The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
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Original Title
Local and Regional Flaps in Head and Neck Cancer / orthodontic courses by Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
www.indiandentalacademy.com PECTORALIS MAJOR MYOCUTANEOUS FLAP Ariyan 1970 www.indiandentalacademy.com Anatomy Origin Vessels Function
www.indiandentalacademy.com large fan-shaped muscle that covers much of the anterior thoracic wall. To a variable extent, it overlies the pectoralis minor, subclavius, serratus anterior, and intercostal muscles. origins -three portions. 1 cephalad -medial third of the clavicle. 2 central,-sternocostal-sternum &cartilages of the first six ribs 3 aponeurosis of the external oblique, is variable in size. www.indiandentalacademy.com vessels
www.indiandentalacademy.com PECTORALIS MAJOR MYOCUTANEOUS FLAP Superior and lateral thoracic arteries - additional pedicles Overlying skin additionally supplied by intercostal perforators 3 subunits each with its own vascular & motor supply www.indiandentalacademy.com functions adduct and medially rotate the arm It becomes active in internal rotation of the arm only when working against resistance. upper muscle fibers help to flex the arm to the horizontal level; the lower fibers assist in arm extension. Contraction helps to extend the arm to the individual's side, but it plays no role in hyperextension beyond that point. loss of the dynamic activity of the pectoralis major appears to be well tolerated Much of the adductor activity is compensated for by the powerful, latissimus dorsi muscle, which makes up the posterior axillary fold. www.indiandentalacademy.com PECTORALIS MAJOR MYOCUTANEOUS FLAP Types www.indiandentalacademy.com PECTORALIS MAJOR MYOCUTANEOUS FLAP ADVANTAGES One stage Generous portion of skin & soft tissue(400cm2) Consistent blood supply highly reliable Adequate arc of rotation for facial defects Donor site can be closed primarily Two skin islands on the same muscle paddle Protects the carotid artery Technically, the flap is ease to elevate
www.indiandentalacademy.com PECTORALIS MAJOR MYOCUTANEOUS FLAP DISADVANTAGES Arc of rotation limited for oromaxillary defects It can be too bulky There is distortion of symmetry at the donor site Shoulder function is impaired Distal skin of the flap is not reliable
www.indiandentalacademy.com Methods to Improve the Arc of Rotation Ariyan's -incorporated a long segment of skin that extended from the clavicle to the caudal extent of the muscle. Distal skin paddle placed over the caudal extent of the muscle Maghee- skin paddle extended over rectus abdominus Lee and Lore -removal of a segment of the clavicle to gain up to 3 cm of length. Wilson et al. -tunneling the muscle pedicle deep to the clavicle in a subperiosteal plane .
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www.indiandentalacademy.com Methods to Deal with Excessive Bulk Sharzer et al. - harvesting a vertically oriented "parasternal skin paddle that extended across the sternum to the opposite internal mammary perforators. www.indiandentalacademy.com Murakami et al. -eliminating the skin paddle entirely. two-stage procedure a split-thickness skin graft was placed over the muscle 3 to 4 weeks later harvest the muscle-skin graft unit. Maintain nerve supply or not
Methods to Deal with Excessive Bulk www.indiandentalacademy.com Methods to Achieve Two Epithelial Surfaces for Reconstruction of Compound Defects www.indiandentalacademy.com Gemini flaps www.indiandentalacademy.com POTENTIAL PITFALLS Incidence of total flap necrosis was reported to be 1.0%, 1.5%, 3%, and 7%. Partial flap necrosis- 14%-30% Pedicle compression In male patients may lead to problems with excessive hair growth in the oral cavity or pharynx
www.indiandentalacademy.com www.indiandentalacademy.com TEMPORALIS MUSCLE FLAP Golovine 1898 - orbital exenteration Gilles - reanimation of paralyzed face Fan - shaped muscle arising from temporal fossa & the superior temporal line The muscle is bipennate, with an additional superficial origin from the temporalis fascia
www.indiandentalacademy.com TEMPORALIS MUSCLE FLAP Main blood supply - anterior & posterior deep temporal artery Anterior deep temporal artery & Posterior deep temporal enter the muscle approximately 1cm anterior & 1.7cm posterior to coronoid process respectively This vascular anatomy allows splitting of muscle into anterior & posterior flap
www.indiandentalacademy.com TEMPORALIS MUSCLE FLAP Mobilized flap consists of fascia, muscle, & pericranium Two distinct fascial layers, the superficial & deep temporal fascia Superficial temporal fascia is a thin, highly vascular layer of moderately dense Connective tissue The absence of vascularity between this two layers www.indiandentalacademy.com TEMPORALIS MUSCLE FLAP Hemicoronal flap provides excellent access Incision ends above the superior temporal line Dissections proceeds down to the deep temporal fascia until the entire muscle is exposed Dissection in this plane protects the temporal branch of facial nerve Reflection of the muscle of the temporal bone should be performed in a strict subperiosteal plane Rotation can be improved by dividing ZA & base of the coronoid www.indiandentalacademy.com TEMPORALIS MUSCLE FLAP If the muscle is split in coronal plane posterior portion of muscle is transposed anteriorly Donor site - secondarily reconstructed by alloplastic implants Alopecia avoided by careful placement of coronal incision parallel to hair shaft Bradley & Brock hank - flap does not require skin grafting & rapid mucolization occur
www.indiandentalacademy.com It is relatively short (3 to 5 cm) and thin (2 to 3mm) and has a contraction capability of 1 to 1.5 cm flap has a rotational radius of 8 cm it is possible to cover defects of the mastoid, cheek, pharynx, and palate. www.indiandentalacademy.com TEMPORALIS MUSCLE FLAP ADVANTAGES Ease of elevation Reliable blood supply Proximity Camouflage of incision with in hair line Muscle support graft & alloplast well DISADVANTAGES Sensory disturbances Potential facial nerve injury Temporal hallowing
www.indiandentalacademy.com www.indiandentalacademy.com www.indiandentalacademy.com STERNOCLEDOMASTOID MYOCUTANEOUS FLAP www.indiandentalacademy.com STERNOCLEDOMASTOID MYOCUTANEOUS FLAP Long strap muscle Muscular origin Tendinous origin Insertion Branch of spinal accessory nerve Dominant blood supply branches of occipital artery & its draining vein Middle third of the muscle Inferior third of the muscle www.indiandentalacademy.com STERNOCLEDOMASTOID MYOCUTANEOUS FLAP REPORTED INDICATIONS Provision of epithelial lining for mucosal reconstruction Closure of orocutaneous fistulas Release of scar contracture in submandibular & angle region Provision of additional vascularized tissue around a bone graft when the tissue bed has been heavily irradiated www.indiandentalacademy.com STERNOCLEDOMASTOID MYOCUTANEOUS FLAP Superior blood supply 6 x 8 cm paddle of skin Skin paddle should be kept overlying the muscle above the level of clavicle Skin paddle is tacked down to the muscle fascia Muscle dissected & elevated by incising the fascia www.indiandentalacademy.com STERNOCLEDOMASTOID MYOCUTANEOUS FLAP Inferior blood supply Branches of superior thyroid artery are noted to enter the anterior aspect of muscle at the level of carotid bifurcation www.indiandentalacademy.com MASSETER FLAP Lexer and Eden in 1911 Short, flat, thick quadrangular muscle Superior belly - downwards & backwards Deep belly - vertically & slightly forwards Massetric nerve & artery Hemimandiblectemy. suturing the masseter to the hyoid bone to assist in laryngeal elevation during swallowing. www.indiandentalacademy.com Does not restore emotional mimetic movements Muscle eliminated in extensive ablative surgery Limited in size & volume Does not have skin paddle Restricted arc of rotation
www.indiandentalacademy.com DELTOPECTORAL FLAP First axial pattern skin flap The base of flap is parasternal includes the first three or four perforating branches of internal mammary artery, second perforator is largest Artery as rich anastomosis, accompanied by Vein It extend laterally over the upper chest at the level of clavicle on to the deltoid muscle & shoulder Width 8 - 12 cm, Length 18 - 22 cm reverse of deltopectoral flap - Thoracoacromial flap www.indiandentalacademy.com DELTOPECTORAL FLAP ADVANTAGES High biologic dependability Readily accessible Arc of rotation 45 - 135 May be used in male, female & children Hairless skin
www.indiandentalacademy.com DELTOPECTORAL FLAP DISADVANTAGES Donor site require skin grafting Moderate amount of scarring & deformity is unacceptable in women Physiologic disadvantage in malnourished patient or post operative irradiation Flap should not be used if previous scarring on donor area www.indiandentalacademy.com DELTOPECTORAL FLAP Superior incision is placed just below the clavicle inferior one run parallel to it Flap raised from lateral extent medially Incision is carried down through the pectoral fascia Plane of dissection is sub fascial Dissection proceeds up to 2 cm of lateral border of sternum Back cut on medial aspect - improve the flap rotation 90% success rate
www.indiandentalacademy.com www.indiandentalacademy.com PLATYSMA FLAP Extremely thin band like & variable muscle forming superficial boundary of neck Arises from clavicle superiorly continues with the attachment to the mandible Submental branch of the facial artery Flap size Muscle - 10 x 10 cm to 10 x 20 cm skin paddle - 3 x 6 cm to 6 x 20 cm
www.indiandentalacademy.com PLATYSMA FLAP ADVANTAGES Proximity & Regionality Thin & delicate Reliable when vascu- - lar criteria adhered Arc of rotation - 180 No donor site disability
DISADVANTAGES Lack of bulk Hair bearing in male Reliability 85% Complication like skin loss & fistula
www.indiandentalacademy.com TRAPEZIUS FLAP Mutter 1842 Originally described as superior based cutaneous flap Flat & triangular and cover the superoposterior aspect of the neck & shoulder Dominant pedicle, the transverse cervical artery Functions to rotate the scapula & to elevate, rotate & adduct upper arm 10 x 20 cm in size
www.indiandentalacademy.com TRAPEZIUS FLAP Lateral positioning of patient to elevate flap Ideally suited for radical parotidectomy Limited to small defects in oral cavity
Generous amount of soft tissue & large portion of skin island 90 95 % of success
www.indiandentalacademy.com TRAPEZIUS FLAP ADVANTAGES Flap is versatile Regionality of flap Strong vascular security Supplies considerable bulk Arc of rotation 90 180 degree One stage procedure Minimum deficit at donor area www.indiandentalacademy.com TRAPEZIUS FLAP DISADVANTAGES Venous system difficult to preserve Vascular supply in general difficult to preserve Can present with excessive bulk Cannot be easily tubed Moderate shoulder drop postoperatively www.indiandentalacademy.com LATISSIMUS DORSI MYOCUTANEOUS FLAP Distant flap, provides largest possible skin paddle, involves the most complex donor site dissection, and arc of rotation extremely versatile Donor site skin paddle measures 40 by 25 cm & still allows primary closure The latissimus dorsi is very broad muscle of the back with a fascial origin from T7 to T12, from the lumbar & sacral vertebrae, from posterior crest of the ilium & also minor origination from the last four ribs www.indiandentalacademy.com LATISSIMUS DORSI MYOCUTANEOUS FLAP Insertion on the intertubercular groove of the humerus Extend, adduct, & medially rotate the arm Major pedicle is thoracodorsal artery, a terminal branch of the subscapular artery Perforators enter the muscle medially along the spine secondary supply
www.indiandentalacademy.com LATISSIMUS DORSI MYOCUTANEOUS FLAP ADVANTAGES Size largest flap in the body Flap location Arc of rotation - 180 Large, reliable unicentric neurovascular pedicle Donor area 90% success rate
www.indiandentalacademy.com LATISSIMUS DORSI MYOCUTANEOUS FLAP DISADVANTAGES Repositioning of the patient Skin paddle is thick & has strong attachment to the underlying muscle Considerable bulk postoperative sagging & pendulosity Donor area may need skin graft It is in competition with other very suitable flaps www.indiandentalacademy.com conclusion Success in reconstruction of the craniofacial region by local and regional flaps requires knowledge ,careful preop planning, skilled tecqniques, and meticulous care after operation The goal is to return the patient as closely as possible to the preop aesthetic and functional level www.indiandentalacademy.com Thank you www.indiandentalacademy.com REFERENCES Oral and Maxillofacial surgery clinics of North America November 1993 Flaps in Head and Neck Surgery 1989 John Conley and Carl Patow Oral cancer Jatin P shah GRABBS Encyclopedia of flaps Volume 1 Maxillofacial Surgery Vol. 1 Peter Ward Booth Atlas of Regional and Free Flaps for head and neck reconstruction Mark L. Urken Plastic surgery McCarthy.vol-1 Fonseca OMFS Vol-7 Mastery in plastic and reconstructive surgery-Mimis Cohen www.indiandentalacademy.com REFERENCES Oral and Maxillofacial surgery clinics of North America NOVEMBER 1993 Flaps in Head and Neck Surgery 1989 John Conley and Carl Patow Oral cancer Jatin P shah GRABBS Encyclopedia of flaps Maxillofacial Surgery Vol. 1 Peter Ward Booth www.indiandentalacademy.com Defect PMMC VERTICAL TREPIZIUS PLATYSAMA DELTO PECTROL ORAL MUCOSA mnd intact Centrl mnd defects Lateral mnd - male - female
1 st
1 st
2 nd
2 nd 1st
1 st
EXT FACIAL DEFECT Mand intact Mand defect
3 rd 2nd
2 nd
1 st
1 st 2nd www.indiandentalacademy.com
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