PECTORALIS MAJOR MYOCUTANEOUS FLAP

Ariyan 1979 Broad triangular muscle Arises from bony portion of 4th , 5th & 6th ribs, cartilaginous portion of the first six ribs & medial half of clavicle Insertion in to greater tubercle of humerus Thoracoacromial artery, 1st or 2nd division of axillary artery

PECTORALIS MAJOR MYOCUTANEOUS FLAP

Superior and lateral thoracic arteries additional pedicles Overlying skin additionally supplied by intercostal perforators Action - adduct, flex & medially rotate the humerus 3 subunits each with its own vascular & motor supply

PECTORALIS MAJOR MYOCUTANEOUS FLAP Types

PECTORALIS MAJOR MYOCUTANEOUS FLAP

Ariyans technique strip technique A improved technique for development of the PMMC flap (JOMS 48 - 1990
by Marx & Smith)

1.
2.

Entire muscle from chest wall Based primarily on thoracoacromial artery & secondarily on the lateral & superior thoracic artery

PECTORALIS MAJOR MYOCUTANEOUS FLAP

Cadaver studies of vascular anatomy of the PMM demonstrated lateral thoracic artery was larger than pectoral branch of the thoracoacromial artery in 25% of cases Remaining 75% of cases artery were about equal size Draw back of strip technique Total complication rate of 58% - review by Huang et al of 45 cases, 7 total loss & 16 partial loss Major axial branches of the pedicle are likely to be transected in developing only strip of muscle Contribution from lateral & superior thoracic artery is lost

PECTORALIS MAJOR MYOCUTANEOUS FLAP

Advantages of Marx & Smith modification of the Ariyans technique Greater volume of muscle based on 3 arteries

Greater surface area of vascular soft tissue thus minimizing skin & mucosal dehiscence following radiation therapy

Greater perfusion to the distant portion of the muscle & overlying skin paddle

PECTORALIS MAJOR MYOCUTANEOUS FLAP ADVANTAGES One stage Generous portion of skin & soft tissue 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

PECTORALIS MAJOR MYOCUTANEOUS FLAP DISADVANTAGES It can be to bulky Arc of rotation limited for oromaxillary defects There is distortion of symmetry at the donor site Shoulder function is impaired Distal skin of the flap is reliable

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

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

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

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

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

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

CERVICAL FLAP

Regional flap with random pattern circulation Superiorly or Posteriorly - Based Vertical or Transverse plane - Orientation Anterior Cervical Flap Posterior Cervical Flap (Mutter flap) 250 sq cm of neck skin May or may not contain regional muscles of neck

CERVICAL FLAP
ADVANTAGES Regionality Delicate & flexible Lack of bulk One stage Used with other regional flap Arc of rotation Donor site - minimal

CERVICAL FLAP
DISADVANTAGES In male upper cervical flap is hair bearing Neck may be scarred No sufficient bulk Obviated by other ablative procedure Atrophic cervical tissue in elderly patients Effect of heavy irradiation in some neck It may not be large enough Since the blood supply of flap is random, width to length ratio should not exceed 1 : 3

CERVICAL FLAP
POSTERIOR CERVICAL FLAP Blood supply - occipital & posterior auricular Random blood supply to distal part of flap Lateral aspect of neck & retromadibular area Esthetic deformity - donor site Not preferred choice for intra oral reconstruction

TEMPOROPARIETAL FLAP

Fascial or Fasciocutaneous flap Thin, pliable, abundant & well vascularized Superficial temporal artery Anterior & posterior division occur about 2cm above & 2cm anterior to superior attachment of helix in 80% of cases Venous drainage is STV - superficial to artery Arising from temporal fascia above & anterior to ear & divided in to three part

TEMPOROPARIETAL FLAP

TEMPOROPARIETAL FLAP

TEMPOROPARIETAL FLAP

Vascularised pedicle is carefully skeletonized ZA can be osteotomised Temporal Br. - 7th nerve Auriculotemporal nerve Flap is allowed to epithelialised or skin grafted Donor site - alopecia

TEMPOROPARIETAL FLAP

TEMPOROPARIETAL FLAP
ADVANTAGES Rich blood supply Thinner Lack of hair Well camouflaged donor site Ease of elevation Vascularised Autogenous bone graft ( calvarial ) DISADVANTAGES Limited rotation Lack of skin paddle to monitor flap Numbness of donor site Alopecia

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

DELTOPECTORAL FLAP
ADVANTAGES

High biologic dependability Readily accessible Arc of rotation 45 - 135 May be used in male, female & children Hairless skin

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

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

PLATYSMA FLAP

Extremely thin band like & variable muscle forming superficial boundary of neck Arises from clavicle superiorly continues with the SMAS & has some 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

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

MASSETER FLAP

Short, flat, thick quadrangular muscle Superior belly - downwards & backwards Deep belly - vertically & slightly forwards Massetric nerve & artery Used in rehabilitation of paralyzed face 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

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 10 x 20 cm in size

TRAPEZIUS FLAP

TCA, passes from the anterior neck to the posterior neck to enter the muscle At the border of the muscle the vessel divides in to ascending & descending branches Ascending branch muscle that overlies the spine of the scapula & acromion Descending branch passes beneath the muscle at the base of the neck & supplies the most of the muscle located on the back Also supplied by deep perforating vessels from intercostal system

TRAPEZIUS FLAP

Lateral neck & lower face Raised in lateral decubitus position Base should be wide to incorporate paraspinal perforator Donor site - skin graft at distal aspect Two stage

TRAPEZIUS FLAP

Myocutaneous flap overlying acromioclavicular region Require integrity of TCA Limited in its surface extent & arc of rotation Limited to small defects in oral cavity Dissection is carried deep to anterior border Donor site closed primarily

TRAPEZIUS FLAP

Descending branch Lateral positioning of patient to elevate flap Ideally suited for radical parotidectomy Generous amount of soft tissue & large portion of skin island 90 95 % of success

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

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

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

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 Spinal accessory nerve enters the posterior dorsal surface of the muscle just below the level of the carotid bifuracation

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

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

LATISSIMUS DORSI MYOCUTANEOUS FLAP

Repositioning of the patient in lateral or prone position Skin paddle sutured to the fascia Full extent of the muscle is identified (midline, laterally, superiorly, caudally) Elevation inferiomedially Fully mobilized passed through the axillary tunnel

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

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

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