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Reconstructive Flap 101:
Basic Principles, Imaging, and Beyond
eEdE#: eEdE-88
E Supsupin1, I Alava2, D Freet3, E Bonfante1, S Garza1, Y Weinstock2
Institutions:
1University of Texas Houston Department of Diagnostic & Interventional Imaging,
Houston, TX,
2University of Texas Houston Department of Otorhinolaryngology, Head & Neck
Surgery, Houston, TX,
3University of Texas Houston Department of Plastic Surgery, Houston, TX
Author disclosures
None
Reconstructive flaps in
head &neck surgery
 Basics of flaps
 Case illustrations (including imaging):
 Flaps for restitution of function
 Flaps for restitution of function and cosmesis
 Flap for cosmesis
Define “Flap”
A “Flap” can be defined as a piece of tissue that is
moved from one part of the body to another part of
the body with a blood supply intact.
Flaps
 A flap is referred to as a “Pedicled” flap if its blood supply is
left intact at its origin when it is moved to the new site.
 A flap is referred to as a “Free” flap if the blood supply of the
donor tissue to be moved is severed from its origin and then
re-connected to a new artery and vein at the recipient site.
 A flap can be made of any type of tissue: bone, cartilage,
fascia, subcutaneous tissue, skin, or any combination of
these.
Flaps
 Flaps are required for reconstruction of large composite
defects resulting from trauma or cancer extirpation.
 A flap is referred to as a “Free” flap if the blood supply of the
donor tissue to be moved is severed from its origin and then
re-connected to a new artery and vein at the recipient site.
 A flap can be made of any type of tissue: bone, cartilage,
fascia, subcutaneous tissue, skin, or any combination of
these.
Flaps
 Flaps can be used for cosmetic purposes, functional
purposes, or a combination of both depending on the needs
of the patient.
Flaps
 Flaps can be used for cosmetic purposes, functional
purposes, or a combination of both depending on the needs
of the patient.
What are commonly used flaps for head and
neck reconstruction?
 Pectoralis major
 Latissimus dorsi
 Rectus Abdominis
 Radial Forearm
 Free Fibula
 Free Iliac Crest
Pectoralis major
 Is considered a “work horse” in head and neck
reconstruction
 Can be used as a muscle-only flap or can include skin
 Most commonly transferred as a pedicled flap based on the
pectoral branch of the thoracoacromial arterial trunk
 Can be used for intra-oral lining, head and neck skin
resurfacing or tubed for creation of a neopharynx
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
Latissimus Dorsi
 Can be used as a pedicled flap or free flap
 Large bulky muscle or muscle and skin flap based on the
thoracodorsal branch of the subscapular artery
 In head and neck reconstruction, this flap is used to fill large
defects.
 Can provide a very large amount of skin if needed
 Not commonly used secondary to its bulky nature
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
Rectus abdominis
 Always used as a free flap
 Muscle or muscle and skin flap based on the deep inferior
epigastric artery
 Used to fill large defects such as that of a total glossectomy
 Disadvantage is abdominal wall weakness.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
Radial Forearm
 This is a free flap based on the radial artery.
 Thin fasciocutaneous (fascia and skin) flap that can be used
for intra-oral lining, used to resurface a tongue defect or can
be tubed to create a neo-pharynx
 Donor site can be problematic (poor healing).
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
Anteriolateral thigh
 Free flap that is based on the descending branch of the
lateral circumflex femoral artery.
 Fasciocutaneous flap that can be made very large for large
complex defects.
 Can be used for intra-oral lining, can be tubed for neo-
pharynx, can be used for head and neck resurfacing, or can
be a combination of any of these
 Minimal donor site morbidity
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
Free Fibula
 Free flap based on the peroneal artery that uses a portion of
the fibula and sometimes the overlying skin of the leg for
complex reconstruction of the mandible and intra-oral lining
 An excellent source of a large amount of bone.
 Minimal donor site morbidity
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
From:
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3:
The Head and Neck, Part 2. Philadelphia, PA:
Saunders Elsevier.
Free Iliac Crest
 Free flap that is based on the deep circumflex iliac artery.
 Can be bone only or can be bone and skin
 Used mostly for mandibular reconstruction. Skin can be
used for intra-oral lining.
 Donor site can be very painful.
Image: AO Foundation
Flap for subtotal glossectomy
Necrotic, malignant infiltrating mass in the left
tongue/floor of mouth. Resection of the mass and free
flap reconstruction was planned.
Flap for subtotal glossectomy
Neck dissection prior to extirpation of mass.
Apron flap is lifted up (yellow arcs).
Tongue mass is resected.
Apron flap is lifted up (yellow arcs).
Flap for subtotal glossectomy
Flap is harvested from the anterolateral thigh
Flap (bracket) with its vascular (arrows) pedicle
is shown.
Flap for subtotal glossectomy
Harvested flap
from thigh
Free flap sawn into tongue stump
and floor of mouth
Immediate postoperative result
Flap for total glossectomy
Images taken Intraoperatively and 1 month after surgery
This case illustrates the use of free flap mainly for restoration of function.
Flap for layngopharyngectomy
This patient presented with advanced transglottic laryngeal squamous cell cancer that ruptured into the
skin (brackets & circle). The mass has obliterated the upper airway requiring tracheostomy (red arrow).
Total laryngopharyngectomy with Free flap reconstruction was planned.
Flap for layngopharyngectomy
Large flap harvested from anterolateral thigh for free flap
reconstruction and creation of neopharynx
Flap for layngopharyngectomy
Defect after neck dissection and extirpation of mass
Flap for layngopharyngectomy
Creation of tube/neopharynx from free flap harvested from thigh
Flap for layngopharyngectomy
Creation of tube/neopharynx from free flap harvested from thigh
Uvula – yellow arrow
Flap for layngopharyngectomy
This case illustrates the use of free flap for creation of neopharynx
and closure of a large soft tissue defect. Flap is employed both for
restitution of function and cosmesis.
Pectoralis flap
A diabetic woman with poor glycemic control who developed multicompartmental
abscesses in the suprahyoid neck and necrotizing fasciitis (CT).
Full thickness loss of tissue in the face and neck after debridement with exposed
mandible (arrow). Flap reconstruction is required to close the defect.
Pectoralis flap
Pectoralis flap is used to fill the soft tissue defect.
Pectoralis flap - postop
Free flap used to fill the soft tissue defect in the left face and neck, and create the
lining of the oral cavity. There is persistent enhancement in the masticator space on
MR (circle) a year after surgery, with no clinical signs of active infection.
Pectoralis myocutaneous flap - postop
M
F
Postoperative CT showing the pectoralis myocutaneous flap (arrows). M – muscle F- Fat
In this case the flap serve both purposes of restoration of function and cosmesis
Total glossectomy and mandibular
resection with free flap reconstruction
This patient presented with oral tongue mass, later proven to be squamous cell carcinoma.
The plan was resection of the tongue mass including the mandible, with free flap reconstruction.
Total glossectomy and mandibular
resection with free flap reconstruction
Courtesy of James Melville DDS
Resection of tongue and mandible
Total glossectomy and mandibular
resection with free flap reconstruction
Courtesy of James Melville DDS
Specimen removed
Total glossectomy and mandibular
resection with free flap reconstruction
Courtesy of James Melville DDS
After resection of tongue and mandible
Harvesting flap from thigh
Total glossectomy and mandibular
resection with free flap reconstruction
Courtesy of James Melville DDS
Mandibular reconstruction with Titanium chain
Total glossectomy and mandibular
resection with free flap reconstruction
Courtesy of James Melville DDS
Flap implantation
Total glossectomy and mandibular
resection with free flap reconstruction
Courtesy of James Melville DDS
Immediate postoperative result – this case illustrates
use of flap for both restoration of function and cosmesis
Example of free flap reconstruction for cosmesis
Preoperative CT with cosmetic
defect on the right (bracket)
after prior parotidectomy
10 years earlier for adenoid
cystic carcinoma. Free flap
reconstruction was decided
after a negative workup for
disease recurrence.
Flap harvested from the
thigh
Neck dissection in preparation for
free flap reconstruction
SCM – sternocleidomastoid muscle
CCA – common carotid artery bifurcation
Immediate postsurgical
result
Example of free flap reconstruction for cosmesis
Before
After
Summary
 Reconstructive flaps in the head and neck are used for
restitution of function or cosmesis, or both, depending on
the needs of the patient.
 Case illustrations are provided.
Bibliography of illustrations
Slides 11-14; 16-19; 21; 23-26; 28-31; 33-36; 38
Mathes, S. J. (Ed.). (2006). Plastic Surgery Volume 3: The Head
and Neck, Part 2. Philadelphia, PA: Saunders Elsevier.
Slide 36:
“Reconstruction: Harvesting.” AOfoundation.org. Web. 23 Mar.
2015.