Flaps in Head & Neck Reconstruction

Contents
INTRODUCTION HISTORY RECONSTRUCTIVE LADDER PLANNING CONSIDERATIONS SKIN FLAP PHYSIOLOGY CLASSIFICATION LOCAL FLAPS REGIONAL FLAPS DISTANT FLAPS FREE FLAPS MONITORING OF FLAP MEASURES TO INCREASE THE VIABILITY OF FLAPS FATE OF FLAP COMPLICATIONS SALVAGING REFERENCES

Introduction
A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply.
1440 : Dutch word "flappe" : something that hung broad and loose, fastened only by one side

HISTORY
Tansini first described the latissimus dorsi flap in 1896 Before 1963, oral and pharyngeal defects were closed primarily and reconstructed with random pattern skin flaps or tubed-pedicled flaps of skin from the trunk. In 1973, Daniel and Taylor reported the first free flap, In 1976, Panje and Harashina simultaneously described the use of free flaps to reconstruct defects of the oral cavity. In the late 1980s and early 1990s, the use of osteocutaneous free flaps to reconstruct mandibular defects was advanced.

Reconstruction Ladder

Planning considerations
The anatomy & physiology of skin, including color, texture, appearance & amount. Local muscle anatomy : vascular, nerve supply & lymphatic drainage The aesthetics of the area Possible sites for incision placement Areas of local tissue availability i.r.t the area to be reconstructed

NEUROVASCULAR SUPPLY TO LOCAL SKIN FLAPS

Segmental Perforators Cutaneous Musculocutaneous Septocutaneous

The sensory nerves are distributed in a segmental fashion Sympathetic nerves in the area of cutaneous arterioles Precapillary sphincter- nutritive blood flow, local stimuli Preshunt sphincter- thermoregulation, sympathetic stimulation

The facial subunits

The subunit principle is only a starting point, but it is the foundation for adequate reconstruction of facial defects.
With the subunit principle, skin color, skin texture, skin thickness, hair growth, and surrounding contours at subunit junctions are considered; these features can provide optimal camouflage for incisions and transition

CLASSIFICATION
Based on blood supply Axial
Random

Mathes and Nahai classification

CLASSIFICATION
By method of movement from the donor site 1) Advancement flaps 2) Transposition flaps 3) Rotation flaps 4) Interposition flaps By distance from donor site
Local Flaps Regional flaps

By the tissues they contain

Skin flaps Composite flap Free flaps

Local Flap
Advancement flaps Linear or rectangular configuration Sub classification Single pedicle Bipedicle V-Y flaps Single-pedicle advancement flap A rectangle of skin is moved forwardly elasticity of skin The advancement creates a length discrepancy which creates standing cone deformities

Local Flap
Bipedicle advancement flaps Advanced into the adjacent defect in a vector that is perpendicular to the flap axis Used to close a defect in an area of high visibility by moving the defect into an area of low visibility The V-Y advancement flap Pushed rather than stretched into the defect The donor flap, which usually is triangular, is advanced, and the resulting donor defect is closed in a straight line This approach results in a suture line with a Y configuration

Local Flap
Pivotal flaps Moved about a pivotal point from the donor site to the defect Rotation Transposition Interpolation flaps Interpolation flaps The flap is moved about the pedicle and the pedicle rests over the intervening tissue. The most common interpolation flap is the forehead flap.

Local Flap
Rotation flaps The leading edge of the flap also is a border of the defect Based inferiorly to promote lymphatic drainage The border perpendicular to the axis of rotation usually is curvilinear and designed to contact at the junction of 2 facial subunits for optimal scar camouflage The length of the flap should be larger than the defect by a 4:1 ratio.

Local Flap
Transposition flaps The flap is moved about the pedicle and transposed over the intervening tissue into the defect Versatile and offer a choice of flaps of similar color and texture from various donor sites -defects in the head and neck

In the head and neck the length-to-width ratio exceeds 3:1

Z-plasty
2 transposition flaps with identical angles to the direction of the defect and transposing them in opposite directions

Local Flap
Rhombic flaps Limberg specially designed transposition flap used to correct a rhombus-shaped surgical defect The classic rhombus defect has sides of equal length, with 2 opposing 60 angles and 2 opposing 120 angles. This configuration creates a short diagonal of the same length as that of the sides of the rhombus.
The Dufourmentel flap is a variation of the classic Limberg rhombic flap with any 2 opposite angles rather than the 60 and 120 angles.

Local Flap
Bilobed flaps 2 transposition flaps that share a common pedicle 1st -to reconstruct the defect 2nd -to repair the donor site for the flap The angle between each flap is 90, with a total transposition of 180 Standing cone deformities, Pincushioning Zitelli's modification 45 & 90 The key to the success of the bilobed flap is the distribution of tension over both limbs of the flap.

Local Flap
Abbe cross-lip flap 1/2-2/3 lip defects. Flap width should approximate half width of excised tissue. The recommended limit of flap width is 2 cm. The flap blood supply is based upon the labial artery The advantage is maintenance of sensory and motor competent lip segment. The disadvantage is second stage requirement and relative microstomia. Potential complications include vascular compromise, vermilion notching, lip asymmetry, and scarring extension beyond the sublabial crease

Local Flap
Estlander flap 1/2-2/3 lip defects. The Estlander flap involves rotating the upper lip tissue around the lateral edge of the mouth to correct defects involving the oral commissure. It is based upon the labial artery. The flap maintains motor and sensory competence of lip. The pedicle is divided at 2-3 weeks It requires commissure plasty at 3 months.

Local Flap
Karapandizic flap A complete lip is formed by rotating the upper lip and perioral tissue by bilateral advancement flaps. The disadvantage of this technique is frequent loss of sensory and motor innervation Potential complications include microstomia, difficulty of introducing full dentures, inversion of the vermilion and flattened mentolabial junction, and dysesthesia/anesthesia of the lip

FOREHEAD FLAP McGregor

Axial flap- to reconstruct defects below the level of eyes Anterior branch of temporal A Cutaneous axial median forehead flap- supratrochlear A Uses :
For nasal reconstruction defects larges than 2.5 cm in length along the horizontal transverse plane. Defects of medial canthal region, upper or lower eyelids, medial cheek, melolabial region, upper lip In combination with other larger flaps complex facial defects

REGIONAL FLAPS

TONGUE FLAP

Eiselberg 1901
Advantages
Adjacent tissue Excellent blood supply

Low morbidity
Reinnervated from adjacent host tissue Provide 90 to 100 cm2 of mucosal surface for rotation Half of tongue can be used without compromising the functions. Can be used in irradiated patients

REGIONAL FLAPS

TONGUE FLAP

Vasculature : Suprahyoid artery Dorsal lingual artery Sublingual artery Deep lingual artery Types : I : Random flap design a) Dorsal tongue flap - Posteriorly based to treat defects of soft palate, retromolar region. - Anteriorly based hard palate anterior buccal mucosa, anterior FOM, lips

REGIONAL FLAPS

TONGUE FLAP

Lateral tongue flap

Treatment of defects - buccal mucosa, lateral palate, alveolus, orointral communication

Double door tongue flap

Used to reline large defects of buccal mucosa extending form the commissure to the anterior mandibular ramus.

REGIONAL FLAPS

TONGUE FLAP

II. Axial flap design Sliding posterior tongue flap Coverage of lateral tongue defect measuring 4-6 cm. Created by releasing the tongue from the hyoid bone and maintaining the dorsolingual branch of the lingual artery

REGIONAL FLAPS

TEMPORALIS FLAP Verneuil 1872 gap arthroplasty of TMJ

Blood supply 3 sources : Anterior deep temporal artery 21 % of the muscle Middle temporal artery 38% of the muscle Posterior deep temporal artery 41% of the muscle

REGIONAL FLAPS

TEMPORALIS FLAP Verneuil 1872 gap arthroplasty of TMJ

Uses Obliteration of oral defects Gap arthroplasty of TMJ Cranial base reconstruction Obliteration of orbital defects after enucleation Facial reanimation Midface suspension or orbital repair with the coronoid process, attached to temporalis after maxillectomy

REGIONAL FLAPS

TEMPORALIS FLAP
Disadvantages
Sensory disturbance Potential facial N injury Temporal hollowing

Advantages
Ease of elevation Reliable blood supply Proximity to maxillofacial skeleton Camouflage of incision within hair line

REGIONAL FLAPS

Temperoparietal Galea Flap

Monks, Golovine and Brown 1898 repair eyelid and orbital defects, and perform auricular reconstruction TPGF is pedicled on the superficial temporal vessels and is a component of the SMAS TPGF can be made as wide as 14 cm on a 18 cm superficial temporal vascular pedicle. Superficial temporal V is posterior & superior to A Uniform location of vascular pedicle micro vascular transfer

REGIONAL FLAPS

Temperoparietal Galea Flap

Uses Obliteration of oral defects Cranial base reconstruction Obliteration of orbital defects after enucleation Malar augmentation, maxillary & mandibular reconstruction with vascularised osseous cranial bone As a skin island flap- hair bearing upper lip/ brow reconstuction

REGIONAL FLAPS

Temperoparietal Galea Flap

Disadvantages
Limited rotation Lack of skin paddle for flap monitoring Numbness of donor site Potential for development of alopecia

Advantages
Relatively constant & reliable blood supply Ultrathin ~ 2-4 mm Surface area ~ 120 cm.sq Lack of hair Well camouflaged donor site

REGIONAL FLAPS

Masseter Flap

In 1987 Tiwari as a cross-over flap in the tonsillar repair and retromolar trigone Origin: Superficial anterior 2/3 lower border of zygomatic arch Deep inner surface of zygomatic Insertion: Superficial lower portion of mandibular ramus Deep lateral surface of the coronoid process Innervations: Masseteric nerve (CN V3) Blood supply: Masseteric artery (internal maxillary artery)

REGIONAL FLAPS

Masseter Flap

Uses
Reconstruction of ablative procedures of parotid gland, mandible, palate and nasopharyma

Advantages
Usefull, readily available local tissue for site specific defects of oral cavity

Disadvantages
Limited tissue volume Potential for devolopment of trismus Training for emotional mimetic movement Limited arc of rotation

REGIONAL FLAPS

Plastysma Myocutaneous Flap

1887 1st used by Gersony through and through cheek defect. 1951 Edgerton lateral cervical island flap 1959 Desprez and Klehn modified apron flap Arterial supply
Anterior superior
Sub mental A

Posterior superior
Occipital and posterior auricular arteries

Anterior midportion
Superior thyroid artery

Inferiorly
Transverse or superficial cervical arteries

Skin
Fasciocutaneous perforators

REGIONAL FLAPS

Plastysma Myocutaneous Flap

Venous drainage
Postrior- EJV AJV, sub mental V, anterior communicating V

Innervation
Cervical branches of 7th CN

Contraindications
Previous radiotherapy to neck Dominant blood supply violated due to previous surgery Muscle previously transected

Flap designs
Posteriorly based Superiorly based Inferiorly based

REGIONAL FLAPS

Posteriorly Plastysma Myocutaneous Flap

Occipital A- fascia at the anterior border of SCM Collaterals- sup. Thyroid & post. Auricular A EJV Arc of rotation is suitable for reconstruction of
Lower lip FOM Ventral tongue Lower 1/3rd of face

SOND / SND preserving SCM & associated fascia

REGIONAL FLAPS

Superiorly Plastysma Myocutaneous Flap Dominant A submental branch of facial A near inferior border of mandible Submental V Arc of rotation is suitable for reconstruction of
Ant. & lateral FOM Buccal mucosa Retromolar trigone Skin of lower cheek & parotid region Facial animation- Cervical branch of 7th CN

REGIONAL FLAPS

Plastysma Myocutaneous Flap

Disadvantages
Blood supply unreliable When based on submental A, requires preservation of muscularity in a area of oncologic significance which may have to be addressed in resection Removal of platysma interferes with the blood supply to the overlying skin, which can have disastrous results

Advantages
Good color match Easy access to donor site Minimal donor site morbidity Easy primary closure of donor site Appropriate flap thickness for oral & facial defects

REGIONAL FLAPS

Nasolabial Flap

Sushrutha samhitha, 700 BC Diffenbach , 1830- nasal alae reconstruction Nasolabial crease 1cm superior- lateral alar rim 1cm lateral- corner of mouth Medially- orbicularis oris muscle Superior & lateral cheek Buccal & zygomatic branches of facial N

REGIONAL FLAPS

Inferiorly Based Nasolabial Flap

Facial A Uses Reconstructing perioral defects Upper or lower lips Comissure Buccal mucosa Full thickness defects immediately following trauma Reconstruction of upper lip scarring secondary to trauma

REGIONAL FLAPS

Superiorly Based Nasolabial Flap

Infra-orbital & transverse facial A Used to reconstruct Maxillary lip Buccal mucosa Nasal defect Columella Moderately sized maxillary defect

DISTANT FLAPS

Pectoralis Major Flap Aryian 1977

Origin
Medial 11/2 2/3 of clavicle Lateral portion of entire sternum Adjacent cartilages of first 6 ribs Bony portion of 4th ,5th ,6th ribs

Insertion
Intertubercular groove of humerus

Action
Abducts , Flexes & Medially Rotates Arm

DISTANT FLAPS

Segmental subunits- PMMC

Clavicular
Arises from clavicle Deltoid branch of thoracoacromial A Lateral pectoral N

Sternocostal segment
Most muscle mass Pectoral branch of thoracoacromial A & parasternal perforators of internal mammary A Lateral pectoral N

External segment
Medial pectoral N Lateral thoracic A / Pectoral branch of thoracoacromial A/ combination

DISTANT FLAPS

Pectoralis Major Flap

Disadvantages
Bulk Nerve sectioning Poor colour match In females , breast size limits its use Hair bearing

Advantages
Familiar, accessible Large skin territory Rich vascular supply Large arc of rotation Used with other flaps

DISTANT FLAPS

Complications- PMMC
Donor site Uncontrolled bleeding Hematoma Wound dehiscence Infection & seroma Rarely Rib osteomyletis Seeding of tumor Metastasis

Recipient site Flap necrosis Poor healing Infections Fistulization seroma

DISTANT FLAPS

Sternocleidomastoid flap owens 1955

Origin Clavicular head Sternal head Insertion Mastoid process of temporal bone Innervation Spinal accessory N Proprioception cervical spinal N Blood supply Occipital A / direct from ECA Superior thyroid A Transverse cervical A

DISTANT FLAPS

Sternocleidomastoid flap

Flap types Composite skin muscle flap Myocutaneous skin island flap Composite muscle bone flap Use Reconstruction- oral cavity, cheek lip Particularly as superiorly based muscle flap small defects of pharynx & oral cavity Split along its length & rotated anteriorly to cover vessels of compromised neck

DISTANT FLAPS

Sternocleidomastoid Flap
Disadvantages
Upper scm composite skin flap is poorly viable Vascularity of lower muscle flap is unreliable Upper & lower ends are of oncologic significance

Advantages
Accessible Good colour match Proximity to defect site Lack of requirement of another incision when used in conjunction with neck dissection Good thickness tissue coverage

DISTANT FLAPS

Anterolateral Thigh Flap Song 1984

Perforator flap Based on lateralcircumflex thoracic A- descending branch Pedicle descends down b/w rectus femoralis & vastus lateralis muscles Venous drainage- 2 vena comitans of LCFA Sensate flap lateral cutaneous N of thigh

DISTANT FLAPS

Anterolateral Thigh Flap

Contraindicatios
Previous thigh injury Prior surgery of upper thigh

Uses Thicker flaps

Total glossectomy Hypopharyngeal defects Laterl temporal defects

Thinner flaps
Orophyngeal / Hypopharyngeal reconstruction

DISTANT FLAPS

Anterolateral Thigh Flap

Disadvantages
Elevation difficulty musculocutaneous perforator Obese pt, esp. women bulky Inconsistent vascular pedicle transverse branch

Advantages
Low donor site morbidity Primary closure Two team approach Long vascular pedicle ~15cm Large vessels ~ 2-4 cm Large skin paddle ~ 10 x 20 cm Pliable, hairless skin

DISTANT FLAPS

DELTOPECTORAL FALP Bakanjian 1965

Is an axial pattern flap Composed of fascia, subcutaneous tissue and skin; muscle is not transferred with this flap Boundaries Clavicle superiorly Acromium laterally A line running through the anterior axillary fold to above the nipple inferiorly Based medially on the upper chest in the upper 3 or 4 perforating branches of internal mammary A from medial end of intercostal spaces

DISTANT FLAPS

Deltopectoral Falp

Extends to any site in neck & occasionally up to zygoma Flexibility of the flap
Retracts from side to side Anomolous pivot point

Uses
To cover whole anterior neck without any subsequent revision To reconstruct a defect by passing as a bridge over normal tissues where conventionally the pedicle may be tubed Repair of pharyngeal fistula but lacks muscle bulk Reconstruct defects lower face & upper neck

DISTANT FLAPS

Deltopectoral Falp
Disadvantages
Failure rate is 9 to 18%. If flap is used to cover the carotid vessels, blow out of the carotid artery is a hazard if the flap fails.

Advantages
Usually not delayed Unilateral or bilateral Deltoid portion usually not hair bearing Excellent blood supply, with dependent venous drainage Donor site hidden, thus cosmetically acceptable Outside radiation field

DISTANT FLAPS

Latissimus Dorsi Myocutaneous Flap

Tanzini,1896- 1st myocutaneous flap in medical literature Quillen,1978- head & neck reconstruction Origin Sacrum & lumbar vertebrae Posterior iliac crest Lower 6 thoracic vertebrae Slips from lower 3 ribs Insertion Intertubercular groove of humerus

DISTANT FLAPS

Latissimus Dorsi Myocutaneous Flap

Thoracodorsal vessels from subscapular A Venacommitans draining into axillary V 10 x 8 cm- easily harvested with primary closure Musculocutaneous flap ~ 40 x 20 cm skin grafting As a free tissue- dividing circumflex scapular A , pedicle 10cm long, 3 mm diameter

DISTANT FLAPS

Latissimus Dorsi Myocutaneous Flap

Disadvantages
Very bulky Occasional donor site dehiscence Reduction in upper limb power Need to move pt to harvest.

Advantages
Large amount of tissue can be transferred Pedicled or free tissue transfer Cosmetic advantage, esp. females Versatile ; tubed/ multiple/ osseous components When pedicled can reach upper face & scalp

Free Flap
Criteria for selection The length & diameter of vascular pedicle available The type, thickness & color match of the skin required Whether associated tendon, fascia or nerves are needed Whether a large composite free flap is required The morbidity caused by harvesting the flap should be considered

Radial Forearm Free Flap

1978-China
As a fasciocutaneous flap- volar forearm skin, antebrachial fascia & intermuscular fascia containing vascular pedicle. Radial A- deep palmer branch of hand , b/w brachis radialis & flexor carpi radialis muscle Ulnar A- superficial palmer branch of hand Anastomosis prevents ischemia & necrosis of hand particularly index finger & thumb Allens test Venae comitantes {1-2mm} / cephalic vein{3-4mm}

Radial Forearm Free Flap

As a sensate flap- Lateral antebrachial cutaneous nerve Composite flap - bone, tendon, brachioradialis muscle and vascularized nerve. Use Oral cavity, base of tongue, pharynx, soft palate, cutaneous defects, base of skull, small volume bone and soft tissue defects of face

Radial Forearm Free Flap

Advantages
Consistent vascular anatomy Up to 20 cm long Vessel caliber 2 2.5 mm Location allows 2 team approach Pedicle can be outlined prior to incision Composite flap Acceptable donor site cosmesis

Disadvantages
Partial skin graft loss Tendon exposure Delayed healing of STSG donor site # radius at harvest Sensory loss in distribution of superficial radial N Restricted forearm function

The Free Fibula Flap

Hidalgo 1989

Tubular shaped with Thick cortical bone Nutrient A from peroneal A enters the medial surface of bone just above its midpoint Pedicle up to 8cm Venacommitans Fasciocutaneous- skin paddle centered over intermuscular septum & including deep fascia

The Free Fibula Flap

Indications
Short & long, anterior & lateral segment reconstruction of mandible Reconstruction of hemimandible Ideal angle to angle mandibular reconstruction

Complications
Partial loss of donor site STSG Ankle stiffness Donor site pain Ankle instability Peroneal N motor & sensory loss Decreased knee extension Decreased flexion strength

Contraindication
Peripheral vascular disease

The Free Fibula Flap

Advantages
Good vessel quality with regard to both length & diameter Up to 27cm of bone Segmental & intraosseous blood supply- multiple osteotomies Long bicortical boneosseointegration Allows for reshaping of bone Two team approach

Disadvantages
Ltd cutaneous paddle Soft tissue bulk often requiring a second free flap

Scapular Flaps
In 1978, Saijo was 1st to describe the scapular fasciocutaneous flap anatomy based on the circumflex scapular artery (CSA). This donor site was popularized for head and neck reconstruction by Swartz et al in 1986 Based on the subscapular artery and vein, branches of the third part of the axillary artery and vein.

Scapular Flaps
Indications: Oromandibular defects, scalp defects, Palatal / midface defects Flaps based on the subscapular arterial system Scapular/parascapular fasciocutaneous flap Scapular/parascapular osteocutaneous flap Latissimus dorsi muscle flap Latissimus dorsi musculocutaneous flap Serratus anterior muscle flap Serratus anterior musculocutaneous flap Dorsal thoracic fascia flap

Iliac crest flaps

Osteocutaneous, osteomusculocutaneous Segmental mandibular defects Up to 16 cm bone Oromandibular reconstruction No motor or sensate reconstruction With or without simultaneous implant placement. Skin paddle is not ideal for relining the oral cavity as it is too thick Denervated muscle undergoes atrophy that leaves a thin, fixed, soft tissue coverage over the bone.

Iliac crest flaps

Deep circumflex iliac artery from lateral aspect of external iliac artery 1 2 cm cephalic to inguinal ligament Ascending branch of deep circumflex iliac artery supplies internal oblique muscle Pedicle to internal oblique can arise separately from deep circumflex iliac artery Deep circumflex iliac vein 2 venae comitantes Can pass either superficial to deep to artery

Monitoring of Flaps
Signs of abnormal perfusion Arterial compromise Skin Pale, slow capillary refill; cool. Muscle Pale; no brisk bleeding; skin graft not adherent; no doppler signal. Fascia No palpable pulse; skin graft not adherent; no doppler signal. Venous compromise Skin patchy; bluish fast capillary refill; cool. Muscle Dark; dark red bleeding; skin graft not adherent. Fascia Dark; greyish, doppler signal may remain normal for a longer period

Possible causes of impaired perfusion

Inflow
Arterial kinking Inset too tight Damage to pedicle Arterial insufficiency Thrombosis in extremity. Venous occlusion Tunnel too tight. Venous thrombosis in major veins. Kinking of pedicle.

Outflow

Hematoma under flap

Monitors for Cutaneous Microcirculation

Clinical tests:

Skin colour Temperature of flap Capillary refill and bleeding characteristics

Fluorescein (resorcinol pthalein) Atropine subcutaneous injection in flap to check the systemic effects. Fiberoptic flurometry Fiberoptic dermoflourometer with flourescein delivery. 24Na, 131I, 99mTc, 133Xe

Chemical methods

Radioisotopic methods Instrumental methods

Temperature Transcutaneous gas measurements. Photoelectric method photoplathysmography & reflection spectophotometry. Doppler shift flowmetry Electromagnetic flowmetry Interstitial fluid pressure measurement.

ATTEMPTS TO ALTER SKIN FLAP VIABILITY

Delay in Flaps
Incise and undermine
10 to 21 day delay most common No benefit at 3 wks to 3 mos Improved blood supply
AV shunt closure Conditioning to ischemia Alignment of vessel

Delay Four facts are accepted about the delay phenomenon Surgical trauma to flap Large percentage of the neurovascular supply to the flap must be eliminated. Delay results in increased flap survival at the time of tissue transfer. Beneficial effects can last upto 6 weeks. Three theories Delay improves blood flow Depletion of vasoconstricting substances Formation of collateral and reorientation of vascular channels Stimulation of inflammatory response Release of vasodilating substance Conditions tissue to ischemia Closure of arteriovenous shunts

Fate of flap
In surviving flaps, the blood flow gradually increases if the flap is in a favorable recipient site, A fibrin layer forms with in the first 2 days. Neovascularization of the flap begins 3 to 7 days after flap transposition. Revascularization adequate for division of the flap pedicle by 7th day The return of blood flow to a flap that is ischemic due to excessive release of norepinephrine occurs in approximately 12 48 hours.

CAUSES OF FLAP COMPLICATIONS

Preoperative
Poor flap design Pre morbid condition of the patient

Post operative
Extrinsic
Pedicle kinking Infection Vascular thrombosis

Intraoperative
Technical errors. Design errors Poor choice of recipent vessels

Intrinsic
Distal ischemia

SALVAGING THE FLAPS OF MARGINAL VIABILITY.

Releasing the sutures to relieve any tension which may be compromising the circulation Venous congestion can be relieved by elevating the flap or changing it from a dependent position Hynes (1951) designed a mechanical intermittent venous occluder device, which could be applied to the distal end of the flap Leeches Cooling Hyperbaric oxygen Dextran

References
Head & Neck Surgery- Stell & Maran Grabbs Encyclopedia of Head and Neck Reconstruction:1998 Plastic Surgery, McCarthy, Vol 5 , Tumours of Head & Neck Cancer of Face and the Mouth, Pathology and management for surgeon - Mcgregor. Basic principles of oral and maxillofacial surgery, Peterson Facial Plastic and Reconstructive surgery, Ira A Papel. 1992 Local Flaps in Facial Reconstruction, Shan Ray Baker & Neil A Swanson Maxillofacial Surgery Vol 2; P W Booth, Stephen A Schendel OCNA- 1994, August 2001 OMFSCNA- NOV 2003 AOMFSC- SEPT 2006, MARCH 2007