Flaps for Maxillofacial Reconstruction

(Reconstructive Surgery)

Flaps for Maxillofacial Reconstruction

Flaps for Maxillofacial Reconstruction

Flap: any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply.
This is similar to but different from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels.
This is done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic Structures such as the jaw.














Classification of flaps may be defined by the configuration, tissue layers, blood supply, region, and method of transfer."
• Tissue configuration describes the geometric shape of the flap. These flaps include:
rhomboid bilobed,
z-plasty,
v-y,
rotation, and others

• Flaps can also be classified by their tissue content.

These flaps include:
cutaneous (skin and subcutaneous tissue),
myocutaneous (composite of skin, muscle, and blood supply),
and fasciocutanous (deep muscle fascia, skin, regional artery perforators).








• Arterial supply can be used to classify a cutaneous flap as a random pattern, axial pattern, or pedicle flap
Axial Pattern Flap:
A single flap which has an anatomically recognized arterio-venous system running along its long axis. Such a flap, because of the presence of its axial arterio-venous system.

Random Pattern Flap:

has no named blood supply, rather, it uses the dermal (mucosal) and subdermal (submucosal) plexus as its blood supply (depend von the arterioles and capillaries).

• According to its attachment to blood supply

Pedicled flaps:
remain attached to the donor site via a pedicle that contains the blood supply (in contrast to a free flap).


Free flap:
Has no attachment to blood supply that mean its completely removed from its blood supply

• Classification can also be based on the relative location of the donor site:

Local flaps are considered adjacent to the primary defect.
Regional flap donor sites are located on different areas of the same body part.
If different body parts are used as the donor site, the flap is termed a distant flap.















• Description of the flap movement is the most common method of classifying reconstructive techniques:
Advancement flaps.
rotation flaps.
transposition flaps.
interposition flaps.
and interpolated flaps are common techniques

. Advancement flaps use mobilized tissue in a direction toward the primary defect.

Rotation flaps pivot mobilized tissue around a point toward the primary defect.
Transposition flaps are mobilized tissues that traverse adjacent tissue by rotation and/or advancement in an effort to close the primary defect.

When the adjacent tissue is also mobilized to close a defect by secondary movement, the flap is classified as an interposition flap.

Interpolated flaps are mobilized tissues that traverse over or beneath an otherwise non-compromised skin bridge in the form of a pedicle to close the primary defect. The pedicle consists of skin (possibly subcutaneous fat and muscle) and/or. an individual artery and vein used, with adjacent to maintain vascularity of the flap. At least one additional procedure is required to divide a pedicle.

Examples of Flaps used in Maxillo-Mandibular Reconstruction

Palatal Flap: represents the most commonly used local reconstruction in oral and maxillofacial surgery for the closure of oro-antral fistulas following dental extractions. Palatal reconstructive flaps can be unilateral or bilateral, which are pedicle flaps based on the palatine artery and vein.

The entire palatal mucosa can be raised and rotated as a flap or a finger flap alone can be used. The donor area is left for secondary granulation and is mucosa leaved in three to five weeks yielding a smooth surface. The area should generally be protected during healing and can be painful to the patient. In total, up to 16 cm2 can be harvested.






Tongue Flap: Tongue flaps have been used in the reconstruction of local defects of the floor of the mouth as well as in palatal , The flap is easy to raise and can reach 4 to 5 cm depending on the donor site used; dorsal flaps are used for palatal defects and lateral or ventral flaps are suitable for the mandible or the floor of the mouth. Tongue flap can be anteriorly based or posteriorly based. The primary drawback stems from the donor site of the tongue specifically. The tongue is sensitive and all procedures cause scarring, resulting in potential morbidities for the patient that involves speech and feeding. Leaving the tip of the tongue unharmed is of primary importance.

Buccal Fat Pad flap:

Ideally suited for small retromolar and posterior maxillary defects, this axial pattern flap enjoys a strong blood supply with contributions from the buccal and deep temporal branches of the maxillary artery, the transverse facial branch of the superficial temporal artery, and buccinators branches from the facial artery. Within the fat pad, a network of small arterioles and venules are present and care must be taken to avoid disruption of these vessels through over manipulation.

The buccal branches of the facial nerve and the parotid duct are lateral to the fat pad and are usually not encountered during flap development.
If access to the fat pad has not already been created by the ablative procedure, an incision in the vestibular sulcus distal to the maxillary tuberosity through the periosteum will expose the buccal fat pad

BPFF is used to close class I and Il maxillectomy defects, oro-antral communications, and lateral wall and palatal voids. However, defects larger than 4 cm in diameter may not be suitable for reconstruction with a BFPF. Although the buccal fat pad has been used as a vascularized bed to cover a bone graft during maxillary reconstruction,

Facial Artery Musculomucosal Flap:

An intraoral cheek flap. (FAM flap using the facial vessels and can be raised either as a superiorly or inferiorly based flap. in raising the flap, mucosa and submucosa, buccinator muscle and a slice of the orbicularis oris are incorporated into the flap since the vessels are lateral to these structures. The flap can be used to reconstruct the palate, nasal septum, floor of the mouth, lips, as well as the tongue and alveolus. The flap can be up to 3-cm-wide and the full buccal height can be harvested.
The Stensen duct of the parotid gland must be avoided

Temporalis muscle flap:

The external cheek, orbital exenteration, as well as maxillary and oral defects can be reconstructed using this flap. The temporal muscle elevates the mandible from its origin in the temporalis line and the infratemporal crest for insertion into the coronoid process. The temporal fascia consists of the superficial temporo-parietal and deep temporal fascia, further divided into superficial and deep layers.

The muscle lies beneath the deep temporal fascia. These layers feature their own vasculature, with the superficial temporal fascia stemming from the superficial temporal vessels and the temporal muscle stemming from the deep temporal arteries originating at the internal maxillary artery. When harvesting the muscle flap, temporary removal of the zygomatic arch provides additional length to the flap. The flap measures from 12- to 16-cm-long and 0.5- to 1-cm-thick. Major drawbacks include a risk of injury to the facial nerve, postoperative trismus and temporal hollowing.











Submental Flap: In 1993, Martin et al. presented the submental flap, a perforator or pedicle cutaneous flap from the submental region based on the submental branch of the facial artery. This flap features good color match, good reach to the anterior mouth and the donor site is directly closed; typically, The skin paddle can reach up to 10 cm by 16 cm, the pedicle reaches up to 5 cm and the platysma muscle, a part of the mylohyoid, as well as the anterior digastricus muscle are included.












Vascularized Iliac Crest Grafts (example on free composite flap): Vascularized iliac crest flap is one of the principle flaps for bony reconstruction of head and neck defects following resection of benign or malignant conditions of the mandible and maxilla.




The flap is based on the deep circumflex iliac artery (DCIA), which originates from the external iliac artery and gives off branches into the muscle, bone, and skin.










T
H
A
N
K
S