid. The main disadvantage is the limited arc of rotation and its small size. The flap also remains useful as an emergency flap when prior reconstructive efforts have failed. the donor site has typically received significant radiation. It is best to avoid shortening the tongue by closing it on itself. Technique: A suture is passed through the tip of the uvula and provides traction. while a mucosal incision is made on the side nearest the defect. The result is a mobile tissue with dimmensions of 2-3 cm in length and 1-1. In patients who have a long.5 cm from the origin of the facial artery on the external carotid. In secondary reconstruction. . best means of restoring bulk with an adequate color match in the region of the vermilion. The donor site is closed in two layers. The muscularis uvulae is split by sharp dissection and it is then unrolled from its base to the tip of the uvula.

taking care to protect the marginal mandibular branch of the facial nerve. The incision of the flap is then completed. a major division into anterior and posterior branches occurs about 2 cm above and 2 cm anterior to the superior attachment of the helix. The rich vascular supply assures the survival of tissues grafted to its surface. The submandibular gland is identified and gently retracted posteriorly. The vessels are carefully dissected until the first cutaneous perforator is identified. The flap is inset after creation of the necessary tunneling. Venous drainage is from the superficial temporal vein. platysma. The course of the vein can vary significantly. The vascular pedicle is then dissected proximally as far as necessary. emerging from beneath the parotid gland. abundant and well vascularized tissue with a sufficient are of rotation to reach the majority of areas of the face. Posteriorly is continuous with the occipital fascia. It usually is identified on the superficial aspect of the temporoparietal fascia. The submental artery and vein are found running in a horizontal direction. in the tissue plane between the gland and they mylohyoid muscle. The inferior border of the mandible is palpated and marked. reliable vascular anatomy are of rotation and the ease of elevation make this flap useful for intraoral defect reconstruction. fat and skin are carefully handled to avoid shearing injury to the perforating vessels and the subdermal plexus. . Temporoparietal flap: The aponeurosis has an intermediate extension between the occipitalis and frontalis muscles. The donor site is closed primarily in layers. The dimensions of the available lax tissue are determined by pinching. The earliest reported utilization dates back to 1898. The proximity of the tissue.Technique: The head is extended. It provides with a thin. The upper skin platysma flap is retracted carefully. It may be absent in patients with severe forms of hemifacial microsomia. This flap makes use of the dense communications between the posterior branch of the superficial temporal artery and the retroauricular artery. It is necessary to ligate branches to the gland and muscles to achieve adequate mobilization. The fascia. paliable. oral cavity and oropharynx. The temproparietal fascia is continuous below the zygomatic arch as the superficial musculo aponeurotic system. and a lateral extension also known as the temporoparietal fascia. The vein lies more superficial. It receives its blood supply from the superficial temporal artery. The artery enters near the zygomatic arch where it becomes more superficial. Disadvantages are limited to the incisional scare. The neck is incised through platysma in the submandibular area. The gliding property of the temproparietal fascia has been utilized in extremity reconstruction to cover tendons as a free tissue transfer.

8-3. Above the origin of the temporalis muscle the flap is harvested in a subpericranial plane. The auriculotemporal nerve lies on the temporoparietal fascia and is sacrificed in the dissection leaving an area of anaesthesia of the scalp above the ear. The major advantages are its robust blood supply.5 cm) anterior to the external auditory canal. numbness of the donor site and potential for the development of alopecia. the zygomatic arch can be osteotomized and later replaced with miniplate fixation. band like muscle forming the superficial boundary of the beck and allows successful transfer of a segment of cervical skin to the oral cavity. thinness.Technique: A generous shave and preparation is completed. well camouflaged donor site and ease of elevation. The flap is sutured into position with resorbable suture and is allowed to epithelialize. The temporal branch of the facial nerve crosses the zygomatic arch within. pharynx or face in an unpredictable manner. The flaps are reflected in a subfollicular plane. . lack of skin paddle for flap monitoring. or just superficial to. MUSCLE/MYOCUTANEOUS: Platysma: It is utilized as a means of providing local coverage of defects of the floor of mouth and posterior pharynx. The doppler probe is used to outline the course of the superficial temporal artery. The plasma muscle is a thin. The major blood supply to the platysma is the submental branches of the facial artery. or it can be skin grafted. the temporoparietal fascia an average of 2 cm (range 0. The motor nerve supply to the muscle is supplied by the facial nerve. The major donor site complication is alopecia. Avoidance of injury is accomplished by limiting the dissection of the temporoparietal fascia anteriorly to above the anterior branch of the superficial temporal artery. lack of hair. Careful identification and protection of the superficial temporal vein is required. A vertical preauricular incision is made in the skin with the bifurcation at the superior temporal line. The vascular pedicle is then carefully skeletonized to allow free rotation without kinking of the vessels. It extends as an extremely thin and variable muscle from the clavicles superiorly where it is continuous with the superficial musculo aponeurotic substance (SMAS) and has some attachments to the mandible. Flap is then outlined within the temporoparietal fascia with extension to the galea. Blunt dissection is carried out to allow passage of the flap into the area of the surgical defect. At the superior temporal line the dissection is carried out within the areolar plane between the temporoparietal fascia and the superficial layer of the deep temporal fasica. Disadvantages are limited rotation.

The viability of the skin paddle is not reliable. with a report by Glovine on the use of it for the obliteration of dead space following orbital exenteration. The cervical incision of choice is the McFee incision. Following the elevation the platysma muscle is divided inferiorly. The flap is then passed beneath the central limb of the McFee incision in preparation for its insetting. The arterial blood flow is distributed mainly in the medial and lateral portions of the muscle with . Paddle is taken from the inferior extent of the neck flaps. Its use in intraoral reconstruction was popularized by Tiwari for reconstruction of oral defects following the ablation of small tonsil and retromolar fossa cancers. The anterior deep temporal and the posterior deep temporal arteries are branches from the internal maxillary artery. This flap should not be utilized in previously irradiated patients because the viability of the flap and the skin are questionable. The flap may be used for floor of mouth. Technique: At the completion of the neck dissection the inferior border of the mandible is exposed in a subperiosteal plane. The origin of the temporalis muscle is along the surface of the lateral skull at the temporal line. The masseteric artery passes through the notch and should be carefully protected.Technique: Most commonly utilized in conjunction with a neck dissection. The muscle inserts on the coronoid process of the mandible and is a powerful elevator of the mandible. The superior and inferior limbs are made in a deep subcutaneous plane preserving the integrity of the thin platysma muscle. The importance of this work is the recognition of the bipennate nature of the flap and gives scientific basis for the methods described for the splitting of the muscle in clinical use. It is dissected to the level of the coronoid notch. Temporalis: The use of the temporalis muscle for began in 1898. It is sutured there with restorable suture. The temporalis muscle receives arterial blood from three arteries. Masseter: It has been utilized for many years in the reanimation of the paralyzed face. in such cases. The middle temporal artery arises from the superficial temporal artery just below the zygomatic arch. The tumour is then resected in continuity with the neck dissection. check neck and pharyngeal defects. Masseter muscle is elevated from the lateral surface of the mandible. The dissection is continued on the deep surface taking care not to injury the vascular supply. When the tumour margins have been confirmed clear by frozen section the masseter muscle is transposed to the posterior edge of the mylohyoid muscle.

It runs superiorly to the cephalic extent of the muscle paralleling the direction of its fibres. When doing so the masseteric artery must be protected. . The secondary arises run at right angles to the primaries to interconnect. It is possible to maintain axial blood flow within a flap split in the sagittal plane. the venous network closely follows the arterial distribution. The anterior deep temporal artery arises from the internal maxillary artery and enters the temporalis muscle at its anterior inferior aspect. It arises from the superficial temporal artery and enters the posterior inferior aspect of the temporalis muscle. Technique: A hemicoronal incision with or without anterior and posterior releases is utilized. in which a tempororparietal flap is additionally required. the superficial layer of the deep temporal fascia is incised 1. Dissection in the plane is generally bloodless. Only the quantity of muscle necessary for reconstruction is harvested. The dissection is then continued subperiosteally along the zygomatic arch and the entire temporalis muscle is exposed.5-2. reliable blood supply. The vessel travels perpendicular to the direction of the muscle fibers. another branch of the internal maxillary artery. The temporalis muscle is raised from the skull by dividing its fascial origin above the temporal line. It may be necessary at times to perform an intraoral coronoidectomy to further mobilize the temporalis muscle. The advantages of the temporalis muscle flap are its ease of elevation. An exception. The initial incision is made to the level of the deep temporal fascia. The unelevated muscle remains viable within the temporal fossa limiting the cosmetic deformity of the flap harvest. enters the muscle at its inferior medial aspect. The result is a biplanar arterial distribution.0 cm superior to the zygomatic arch where it splits into two layers separated by a pad of fat. proximity to the maxillofacial structures and camouflage of the incision within the hairline. The muscle is sutured into position with slow reabsorbing sutures. disturbing the remaining muscle as little as possible. However the course of the middle temporal artery is at an oblique angle to the direction of the muscle fibers. potential facial nerve injury and temporal hollowing. Care is taken to avoid injury to the vascular pedicle on the deep surface of the muscle. The posterior deep temporal artery. It travels superiorly to the cephalic extent. Depending on the bulk and its required rotation it may be passed over or beneath the zygomatic arch. The donor site is closed in layers over a suction drain. It is often preferable to perform an osteotomy or resection of the arch to avoid compression of the pedicle.numerous minor interconnecting vessels. The plane is safe until 1-2 cm above the zygomatic arch where the temporal ramus of the facial nerve is encountered. A subperiosteal pathway is cleared for the transposition of the muscle to the recipient site. Disadvantages include sensory disturbance. In that circumstance the temporoparietal flap is first fully elevated exposing the deep temporal fascia.

maxilla. sometimes superficial and sometimes deep to omohyoid. The artery passes deep to trapezius and at the anterior border of levator scapulate it divides into a deep and a superficial branch. finally draining into the external jugular vein just above the clavicle. Flap is unable to turn except in a gentle curve and this has to be taken into account in the geometry of planning. It also has a supply provided by the transverse cervical artery. 2. At the same time its flexibility is substantially increased. cartilage and skin. but running approximately parallel to it. Elimination of the skin element of the pedicle reduces the safety of the flap to a slight but not prohibitive degree. The bulk which the muscle adds to the flap does however reduce its flexibility. Trazepius: Throughout its length the trapezius muscle has a segmental blood supply derived from vessels which reach its deep surface after passing through the post-vertebral muscles. either from the third part of the subclavian artery or the thyrocervical trunk. The standard picture os of a vein is nearer the surface than the artery. The muscle flap is readily combined with grafts of bone. The flap has also been used in the form of an island flap. The deep branch passes deep to levator scapula. 1. . 3. orbit.The flap has founmd utilization in the reconstruction of the lateral face. the superficial branch continues between trapezius and levator scapulae dividing into an ascending branch and a descending branch. Upper trapezius flap Lateral trapezius flap Lower trapezius flap Upper trapezius flap: This flap is the myocutaneous version of the standard nape of neck skin flap in which the strip of trapezius which directly underlies the skin element is raised along with the skin to form a composite myocutaneous flap. It crosses the lower part of the posterior triangle directly from its point of origin. The pattern of veins is much less constant. cheeks and temporomandibular joint. 1. Three basic myocutaneous flaps have been described which make use of trapezius. reaching the anterior border of trapezius close to the accessory nerve.

approximately 5 cm above the clavicle. 2. The flap in the form of an island can be rotated to allow the skin paddle to replace a mucosal defect. There is becomes continuous with the purely vascular element of the pedicle.Transferred with a skin-muscle pedicle the flap finds it has main use in providing skin cover. A flap which combines the island form of the upper trapezius myocutaneous flap with the vascular pedicle of the lateral trapezius myocutaneous flap the double blood supply which such a design would provide could be expected to enhance significantly the safety of the transfer. The lower posterior triangle is virtually never the site of metastasis in the clinical situation potentially suitable for the flap so that its use is unlikely to compromise resection. namely the 12th thoracic spinous process. Its anterior border corresponds approximately to the anterior margin of trapezius and from there it extends backwards and downwards in the general direction of the spine of the scapula. Lateral trapezius flap: This flap is based on the transverse cervical arterio-venous system. Lower trapezius flap: This flap makes use of the anatomical fact that the descending branches of the transverse cervical arterio-venous system run over the deep surface of trapezius in the general direction of its lowest point of origin. In order to be certain of including the vessels in the flap both the muscle element and the skin should extend above the point at which the transverse cervical vessels disappear deep to trapezius. 3. The flap can be used in conjunction either with a radical or a functional neck dissection. branches entering the . The pedicle tolerates the curve to bring the flap forward but the combination of skin and muscle does not permit the torsion which is also required if mucous membrane is being replaced. The vessels reach the muscle approximately 5 cm above the clavicle the length of the pedicle in the posterior triangle can be measured accurately and the pivot point pinpointed. The course of the artery is generally reliable. difficulty concerns the vein and whether it reaches the external jugular vein or passes down behind the clavicle beyond the reach of safe dissection. i.e. The island of skin with the underlying muscle is raised from levator scapulae and elevation of the muscle segment of the pedicle is continued forward at a width similar to that of the island to the anterior border to trapezius. The pivot point of the transfer is the medial end of its feeding arterio-venous system. The double pedicle would however limit the ways in which the flap could be transferred and its reach within the oral cavity.

The principal ones enter its upper half and consist of two branches of the occipital artery. The vessels do not enter the muscle belly immediately but run over its deep surface in a generally downward and medial direction and branching as they go. Sternocleidomastoid: This muscle does not have a localised vascular hilum. The inclusion of the muscle improves the poor viability record of that flap. is the surface making of the neurovascular hilum of the muscle. It is not recommended for routine use. One of the technical problems of the lower trapezius flap. Using this system it is possible to construct a skin paddle overlying the lower trapezius and raise it on a muscle pedicle similar in breadth to the skin island and passing upwards towards the point at which the vessels reach the muscle i. A myocutaneous flap was described by Owens (1955) and is the myocutaneous counterpart of the sternomastoid skin flap. Sternomastoid has also been used as a pedicle to allow transfer of a segment of clavicle in order to reconstruct mandible. Trapezius might be left undisturbed above the level of the scapular spine when the muscle pedicle is being designed so that a degree of accessory nerve function can be maintained. When either of these procedures has been carried out an island sternocleidomastoid myocutaneous flap cannot be used. A radical neck dissection remvoes sternocleidomastoid and a functional neck dissection disrupts its blood supply. . not immediately obvious. concerns the thickness of trapezius along its anterior border in the lower part of the neck. The point 2-3 cm medial to the carocoid process. It is supplied segmentally by vessels which enter it at intervals along its length in the neck. The island sternomastoid myocutaneous flap has very severe restrictions. Pectoralis major: The vascular basis of this flap is the pectoral branch of the acromio-thoracic axis and its associated veins. an upper entering the muscle alongside the accessory nerve and a lower arising close to the origin of the parent vessel and a branch of the superior thyroid artery. The thickness makes it difficult to hinge the flap upwards without endangering its blood supply and the bulk created by the curve is not easy to accommodate without compressing it if the skin is directly closed over. The lateral thoracic vessels also contribute to the blood supply. 5 cm above the clavicle.e.muscle en route.

3-4 cm beyond the muscle on to the abdominal skin probably represents an average extreme and in this extension the aponeurosis overlying rectus abdominis should be raised with the flap. about the level of the 6th rib. The muscle fibres are incised and the flap is elevated from the chest wall. adiposity and muscular development of the patient. The complex can be excised from the flap and grafted back on its original chest site. 1979). one for oral lining. turning down to meet the skin paddle. the ribs.Vessels also reach the muscle from perforating branches of the internal mammary system as well as from branches of the intercostals and injection studies indicate that the several systems communicate freely. The simplest and most direct approach uses a skin incision which passes directly downward and medially from the surface marking of the vascular hilum to meet the skin paddle. or as an island flap (Baek et al. The use of such an incision. In the male patient the lateral extension can include the nipple-areolar complex. the other for skin cover. particularly it size. the skin element extending the entire length of the flap. depending on the geometry of the transfer. sex. The skin incisions are deepened to the muscle which is sectioned in the same line as the skin. 1979). In the female the breast. If it is considered that it is desirable to have a deltopectoral flap available in reserve the incision used to expose the muscle can follow the outline of a deltopectoral flap. The muscle fibres are incised and the times be narrowed. This incision precludes absolutely any subsequent use of a deltopectoral flap. the intercostal muscles and pectoralis minor. it is sometimes possible to avoid dividing the lateral thoracic vessels. is a significant factor in determining the safe extension. allow a combined pectoralis major myocutaneous flap and deltopectoral flap to be used simultaneously. Extension may have to be medial more than lateral and downwards. If an island flap is used the paddle to be transferred is outlined on the skin which is then incised down to muscle or aponeurosis. The skin element of the flap can be designed with a composite skin ± muscle pedicle (Arivan. . When an island flap is used the skin paddle lies below and medial to the nipple. The width of the muscle pedicle is usually made similar to that of the paddle although once the flap is raised and its arterio-venous network is visible the pedicle can sometimes be narrowed. If a composite skin-muscle pedicle is used the parallel lines of the skin element are centred on the surface marking of the neurovascular hilum. The pivot point is the neurovascular hilum of the muscle though. The safe extension varying with the age.

makes it possible to tailor the width of the proximal muscle pedicle. The clear visualisation of the vascular pedicle.Towards the lower end of the line. The skin paddle transferred has varied from almost horizontal to more oblique following the line of the underlying muscle fibres. The oblique construction has the further advantage that the procedure can be carried out without need to move the patient from the usual supine position other than to abduct his arm. The artery and vein to serratus anterior are divided and nearer the axillary vessels the circumflex scapular vessels and any unnamed branches are also sectioned. are not divided. remembering that towards its origin the muscle is thin along this border. Its use in head and neck reconstruction (Quillen et al. The outline of the skin island is incised down to muscle and elevation is commenced anteriorly. Near its insertion the subscapular artery arises from the axillary artery and with its venae comitants passes downwards in the general direction of the muscle. at the same time making sure that the vessels supplying the island. . continuing on as the thoracodrsal artery to enter the muscle approximately 10 cm from its humeral insertion. and the true line may be as much as 3 cm in front of the estimated one. Dissection proximally is continued only as far as the geometry of the transfer dictates.Latissimus dorsi: It originally designed for defects of the chest wall. The skin incision is extended from the island upwards along the anterior border of the muscle and continuing dissection allows the muscle increasingly to fall back as elevation proceeds. When the anterior border of the muscle is reached the plane of elevation is continued deep to it. The line of the anterior border of the muscle is marked out on the skin pre-operatively. exposing the vessels which enter the muscle on its deep surface. Latissimus dorsi form part of the posterior wall of the axilla as it converges on its tendinous insertion into the upper humeral shaft. the skin island is outlined. About 4 cm from its origin it gives off the circumflex scapular artery. 1978) represents an extension of the technique. displaying further the blood vessels on its deep surface. With a pedicle limited to its vascular component it is naturally essential to avoid all traction during and after transfer of the flap. sharp dissection being required to divide the attachment of muscle fibres to the ribs. usually the anterior branches of the thoracodorsal vessels. The branching vessels run generally parallel to the muscle fibres. but if need be the entire muscle pedicle can be divided.

Axial flaps. full-thickness grafts should be preferred.When pedicle and flap are more bulky the direct route to the neck is under pectoralis major and a window has to be cut in the muscle to allow passage. when large intra-extraorally perforating defects have to be covered. There is no continuous superficial fascia overlying the muscles. Closure of tumour related perforating skin defects below the occlusal plane can be reliably and conveniently achieved by a pedicled tissue transfer. The length to width ratio is supposed to be no larger than 2:1 in most regions of the body surface. local random pattern flaps are used for the closure of facial skin defects. For this reason. . in most cases. Entire facial skin is equipped with a rich dermal-subdermal vascular plexus and is particularly intense in the area of the cheek and the nasolabial fold. axial flaps are only used in the forehead region. The main virtue of this flap lies in the large area of skin which can be transferred. as split-thickness grafts often provide inadequate thickness for fully satisfying esthetic results and tend to show discoloration by increased pigmentation. are therefore impossible to dissect without violation of the facial nerve function. Thus. a pectoralis major island flap or a pedicled transfer of the latissimus dorsi. In general. which include the facial artery. Suitable flaps for these locations are the detropectoral flap. The anatomical basis of local flaps in the facial area is different. Pedicled transfer of myocutaneous flaps or free vascularized myocutaneous and fasciocutaneous grafts are the reconstructive means of first choice in these cases. If the donor defect cannot be closed directly it is probably wise to use as a delayed graft. voluminous flaps with a bulk of viable soft tissue are required to provide both volume substitute and safe defect coverage. which usually facilitates the dissection of pedicled skin flaps and the facial nerve limits the depth of dissection to a level above the mimic muscles. where the supratrochlear artery. it can be upto 3:1 in the maxillofacial area. facial skin is best repaired by pedicled transfer of facial skin itself. Skin repair in the head and neck region by local flaps comes to its limits. AN OVERVIEW OF THE PRINCIPLES OF RECONSTRUCTION Principles of soft tissue reconstruction: If non-vascularized transfer of skin is considered. the frontal artery or the superficial temporal artery can be included.

In larger defects situations. in cases of posttraumatic atrophy or congental hypoplasia. Non-vascularized transfer of fat tissue has been subject to resorption of up to more than 50% of the grafted volume in the long term. when in deepithelialized myocutaneous flaps are used to fill in defects of the facial contour. In general. which cover more than two third soft the facial height and require correc5tion by a flat but subtle soft tissue augmentation. vascularized transfer is considered to be a precondition for successful grafting of fat tissue. On the other hand. muscle and cutancous tissue. the rectus abdominis or the parascapular flap. as the transfer of muscles is associated with a division of the nerve supply on the one hand causing shrinkage of graft volume due to denervation atrophy. One of the vasularized free flaps most frequently used for the replacement of subcutaneous soft tissue is the deepithelialized parascapular flap. Reconstruction of subdermal tissue Reconstruction of subdermal tissue may be necessary in postresectionaldefects. In soft tissue defects. The two aims are difficulat to achieve at the same time. Another frequently used donor site for vasularized fat grafts is the groin area. Due to necrosis and subsequent replacement by connective tissue. a vascularized flap form the forearm of the lateral thigh may be the method of choice. additional transfer of muscle tissue of fat tissue may be required using the latissimus dorsi. Reconstruction of muscles Reconstruction of muscles combines both the replacement oof muscle volume and the reinstitution of muscle function. If the defect is shollow and there is not too much volume to be replaced. where the skin surface has been preserved. fat and muscle can be used for the correction of theses deformities. is the long term maintainance of the grafted tissue volume after term maintainance of the grafted tissue volume after transfer to the recipient area. For this reason. This flap offers adequate volume and has a reliable vascular anatomy. involving bone. Free vascularized grafts are preferble such as a fascioucutancous or myocutaneous flaps.Posterior defects may be likewise suitable for closure by a trapezius flap. Other grafts of relevance for the correction of soft tissue deficits may be the latissimus dorsi muscle flap and the rectus abdominis muscle flap. The major problem of any flap used of the augmentation of soft tissue contour and volume in the head and neck region. denervation atrophy can cause and unpredictable reduction correction of volume and contour with the option of secondary surgical reduction. However. the specific arcade-like vascular architecture. it is clear that even reinnervated muscle grafts are unlikely to replace the lost muscle function . however. However for defects above the occlusal plane and extensive defects. but underdevelopment or loss of subdermal soft tissue have resulted in a volume deficit and loss of contour deviation.

desquamationof the surface epithelium and hair growth occurs. the movements of the soft plate and the function of the tongue muscles. subcutaneous scarring with subsequent flap shrinkage. when large mucosal defects were associated with extensive loss of soft tissue volume in subtotal or glossectomies. The use of these skin flaps. Not all of the muscles in the oral and maxillofacial region require reconstruction movements of the facial muscles. pedicled arterialized skin flaps from the forehead and form the deltopectoral region have long been used as standard means of reconstruction of intraoral soft tissue. This can be accomplished by the vascularized transfer of the rectus abdominis and the latissismus dorsi muscle with an overlying skin area for closure of the mucosal defect. has shortcomings in terms of are long-term graft performance. Reconstruction of intraoral mucosa Superficial defects in the floor of mouth and the cheek may be repaired by avascular transfer of split thickness skin grafts. With complete defects. . The use of small bowel grafts for repair of large mucosal defects had considerable improved the functional results. Skin contracture.completely. however. The replacement of tissue volume rather than the closure of the surface defect appears to be of major functional importance. However. Facial reanimation after long standing paralysis of the facial nerve has made a great progress with the transfer of neurovascular segments of the gracilis muscle or the pectoralis minor muscle. if the defects were located unilaterally in the floor of the mouth and the cheek.

4. Maxillofacial surgery ±vol 1.J Oral Maxillofacial Surg 67:1460-1466. Petersons principles of oral and maxillofacial surgery Reconstructive surgery ±fonseca vol 7 Langdon patel ±maxillofacial surgery Oral and maxillofacial surgery clinics of north America-soft tissue flaps-vol 7 5.References : 1. Closure of oroantral communications with Bichat¶s Buccal Fat Pad .2009 . 2.by Peter Ward Booth 6. 3.