Regional Pedicled Flaps

Introduction

• Delay Phenomenon: surgically enhanced viability of flap by incising and partially undermining, but not transposing flap until 2—3 weeks, allows flap conditioning in preparation for transfer by increasing A-V shunting, increases vessel size and number, reorients vessels

Complications

• Vessel Insufficiency and Injury: prevented with atraumatic technique (avoid vasospasm), avoid tension and compression at tunnel, careful postoperative monitoring, prophylactic antibiotics (especially for intraoral contamination)

• Partial Flap Necrosis: skin island most susceptible (epidermolysis); Rx: debridement after adequate demarcation, surviving soft tissue and granulation may allow adequate seal, aggressive treatment of infection or fistula if present

• Fistula: increased risk with flap necrosis, wound infection, soilage by saliva, tight wound closure, immunocompromised or malnourished states; Rx: aggressive antibiotics coverage and wound care (packing), medialization of tract (away from carotid artery), may require another flap for closure

• Hematomas and Seromas: may present at donor site

Pectoralis Major

• Type: myocutaneous

• Advantage: reliable ("the workhorse"), excellent reach (up to lateral canthus), one stage procedure, potential for simultaneous harvesting, easy to harvest

• Disadvantage: may be bulky, potential for breast deformity in women, potential hair transfer, loss of pectoralis function (may be significant with concurrent ipsilateral injury to CN XI)

• Arterial supply: pectoral branch of thoracoacromial artery

• Common Uses: internal and external defects of the oral cavity, oropharynx, hypopharynx

• relatively contraindicated with ipsilateral radical mastectomies

• double paddle may be created by using the lateral thoracic artery

• incision is made along the inframammary crease in women to camouflage closure line

Pectoralis Major Anatomy

• Vascular Anatomy

1. second portion of the axillary artery ^ thoracoacromial artery ^ pectoral branches

2. second portion of the axillary artery ^ lateral thoracic artery

3. first portion of the axillary artery ^ internal mammary artery

• Origin: clavicle, sternum, lower ribs, and rectus abdominis fascia

• Insertion: intertubercular groove of humerus. deltoid tuberosity, deep fascia of arm

• Action: medial rotator and adductor of upper extremities

• Innervation: lateral and medial pectoral nerves

Trapezius

• Type: myocutaneous

• Advantage: 3 forms allows for versatility, relatively flat and thin flap, 1-stage procedure

• Disadvantage: relatively limited arc of rotation, significant donor site morbidity (weakness of upper extremities, may require skin graft for closure), weaker blood supply, awkward positioning

• Common Uses: oropharyngeal and hypopharyngeal defects, lateral neck, posterior face

Flap Designs (Fig. 7-10)

1. Superiorly Based (Upper) Trapezius Flap: vascular supply from the occipital artery and paraspinal perforators, reliable flap, limited arc of rotation, donor site may require a skin graft

Diagrams Types Skin Flaps

FIGURE 7—10. Diagram of the superiorly based (upper) trapezius flap (dotted line) based on the occipital artery and the inferior (lower) trapezius island flap

(solid line) based on the transverse cervical and dorsal scapular arteries.

FIGURE 7—10. Diagram of the superiorly based (upper) trapezius flap (dotted line) based on the occipital artery and the inferior (lower) trapezius island flap

(solid line) based on the transverse cervical and dorsal scapular arteries.

2. Lateral Island Trapezius Flap: vascular supply from the superficial branches of the transverse cervical artery, may cover defects of the oropharynx, posterior oral cavity, and hypopharynx

3. Inferior (Lower) Trapezius Island Flap: vascular supply from the descending branches of the transverse cervical artery and the dorsal scapular artery, provides a long pedicle, most commonly used trapezius flap

Latissimus Dorsi

• Type: myocutaneous

• Advantage: large amount of available skin and soft tissue, long vascular pedicle with extended arc of rotation (to vertex of scalp), less hair transfer, potential for bilobed skin islands, out of irradiated field

• Disadvantage: requires repositioning (lateral decubitus), propensity for seroma formation at donor site, may be bulky in large patients, requires extended tunneling between pectoralis major/minor

• Arterial supply: thoracodorsal artery

• Common Uses: similar to pectoralis major flaps (although not as common)

Sternocleidomastoid

• Type: myocutaneous

• Advantage: donor site located close to defect

• Disadvantage: tenuous blood supply to skin (not a true axial flap), rotation limited by accessory nerve

• Arterial supply: perforating vessels from the occipital, superior thyroid, and thyrocervical arteries (at least 2 of the 3 sources should be preserved)

• Common Uses: small defects in anterior lateral oral cavity and lateral oropharynx

Platysma

• Type: myocutaneous or muscle only

• Advantage: donor site located close to defect, thin and pliable skin

• Disadvantage: inconsistent and weak blood supply (not a true axial flap) from facial artery branches

• Arterial supply: random perforators from external carotid system

• Common Uses: small intraoral defects

Deltopectoral

• Type: fasciocutaneous

• Advantage: strong blood supply, large amount of donor tissue available, tunnel forms a favorable fistula (inferiorly located)

• Disadvantage: requires second stage procedure for detachment (6—8 weeks), requires skin graft at donor site

• Arterial supply: first 4 perforating vessels of internal mammary artery (the second vessel is the largest vessel)

• Common Uses: similar to pectoralis major flaps

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