Local and Regional Flaps

. in OMFS .
DR. NABEEL AHMAD
FCPS RESIDENT(OMFS)
Definition :
A flap is a unit of tissue that is transferred from
donor site to recipient site while maintaining its own blood
supply.
BASED ON LOCATION OF DONOR SITE

LOCAL FLAP: Flap Regional FLAP :Regional

transferred from an flaps are located at a
area adjacent to the signifcant distance
defect. from the donor site. Because
of this distance, the flap
usually has its own blood
supply in the form of a
named vessel
CLASSIFICATION OF LOCAL FLAP
LOCAL/REGIONAL FLAPS
 Random flaps
• Based on the rich sub
-dermal vascular
plexus of the skin.

• Most of the local flap

are random flaps.

• length : breadth ratio

of up to 3 : 1 in the
face.
 Axial flaps
• Derive their blood supply
from a direct cutaneous
artery or named blood
vessel .
• Examples :Nasolabial
flap (angular artery) ,
Forehead
flap(supratrochlear
artery).
• The surviving length of an
axial pattern flap is
entirely related to the
length of the included
artery.
Based on vascular pedicle types
In muscles

Mathes and Nahai (1979)

Type I: one vascular pedicle

Type II: dominant pedicle (s) + minor pedicles
Type III: two dominant pedicles
Type IV: Segmental vascular pedicles
Type V: dominant pedicle + secondary segmental pedicles
 3. Based on composition
Skin (cutaneous)
Visceral ( colon, omentum)
Muscle
Mucosal

Composite
Fasciocutaneous
Myocutaneous
Osseocutaneous
Tendocutaneous
Sensory/innervated flaps
Osseo-myo-cutaneous
 Local / Regional flaps – Goals (Kinnerw &
Jeter)
1. Adequate color match
2. Adequate thickness – avoid protrusions or
deficiencies
3. Preservation of clinically perceivable sensory
innervation
4. Sufficient laxity – avoid retraction or deranged
function
5. Resultant suture lines of either primary or
secondary defects are restricted to anatomic units
and fall within natural skin lines.
 Planning and design of local flap
• Facial defects causes
– Trauma
– Malignancies
 Advancement flaps
flap moves in a straight path without any lateral
movement into the primary defect.
(Burrows Triangle’s)
sites – forehead, brow, cheek.

Single advancement flap:

movement is entirely in one direction.
Advancement Flaps
Burrow’
s
triangle
at the
base of
the flap
 Bilateral advancement flap:
When large tissue is required.
Same technique & principle.

used:
forehead, mustache area
and posterior neck.
 A to T flap:

variant of bilateral advancement flap

Useful for
defects at the periphery of the face
around the nasal ala and upper lip

dog–ear almost always forms

Disadvantages:
number of scars- created with the three limbs and Burow’s triangle
and with the three point closure
 V-y advancement flap: (Herbert flap)

A V shaped flap is moved into a defect with primary closure of the

donor area leaving a final Y shaped suture line.
It is pedicled from the underlying subcutaneous tissue rather
than the surrounding skin.

Ideal for Lesion in

the cheek
and alar base
 Pivot flaps:
Derives its name from the pivot point at the base of the flap
as well as its arc of rotation .

When flap moves laterally into the primary defect - transposition flap

when it is rotated into the defect - rotation flap

 Pivot point
Is the axis around which the transfer takes place.

Flap is designed so that the distance from the pivot

point to each part of the flap before transfer is
atleast equal to the distance to be expected after transfer

pivot point is on the side of the flap away from

the direction of movement of the flap.
Rotation flaps: it is semicircular flap that rotates about a pivot point
to fill the defect.

Place the arc closest to the defect higher than the defect itself,
to reach the most distal point of the defect

Should be 5-8 times the width of the defect

Simple rotation flap

Ideally suited on a convex surface

cheek
Submandibular area
 Transposition flaps
Classic form - a rectangle or near square which is raised
and moved laterally into a triangular defect

In a correctly designed flap, the distance from the pivot point to A

equals the distance to B and the transfer is carried without tension

sites of choice
retroauricular area
submandibular area A
perioral area for upper and
lower lip reconstructions.
scalp B
not to rotate more than 90º

More acute –less dog ear

Transposition flap
 Limberg’s flap:
combination of flap rotation and
transposition

BD=DE=EF
EF at angle of 60º &
Parallel to one side

Disadvantages:
Excess tension

Anatomic landmark displacement because the tissue used to resurface

the rhomboid defect is borrowed from single area.

Best in temple region between the eyebrows and anterior hair line
Limberg’s flap
 First by Esser in 1918
Bilobed flap: popularized by Zimany

reconstruct nasal and facial defects and even full thickness cheek
defects.

Tension free closure of original and secondary defects.

90º is the optimal angle between the first and second flap

Maximum distortion occurs around

the flap bases and the second donor
lobe closure sites
 Interpolation flaps:
An interpolation flap is from a nearby, but not immediately
adjacent donor Site and transposed either above or below
the intervening skin to the Recipient defect

Types:

Cutaneous: requires two stage procedure but more reliable

Subcutaneous
Island

eg: Median forehead flap

Nasolabial flap
Buccal fat Pad
Uses
Reconstruction of appropriately sized defects of
Maxilla
Cheeks
Palate
orbit
Closure of oro antral fistula
Blood Supply
Buccal and deep temporal branches of the maxillary, branches
of the facial, and the transverse facial arteries.
Nasolabial Flap
Uses
Reconstruction of facial skin defects of
Upper lip,
Nose
Cheek
Closure of oroantral fistulae
Blood Supply
Superiorly based flap Perforators from the facial and angular arteries.
Inferiorly based flap Branches of the facial artery.
Tongue Flap
Uses
Tongue Flap can be used in reconstruction of
Vermelion
Floor of the mouth
Palatal fistulae
Tonsillar and retromolar area

Blood Supply
One or more branches of the lingual artery
Submental Flap
Uses
Submental island flap can be used for reconstruction of defects of
Oral cavity
Oropharynx
Hypopharynx
Maxilla,
Chin,
Face,
Upper and lower lip
Neck

Blood Supply
Submental Artery
 Temporoparietal Fascia Flap
Uses
Temporoparietal Flap can be used in reconstruction of defects of
Ear
Orbital
Nasal
Oropharynx
Floor of the mouth
Posterior mandibular defects

Blood Supply
Superfcial temporal artery
Paramedian Forehead Flap
Uses
reconstruction of
Partial Nasal Defects
Total Nasal Defects

Blood Supply
Supratrochlear Artery
Supraclavicular Artery Island Flap
Uses
Supraclavicular Artery Island Flap is used in reconstruction of defects of
Lower face
Neck
Anterior Chest

Blood Supply
Supraclavicular Artery
Temporalis Flap
Uses
It is used in reconstruction of
Lateral face
Orbit
Maxilla
Cheeks
Temporomandibular joint
`reanimation of paralyzed face
Blood Supply
Anterior Deep temporal
Posterior deep temporal
Middle temporal artery
Sternocleidomastoid Flap
Uses
It can be used in reconstruction of various defects in the head and neck as well
as the oral cavity particularly reconstructing pharyngeal fistulas.

Blood Supply
Upper 3rd Branches of Occipital artery
Middle 3rd Branches of Superior Thyroid Artery
Lower 3rd Branches of Suprascapular artery
Latissimus Dorsi Flap
Uses
It is used in reconstruction of defects of
Scalp
Orbital exenteration
Temporal bone defects, as well as for pharyngeal reconstruction

Blood Supply
Thoracodorsal artery and vein
s vv vv b
Pectoralis Major Flap
Uses
Reconstruction secondary to the loss of microvascular flaps
In those patients in whom microvascular flaps is either contraindicated or cautioned due to
existing comorbidities

Blood Supply
Subclavian Artery
 Complications
• Infection
• Dehiscence
• Vascular insufficiency due to
• Mechanical tension
• Kinking
• compression
• Hematoma

• Failure/necrosis
 PREVENTION OF FLAP NECROSIS
Important steps to prevent necrosis :

1. Avoiding tension by prior establishing pivot point or using

planning in reverse if local flap is jumping over intact skin
.
2. Planning the flap with a margin of reserve is an
additional way in which tension can be avoided.

3.Avoding kinking particularly at the base of the flap.

4.In random flap proper length: breadth ratio should be

maintained .
 PREVENTION OF FLAP NECROSIS
5. In axial flap , length does not exceed recognized
safe length.

6.Proper plane for flap elevation while raising flap.

7. No compression at pedicle

8. Using delay principal when it was

considered inadequate .

9. Avoiding infection : prevention of hematoma and

avoidance of raw area .