Local & regional flaps /certified fixed orthodontic courses by Indian dental academy

LOCAL & REGIONAL FLAPS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION

• The compelling drive of human beings to reconstruct deficient
or missing parts and the desire of victims to undergo such
reconstruction are best appreciated by recognizing the early
development and use of pedicle-flap transfers long before the
advent of anesthesia. Imagine, the tolerance a patient must
have had to undergo nasal reconstruction using a fore-head
pedicle flap without anesthesia.
• The seminal work of Sushruta in the pre-christian era must
have resulted in meager success; however, the basic principle
behind the “Indian flap” is so sound that the procedure is still
used in contemporary surgery.

• The later-day developments in anesthesia, antibiotics,
hematology, instrumentation, and wound healing
research have given surgeons devoted to
reconstruction the opportunity to achieve results that
would have been considered miraculous only four
decades ago.


History
• Sushruta Samshita, circa,700 B.C. first to describe a facial (forehead) flap for the
reconstruction of a nose.
• 695 A.D., Justinian II of the Byzantine Empire had a flap restoration of his mutilated
nose.
• Gaspar Tagliocozzi (1597), University of Bologna, Italy:
Experimented with the fabrication of noses from the tissues of the upper arm.
• Gentleman’s Magazine (1794), article by Thomas Cruso and James Findlay, "Indian Flap".
• J.D. Carpue (1816) learned this technique and reconstructed two patients in U.K.
• Tansini (1896), described the concept of muscle and skin flap (LDMF)
• George Monks (1898), Boston Medical and Surgical Journal: First island flap ever
designed in the US.
• Owens (1952): SCM flap.
• Conley (1960): Regional flaps.
• Bakamjian (1965): Deltopectoralis flap.
• Ariyan & Biller (1977): Pectoralis flap.


MANUEL LA ROSA-CRAIG, DDS
SOFT TISSUE FLAPS IN ORAL SURGERY
University of Illinois at Chicago
Department of Oral & Maxillofacial Surgery
FLAPS
•
•
•
•

Definition
(1440) Dutch word "flappe": something broad to strike with, specially a flyswatter.
(1522) English: anything that hangs broad and loose, fastened only by one side.
(1807) English (surgical context):portion of the skin or flesh, separated from the
underlying part, but remaining attached at the base.

•
•
•
•

Definition
Mass of tissue having and maintaining its own blood supply.
Describe different tissue transfer techniques
Implied that the tissue to be transferred is to be used for reconstruction.


Definition
A flap is one which contains within its substance a
network of blood vessels, arterial,venous ,cappilaries
and it is the effectiveness of the circulation through
this network in perfusing the tissues of the flap at each
stage of its transfer from donor to recipient site which
determines its survival.


Alternate wound closure tech. include
1.
2.
3.
4.
5.

Secondary healing-small biopsed lesions
Wound contraction-lesions in region of medial canthus
Primary closure-where there is minimal tension
Skin grafting-open wounds with healthy bed.
Many wounds have poor beds and are deeper in nature and
skin grafting would result in unacceptable contour
deformities.


In Irradiated beds use of flaps brings improved blood
supply to the wound .
When major structures are exposed ex: facial nerve and
carotid artery flap coverage of the wound is needed.


GENERAL CONSIDERATIONS
• Criteria for Choosing a Flap:
•
•
•
•
•
•

Adequate amount of skin or mucosa
Adequate bulk
Good location & colour match
Predictable blood supply
Distance from irradiated sites
Low donor morbidity


•
•
•
•
•
•
•
•
•
•
•
•

Basic Principles of Flaps

Plan
Design
Cannot violate its blood supply
Should generously fit the wound
Ratio length:width (avg) 2:1
Avoid areas of tension
Transfer
Avoid kinking, compression, tension or severe angulation.
Always favor gravity and venous drainage.
Positioning
Use always two layers of sutures
Support


CLASSIFICATION


CLASSIFICATION:
By the tissues they contain
• Skin Flaps:
Donor tissue containing skin and subcutaneous
tissue only. Maintains its vascular supply via a
pedicle attached to adjacent tissue.
• Composite Flaps:
Contains more than a single type of tissues
including skin, subq., muscle and/or bone.


By the vascular system on which they are based
Axial
Incorporate an anatomically recognized arterio-venous system running along the long axis of the
flap.
• Random
Does not incorporate a dominant vascular supply, relying on the networks of small diameter
vessels. Facial Skin.
•

By the way o transfer
Pedicle Flaps:
More than a single layer of tissues, which can include skin + subcutaneous tissue and any
combination of muscle, fascia, bone, fat.
• Free Flaps:
Detached at the donor site from arterial and venous connection and reanastomosed at the recipient
site.
•

•

FREE FLAPS
Iliac crest flap
Radial forearm flap
Fibula flap

By method of movement from the donor site
• Advancement
• Rotation
• Transposition


Advancement flaps
• Undermining an area of tissue and advancing it forward to cover a defect.
• Requires pliable and elastic tissue.
Rotational flaps
• Rotation of skin around an arch to fill a triangular defect.
• Design for non-elastic tissues (scalp, forehead).
• Arch of approximately 180 degrees.
• Base at least twice the width of the defect.
Transposition flaps
• Exchange or transposition of tissue to an adjacent site.
• Single or multiple, unilobed or multilobed and of an infinite variety of
shapes and sizes.

By distance from donor site
Local Flaps:
• Donor site is in close proximity with the defect.
• Defect requires minimum amount of tissue.
Regional Flaps:
• Amount of soft tissue adjacent to the defect is not adequate.
• Donor site is distant to the defect area.


Transposition flap
• When a flap moves laterally into the primary defect it is called
transpositional flap.
• It is designed as a square immediately adjoining to the triangular defect.
• Transfer leaves secondary defect which is closed by split skin graft.
• Length : breadth ration should be considered for the safe vascularity
• Rich perfusion in face & scalp enhances the length: bredth restrictions to
be some what relaxed ,allowing the flap to be planned even in absence of
an anatomically recognized axial system.

• In designing the flap and before any inscion is made
the pivot point must be clearly defined and the distance
from it from each point of the flap compared with its
estimated distance to the same point and the
transposition is complete.


• Clinical role of the transpositional flap is confined to
the situations where a secondary graft is not
contraindicated for cosmetic reasons and so it is used
mainly out side the face.


Advancement flap
• The primary motion of this flap is in a straight line from the
donor site to recipient site with out rotation/lateral moment.
• 1. single pedicle:a rectangular skin is moved forward by virtue
of its elastic properties
• 2 Bipedicle: here an incision is made parallel to the defect and
the flap is undermined and advanced
• 3. V-Y flap: with this flaps a V shape incision in the skin is
closed by advancing the sides of the V and closing it in the
shape of Y.

Rotational flap
• Random pattern sliding pivotal flaps with curvilinear design.
• Used to close triangular defects.
• Raised most often on the cheek, extending to a varying degree on a submandibular
region.
• Inferiorly based
• Superiorly based
• Pivot point – base line, approximately mid way.
• Should be designed so that the distance between pivot and any point on circumference
of flap is equal.

Interpolated flap
• Here the donor site is separated from recipient site ,
and the pedicle of the flap must pass over or under the
tissue to reach the recipient area
ex; nasolabial flap for nose reconstruction.


Z-plasty:
• Involves the transposition of two interdigitating triangular flaps.
• Flap transposition fallows naturally from the change in the shape of
parallelogram, as do the lengthening and shortening.
• Single Z-plasty – achieves 2 cm lengthening and 2cm of shortening in
transverse axis.
• Multiple Z-plasty, each of foure Z-plasties achieve 0.5cm lengthening with
a corresponding 0.5cm of shortening at each transverse axis.
• Common usage: treatment of contracted scars
management of facial scars.

Analysis of the defect and planning of reconstruction using local flaps.
• Any defect/deformity in head and neck area presents several choices to
the surgeon in terms of closure and or reconstruction
• Various factors that must be considered:
• 1. origin,condition,size, shape ,depth and location of the defect/deformity
• 2. the condition of the surrounding tissue and its availability for use n
reconstructive procedure
• 3. pts desire and expectations
• 4. surgeons experience and professiency

Viability of flap :
Blood flow in the local skin flap is characterized by intrinsic
vascular architecture, the nature of which determines the
dimensions of the flap that will survive.
Flap creation decreases the cutaneous blood flow and renders it
dependent on only a few vessels requiring the fundamental
capacity of intrinsic vascular system to reequilibrate.


BLOOD SUPPLY:
A.MUSCULOCUTANEOUS ARTERIES
B.SEPTOCUTANEOUS ARTERIES

COMPOSITION:
Cutaneous
Faciocutaneous
Musculocuaneous
Muscle
Osteocutaneous

PATHOPHYSIOLOGY OF FLAPS
• Flaps undergo necrosis secondary to lack of nutrient blood inflow rather than lack of
venous out flow.
• The sympathetic nervous system is primarily responsible for determining blood flow to
the skin.
• Two main ressions:
1)vassoconstriction
2)arteriovenous shunt
•

cutting the skin causes a release of norepinephrine from the severed sympathetic
nerves and the release of thromboxane A from platelets, both of which are potent
vassoconstrictors.

• Arteriovenous shunting is a lack of nutrient blood flow to the distal part of a flap
through pathological AV shunts.
• Closure of these shunts either pharmacologically are spontaniously will lead to
improvement in the sruvival of the distal portion of the flap.

Clinical factors associated with ischemic flap
necrosis:
1.
2.
3.
4.
5.
6.
•
•

Excessive tension from taut sutures
Compressive dressings
Infection
Hematoma
Subcutanious epinephrin
Smoking
Despite fixed length-width ratio rules for flap, widening of the pedicle
will not always improve vascularity in the distal parts of the flap.
However a thicker flap may improve distal vascularity by including
deeper plexus containing larger caliber vessels.


Therapeutic innervations for flaps:
1.
2.
3.
4.
5.
6.
7.

Direct vassodilators- phenethylamines,calcium chanal
blockers and topical nitroglyerin.
Adrenergic blockage-isoflurane
Growth factors-topical endothelial cell GF.
Hyperbaric O2- 48hrs before or 4hrs after surgery.
Decreasing temp
Tissue expansion
Flap delay


 Leech therapy:
Hermaphroditic ectoparasites
Hirudo medicinalis
leech saliva-hirudin ( inhibitor of thrombin, vassodilators and
hyaluronidase)
leech can ingest up to 8-10 ml of blood and wound can continue to ooze
50ml of blood
thus leech therapy is indicated to relieve venous congestion in failing
flap.
 skin flap delay:
tech to increase vascular teritory of a flap prier to its definitive
transfer to recipient site.


MONITERING OF FLAP CIRCULATION
1.
2.
3.
4.
5.
6.

Lasser doppler flowmetry
Thermocupple probe
Temp probe
Pulseoximetry
Fluorescein dye
Doppler ultrasonography


Pivot point
• This point is the center of the arc around which the
flap is moving in its transfer.
• The distance between the pivot point and each point of
the flap prior to transfer must be equal or not less
than the distance after transfer.


LOCAL FLAPS
• Forehead flap
• Temporal flap
• Nasolabial flap
• Labial flap
• Palatal flap
• Tongue flap
REGIONAL MYOCUTANEOUS FLAPS
• Pectoralis major flap
• Trapezius flap
• Deltopectoralis flap
• Sternocleidomastoid flap
• Latissimus dorsi flap
• Temporalis flap
• Masseter flap
• Platysma flap

TEMPORALIS FLAP
•
•
•
•
•
•
•
•
•

TEMPORALIS MUSCLE
Origin
Deep: Temporal fossa calvarium
Superficial: Deep temporalis fascia
Insertion
Coronoid process & anterior ramus of mandible
Innervation
Motor: Anterior and deep temporal branches
Sensory: Auriculotemporal nerve


• TEMPORALIS MUSCLE
• Blood supply
• Deep temporal fascia: middle temporal branch (superficial
temporal artery).
• Anterior deep temporal artery.
• Posterior deep temporal artery.
•
•
•
•
•
•

TEMPORALIS FLAP
Orbital, skull base and small intraoral defects.
Is in close proximity to defect area.
Small scar with minimal cosmetic deformity
Muscular flap only with a good rotational arch.
Facial nerve injury is not uncommon

•
•
•
•
•
•
•
•
•
•
•

MASSETER FLAP

MASSETER MUSCLE
Origin
Deep: inner surface of ZGM arch
Superficial: ant 2/3 lower border ZGM arch
Insertion
Deep: lateral surface of the coronoid process
Superficial: lower portion of mandibular ramus
Innervation
Masseteric nerve (CN V3)
Blood supply
Masseteric artery (internal maxillary artery)


• MASSETER FLAP
• Reconstruction of ablative procedures of parotid gland,
mandible, palate and nasopharynx.
• Treatment & reanimation of paralyzed face.
• Does not restore emotional mimetic movement,
therefore training is necessary.
• Limited arch of rotation, size and amount.


•
•
•
•
•
•
•
•

PLATYSMA MUSCLEPLATYSMA FLAP
Origin
Subcutaneous tissues, caudal to the clavicle and acromion.
Insertion
Just cephalad to inferior border of mandible
Innervation
Motor: Cervical branches of the facial nerve
Sensory: Cervical branches of C2-C4.

• Blood supply: (Randomized)


• Antero superior
– facial, submental, submandibular arteries
• Posteiro superior
– occipital and posterior auricular arteries
• Midportion
– superior thyroid artery
• Inferiorly
– Transverse or superficial cervical arteries
– Direct branches of subclavian arteries


PLATYSMA FLAP
• Close proximity to defects.
• Good arch of rotation.(180 degrees)
• Primary closure of the donor site can be easily done.
• Thin, delicate, pliable flap.
• Vulnerable to radical ablations
• Not suitable where bulk is necessary


FOREHEAD SKIN FLAP
Introduction:- one of the first pedicled flap to be described.
Advantages:• reliability of its vascular supply
• Excellent colour match
• Proximity to the face
• Larger area provided
• Pt not confined to bed with limitation of neck movements as in other flaps.
Disadvantages:• Secondary defect


Anatomy:• Lateral forehead- zygomatic and ant branches of
superficial temporal artery( branch of external
carotid)
• Middle forehead- supplied bilaterally by supra
trochlear artery, supraorbital artery (branches of
opthalamic artery)
• All 4 vessels anastomose and supply forehead as a
whole.


Operating tech:
• Due to large amount of anastomosis of the contraletral
arteries, flap can be elevated from one malar bone to another
• Flap can reach up to 25 cm in length
• Pedicle should not be more than 2 cm wide at its base to
provide max mobility
• Pedicle should of sufficient length to transpose the flap with out
tension
• First, course of superficial temporal artery is marked.


• As the flap is raised , care must be taken not to lift the
periostium from bone, and usage of diathermy should be
minimal.
• If these two are not fallowed, delayed healing of applied skin
graft will result.
• A cosmetic result is achieved by beveling the flap borders by
45 degrees so the marginal step deformity is kept to the
minimum.
• Upper inscission line should be just below the hair line, lower
inscission line just above the eyebrows and at midline it is
carried down to the glabellar region of the nose.
• Donar site closed with a sheet of skin obtained by a dermotome.

NAS0LABIAL SKIN FLAP
Indications:
Bilateral nasolabial flap:
1. Small tumors of the ant floor of mouth
2. Mucosal defect of the lip
3. Ventral surface of the tongue
4. Nose
Unilateral nasolabial flaps:
• Adjoining buccal mucosa,lips ,alveoli,buccal sulci(upper &
lower),palate and tonsillar area


• Anatomy:
• Blood supply: angular.a (branch of ant facial),infraorbital.a ,
transverse facial.a , infra trochelear.a
• These are random flaps because no attempt is usually made to
include any specific arterial supply.
• Because of the rich anastomosis pof arteries and veins,
superior, medial, lateral, inf, pedicles are possible.


• Operating tech:
• Incision is placed passing upwards from base lateral to angle of
mouth and centered approximately along the line of the
nasolabil fold.
• Then the flap is raised superficial to the facial muscles and
stopped a little short of the canthal area.
• Then the tunnel is made through the soft tissue of the cheek
near the base of the flap to take the most direct route to the
defect.


TONGUE FLAPS IN MAX FACS


• Tongue – Excellent donor site because of its abundant
vascularity and low morbidity .
• Tongue has been used in reconstruction of oral cavity since
from 100 years .
• Eiselsberg was first to use pedicled tongue flaps in 1901.
• Cadennat etal described the rich submucous vascular plexus
found in the Tongue and this allows elevation of thin flaps (3
mm).


RANDOM FLAP DESIGN
Dorsal tongue flap: most commonly used
Posterior based : Soft palate,
Retromolar region,
Post buccal mucosa.
Anteriorly based: Defects of Hard palate,
Ant buccal mucosa,
Ant floor of the mouth,
Lip reconstruction.


• Elevation of flap post to the circumvalate papilla is avoided to maximize
flap survival .
• Length of the flap should be sufficient to cover the defect and to allow the
mobility of the Tongue, which can make flap more versatile.
• Following and adequate healing period of 14 – 21 days, the pedicle is
severed.
• Reinserting of maximal muscular bulk is strongly recommended to
prevent post opp tongue deformity.
• Debulking of recipient site should not be performed before 3 months after
separation of the pedicle.


• Lateral Tongue flap:

Buccal mucosa
Lateral palate
Alveolus

• Incisions are made on the ventral and dorsal surface
of the Tongue in a V shaped fashion, which allows
primary closure of the donor site.
• Pedicle is severed at 14th day.


Double Door Tongue flap:
• Large defects of buccal mucosa
extending from the commissure to the
Ant mandibular Ramus.
• Horizontal incision is placed on the
lateral border of the Tongue of the
same length of the defect.
• Flaps are elevated and swung upwards
and downwards and sutured to the
margin of the buccal mucosa defect .
• Flaps are divided after 3 weeks and
the donor site is closed primarily.


•
•
•
•
•

Median Transit Tongue flap:
Defects of Sublingual region.
An incision is made in the Sagittal midline of the Tongue
of the same length as the width of the flap,
Tunnel is created to allow the flap to reach the floor of
the mouth.
The relative avascularity of the median raphe allows
easy formation of the tunnel.
Pedicle is divided after 2 – 3 weeks.


Sliding posterior Tongue flap:
• This flap design allows coverage of lateral Tongue defects and
it is the modification of Hemitongue advancement flap.
• Mayomucosal flap is created by releasing the Tongue from the
Hyoid bone and maintaining the Dorsolingual branch of Lingual A
as feeding vessel.
• To allow the complete mobilization the entire ipsilateral base
must be freed from vertical septum.
Clinical indications:
• Repair of oronasal communication,
• Repair of oroantral communications,
• Lip reconstructions,
• Buccal mucosa reconstructions,
• Reconstruction of Hypopharynx.

REHRMAN BUCCAL ADVANCEMENT FLAP
• Commonly used for closure of
oroantral fistulas.

• Trapezoidal in shape, with its base
at the buccal sulcus to maintain
adequate blood supply.
• Small horizontal relieving incisions
through periosteum at the base of
the flap allows for greater
lengthning.
• Moajor drawback is reduction in
vestibular depth.


MOCZAIR BUCCAL SLIDING ADV FLAP
• Minimizes the reduction in vestibular
depth.
• Similar to rehrman flap but it is shifted
one tooth distally to reduce tension on
vestibular tissues.
• Drawback- when used in dentate
patient, bone is exposed on the facial
aspect of the adjacent tooth.
• So mainly used in edentulous patients.


Buccal transposition flap
• Flap is taken horizontally, parallel to the buccal sulcus,
and may be pedicled mesially or distally.
• After adequate reflection, the flap is rotated 90
degrees to cover the defect.
• Drawback – loss of keratinized mucosa and distortion
of buccal sulcus.


BUCCAL FAT PAD

•
First described by Egyedi in 1977.
Anatomy :
•
Consists of a central body and 4 processes. (buccal, pterygoid,
superfeecial & temporal extensions.
Blood supply:
1.
Buccal and deep temporal branches of the maxillary.a
2. Transversefacial branches of the superfecial temporal.a
3. Small branches of facial.a
INDICATION-closure of oral defects up to an area of 50x60mm and a
thickness of 6mm.


TECH:
• The buccal fat is exposed through a 1 cm vertical incision
placed through the sulcus post to the zygomatic buttress.
• The fat is gently advanced over the defect and secured with
sutures.
• Epithelialization of the exposed adipose tissue occurs between
2 to 4 weeks post opp.
ADVANTAGES:
• Little decrease in vestibular depth
• Low morbidity
• Abundant tissue availability
• Expandable tissue


Palatal flaps


PALATAL MUCOPERIOSTEAL FLAP
(ASHLEY’S FLAP)
• This flap is mainly based on the G.P
artery
• Flap is thick and inelastic, so it must be
made longer than would appear
necessary
• Rotation posterior to the second molar
is not recommended but can be used
for the contralateral side.
• An incision is made along the mid
palatal line just ant to the junction of
hard and soft palate and curved
laterally toward the affected side, when
it has reached the canine and lateral
incissor region.


PALATAL ISLAND FLAP:
• this procedure dissects out
an island of palatal mucosa
but retains its connection to
the G.P artery.


BRIDGE FLAP:
• Incisions are placed
transversly across the line
of the arch with limited on
the palatal side to preserve
the blood supply (GPA) but
can be extended buccally to
reduce tension.


COMPOSITE PALATAL FLAP:
• In this procedure the palatal flap is divided in to an upper
mucosal layer and an underlying connective tissue layer.
• The connective tissue layer is used to cover the defect and the
epithelial layer is replaced over the donor site to allow primary
closure.
COMPOUND FLAP:
• This procedure involves mobilization of both buccal and palatal
flaps over the defect and suturing them to each other.
• Buccal sulcus obliteration is minimised.


ABBE-ESTERLANDER FLAP REPAIR


KARPANDZIC FLAP REPAIR


BERNARD RECONSTRUCTION


PECTORALIS MAJOR MYOCUTANEOUS FLAP
PECTORALIS MAJOR MUSCLE
• Fan-shaped,
• clavicular & sternocostal segments
• Boundaries
• Superior: Clavicle
• Medial: Sternum
• Lateral: Axillary fold
• Fascia connects: serratus anterior & rectus abdominis
Origin
• Clavicular: Medial aspect of clavicle
• Sternocostal: Lateral sternum, 1st - 7th costal cartilages and rectus abdominus muscle
Insertion
•
Bicipital groove humerus


AXIAL ARTERY

THORACOACROMIAL.A


Blood supply
• Thoraco-acromial artery (axillary a.)
• Internal (thoracic) mammary artery
• Lateral thoracic artery (Subclavian a.)
Innervation
• C5, C6 & C7 (lateral pectoral nerve)
• C8, T1 (medial pectoral nerve)
• Sensation: Intercostal nerves


• Island Type
• Paddle Type
• Gemini Type


ADVANTAGES
• Non-delayed, one-stage procedure
• Highly reliable
• Primary closure of the donor site
• Maybe used along with other flaps
• It may be transposed with an attached rib
• Skin coverage, muscle bulk and good blood supply
DISADVANTAGES
• Excessive bulk and thickness may compromise its blood supply
• Hair bearing area
• Shoulder disability

TRAPEZIUS MUSCLE FLAP
TRAPEZIUS MUSCLE
• Origin: nuchal line of occipital bone to spinal process of C7.
• Insertion: Lateral third of the clavicle, acromion and scapula.
• Function: Elevation, flexion and adduction of the upper arm. Movement of the scapula.
•
•
•
•

Blood supply:
Transverse cervical artery
Occipital artery
Perforating blood vessels from the intercostal system through its paraspinous portion.

•
•
•
•
•

Venous drainage:
subdermal veins and concomitant veins of the paravertebral venous system.
Innervation:
Motor: Spinal accessory nerve.
Sensory: Cervical and intercostal nerves.


•
•
•
•
•
•
•

TRAPEZIUS FLAP
3 different types: superior, lateral & inferiorly base flaps.
Gives considerable bulk, treating defects of up to 10x20 cm.
Arch of rotation of up to 180 degrees.
ADVANTAGES
Minimal defect at donor area
Moderate shoulder-drop after surgery.

• Cannot be easily tubed.


DELTOPECTORAL FLAP

• Excellent reliability in head and neck defects, but color match and texture
is less than ideal.
• Donor site requires STSG.
• Horizontal flap design with round tip.
• Perfused by intercostal perforating branches of the internal mammary
artery.
• DELTOPECTORAL FLAP
• Outlined along the inferior border of the clavicle, beginning > sternum
extending lateral > acromion process. Returning at the level of 5th rib.
• Elevation beneath the level of the pec. muscle fascia, lateral to medial.
• Base: 2 cm from the lateral sternal border.
• Provides only skin, subq tissue & muscular fascia.
• If used for oral reconstruction, oral cutaneous fistula will be created and
repaired in a second procedure


•
•
•
•
•
•
•
•
•
•
•
•

STERNOCLEIDOMASTOID (SCM) FLAP

SCM MUSCLE
Origin: sternum and medial half of clavicle (2 heads)
Insertion: lateral surface of mastoid process
Blood supply:
Superior: branches of occipital artery.
Middle: branches of the superior thyroid artery.
Inferiorly: branches of the thyrocervical trunk.
Innervation: spinal accessory nerve.
can be used as muscle flap only, myocutaneous flap or as a composite flap
Can be based superiorly or inferiorly.
The superior thyroid vessels should be preserved at all times.
Limited rotational angle (random-pattern).


•

LATISSIMUS DORSI MYOCUTANEOUS
PEDICLE FLAP
LATISSIMUS DORSI MUSCLE

• Origin: posterior iliac crest, thoracolumbar fascia, external oblique fascia
and the lower six vertebrae.
• Insertion: Intertubercular groove of the humerus
• Blood supply: Circumflex subscapular artery Thoracodorsal artery
• Innervation: Thoracodorsal nerve.


LATISSIMUS DORSI FLAP
Good for scalp, forehead & anterior cranial defects.
Can be transferred as a pedicle flap or as a free flap.
As only muscle or as musculocutaneous flap (bulky).
Reliable and provides large amount of soft tissues >
massive defects.
• Not good for reconstruction of thin, esthetic defects
•
•
•
•
•


THANK YOU


Local & regional flaps /certified fixed orthodontic courses by Indian dental academy

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (20)

Similar a Local & regional flaps /certified fixed orthodontic courses by Indian dental academy

Similar a Local & regional flaps /certified fixed orthodontic courses by Indian dental academy (20)

Más de Indian dental academy

Más de Indian dental academy (20)

Último

Último (20)

Local & regional flaps /certified fixed orthodontic courses by Indian dental academy