The document discusses various types of pedicled flaps that can be used to reconstruct orofacial defects. It begins by classifying flaps based on their blood supply and proximity to the defect. It then describes several commonly used pedicled flaps for the orofacial region, including the deltopectoral flap, pectoralis major myocutaneous flap, forehead flap, temporalis muscle flap, and buccal fat pad flap. It discusses the advantages, disadvantages, indications, and surgical techniques for each flap.

1. Pedicled flaps
in orofacial defects
Presented by:
Dr.N.R.K.Anil Kumar,
II yr PG

2. CONTENTS
 INTRODUCTION
 CLASSIFICATION OF FLAPS
 PEDICLED FLAPS IN OROFACIAL REGION
 MONITORING OF FLAP
 COMPLICATIONS
 REFERENCES

3. Free flaps
Distant
flap
Regional
flap
Local
flap
Skin
grafts
Primary
closure
INTRODUCTION
“WHEN YOUR ONLY TOOL
IS A NAIL,
THE WHOLE WORLD LOOKS
LIKE A HAMMER”

4.  A flap is a segment of tissue that contains a network of
blood vessels that may be transferred from a donor site to
reconstruct a secondary defect.
 1440 : Dutch word "flappe" : something that hung broad and
loose, fastened only by one side.
 Whether or not we use our best flap choice in the first instance,
we must always be ready for its failure and have a backup flap
in mind which will “dig us out of a hole”.
Introduction

5.  Based on Blood supply
 Random Axial
 Random-pattern flaps: Have no dominant blood supply.
 Axial flaps: Have a dominant feeding vessel.
 Reverse-flow flaps (also known as distal pedicle flaps
or reverse axial pattern flaps): The proximal blood
supply is divided, leaving the flap to survive on the
intact distally based vessels.
 Peninsular flap / Island flap.
CLASSIFICATION

6. CLASSIFICATION
According to the proximity to the defect
 Local: The flap shares a side with the defect (e.g.,
rhomboid flap).
Regional: The flap is near, but not immediately
adjacent to the defect (e.g., paramedian forehead flap).
Distant: The flap is not near the defect (e.g., PMMC
flap).
Free flap: Free tissue transfer.

7. Local flaps
 Flaps adjacent to the defect requiring
reconstruction – Local flaps.

8. Distant flaps
 Flaps which are further away and
not contiguous with the defect –
Distant flaps.
 Distant flaps that remain attached
to the body – Pedicled flaps. The
base of the flap that contains the
blood supply is called the pedicle.
 Distant flaps those detached and
revascularised by anastomising
arteries and veins – Free flaps.

9. CLASSIFICATION
 By method of tranfer from the donor site
1) Advancement flaps
2) Rotation flaps
3) Transposition flaps : Rhombic and Bilobed flaps.

10. According to the tissue contained
a. Cutaneous
b. Fasciocutaneous
c. Musculocutaneous
d. Osteocutaneous
e. Osteomusculocutaneous

11. Selection of flap
 Multi-factorial
 Size, location, depth and nature of defect.
 Size and arc of rotation of flap
 Vascularity
 Accessibility
 Donor site
 Function

12. PEDICLED FLAPS
 PMMC Flap
 Fore Head flap
 Temporalis flap
 Lattissmus dorsi flap
 Delto pectoral flap
 Trapezius flap
 Buccal Fat Pad
 Sub mental island flap
 Platysma flap
 FAMM flap

13.  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
DELTOPECTORAL FALP
Bakanjian –1965

14.  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
Deltopectoral Falp

15. Deltopectoral Falp
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
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.
 Staged approach.

16. PECTORALIS MAJOR
MYOCUTANEOUS FLAP
 Ariyan in 1979
 Work horse for H & N
 Origins -three portions.
Medial third of the clavicle,
Sternum
Cartilages of the first six ribs.
 Insertion : crest of greater
tubercle of humerus
 Medial rotator and adductor
 Thoraco acromial artery.

17. PECTORALIS MAJOR
MYOCUTANEOUS FLAP
Can reach till zygoma.
Most reliable for neck and
Lower part of face.

19. ADVANTAGES
 One stage
 Large skin territory
 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 easy to elevate
PECTORALIS MAJOR
MYOCUTANEOUS FLAP

20.  DISADVANTAGES
 Arc of rotation limited for oro maxillary defects
 It can be too bulky
 There is distortion of symmetry at the donor site
 Shoulder function can be impaired
 Distal skin of the flap is not reliable
PECTORALIS MAJOR
MYOCUTANEOUS FLAP

21. POTENTIAL PITFALLS - PMMC
 Incidence of total flap necrosis - reported to be 1- 7%.
 Partial flap necrosis- 14%-30%
 Pedicle compression
 In male patients - excessive hair growth in the oral cavity
or pharynx

22. FORE HEAD FLAP
 Median fore head flap – Sushruta samita
700 BC
 Mid fore head flap
Median
Para median
 Mid facial reconstruction
 Para median flap - supra trochlear artery
 Revascularization of cartilage & bone

23.  Largest area of donor site - matching
color & texture to facial skin
 Safest flap
 85% to 95% success
 Long enough to reach
any part of the ipsilateral face
 Different types due to
variation in flap pedicle
FORE HEAD FLAP

24. McGregor Millard Wilson
FORE HEAD FLAP
Variations of pedicle of forehead
flap

25. TEMPORALIS MUSCLE FLAP
 Golovine 1898 - orbital exenteration
 Gilles - reanimation of paralyzed face
 Fan - shaped muscle, temporal fossa
& the superior temporal line
 Vascular anatomy allows splitting of
muscle into anterior & posterior flap

26.  Mobilized flap - 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
 Absence of vascularity
 Facial nerve and deep temporal
TEMPORALIS MUSCLE FLAP

27.  Hemi coronal flap - excellent
access
 Incision - above 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
TEMPORALIS MUSCLE FLAP

29. TEMPORALIS MUSCLE FLAP
ADVANTAGES
 Ease of elevation
 Reliable blood supply
 Proximity
 Camouflage of incision
with in hair line
 Muscle support graft
DISADVANTAGES
 Sensory disturbances
 Potential facial nerve injury
 Temporal hallowing

30. LATISSIMUS DORSI
MYOCUTANEOUS FLAP
 First myocutaneous flap – Tanzini 1896
 Quillen 1978
 Distant flap, provides largest possible
skin paddle
 Most complex donor site dissection,
 arc of rotation extremely versatile
 Insertion - inter tubercular groove of the
humerus

31. LATISSIMUS DORSI
MYOCUTANEOUS FLAP
 10 X 8 cm
 40 X 20 cm
 Safe as free flap
 Position intra - op
 Extend, adduct, & medially rotate the arm
 Thoraco dorsal artery - sub scapular artery
 Perforators , medially along the spine – secondary supply

32. STERNOCLEDOMASTOID
MYOCUTANEOUS FLAP
Jinau – 1909
Long strap muscle
Muscular origin
Branch of spinal accessory
nerve
Segmental supply – dominant
blood supply – occipital artery,
STA , thyrocervical trunk
inferiorly.
 Retain 2 out of 3 vessels.

33. Indications
 Epithelial lining for mucosal reconstruction
 Closure of oro cutaneous fistulas
 Tongue, floor of the mouth, cheek
 Compromised neck
 Small defects of pharynx
STERNOCLEDOMASTOID
MYOCUTANEOUS FLAP

34.  Superior/ inferior blood supply
 Paddle of skin over one end of
pedicle
 Local advancement/
transposition
 6 x 8 cm paddle of skin
STERNOCLEDOMASTOID
MYOCUTANEOUS FLAP
 Disadvantage :
- Upper skin muscle flap – poorly
viable
- Lower third blood supply –
unreliable not used for mandible

35. PLATYSMA FLAP
 Extremely thin band like & variable muscle
forming superficial boundary of neck.
 Anatomy :
 Arises from clavicle superiorly continues with
the attachment to the mandible
 Submental branch of the facial artery
 Dermal – subdermal plexus
 Flap size
Muscle - 10 x 10 cm to 10 x 20 cm
Skin paddle - 3 x 6 cm to 6 x 20 cm

36. PLATYSMA FLAP
PROCEDURE :
Marking by volunterily activating
muscle, skin island.
Submandibular incision
Platysma incised
INDICATIONS :
- Tumors involving Buccal
mucosa and buccal sulcus.
- Cicatricial release of burns.
- Resurfacing lower lip &
creating deep sulcus.

37. ADVANTAGES
 Proximity & regionality
 Thin & delicate
 Reliable when vascular
criteria adhered
 Arc of rotation - 180
 No donor site disability
 Sensitive skin
 Donor site: free of Hair
 Primary closure
DISADVANTAGES
 Lack of bulk
 Reliability 85%
 Complication like skin loss
& fistula, necrosis, delayed
wound healing.
 In patients with prior
surgery and radiation
 Paresthesia
 No lip splitting incision
PLATYSMA FLAP

38. TRAPEZIUS FLAP
 Mutter Flap – Mc Craw s
1842
 Originally described as
superior based cutaneous
flap
 Flat & triangular - supero
posterior aspect of the neck &
shoulder
 Transverse cervical artery
 Spinal accessory nerve
 Rotate the scapula
elevate, rotate & adduct
upper arm
 10 x 20 cm in size

39.  Lateral positioning of patient
to elevate flap
 Ideally suited
- radical parotidectomy
- anterior neck coverage
- lateral face, posterior scalp
neck
 Generous amount of soft
tissue & large portion of skin
island
 90 – 95 % of success
TRAPEZIUS FLAP

40.  ADVANTAGES
 Versatile
 Regionality of flap
 Strong vascular security
 Supplies considerable bulk
 Arc of rotation 90 – 180
degree
 One stage procedure
 Minimum deficit at donor
area
TRAPEZIUS FLAP
DISADVANTAGES
Venous system difficult to preserve
Vascular supply in general difficult
to preserve
Can present with excessive bulk
Cannot be easily tubed
Moderate shoulder drop
postoperatively

41. Sub mental island flap
 Based on submental artery branch
of facial artery.
 Consists of skin, subcutaneous
tissue, fascia.
 Vascular pedicle of 8cm length can
be taken.
 Used for reconstruction of defects
of lower face, preauricular defects,
inferior and lateral neck defects.
 Skin paddle – 4 x 10 cms with
maximum of 14 x 7 cms in lax
neck.

42. Sub mental island flap

43. Sub mental island flap
Procedure:
 Marked with neck extended.
 Submental area 1-2 cms
posterior to mandiblar border.
 Subplatysmal dissection
 Flap dissected till level of facial
artery
 Donor site – primary closure.

44. Sub mental island flap

45. Floor of Mouth

46. FAMM flap
 The facial artery forms the vascular pedicle.
 It consists of buccal mucosa, underlying submucosa, a
portion of the buccinator muscle, deeper fibers of the
orbicularis oris, and the facial artery with its venous
plexus.
 The flap is an axial pattern flap designed along and
including the length of the facial artery, based either
inferiorly or superiorly.
 Can be used to cover defects in the hard palate,
alveolus, nasal lining, upper lip, and lower orbit, lower
lip including the vermilion, alveolus, retromolar area,
tonsillar fossa, and the floor of the mouth (Pribaz et al.,
1992).

47. FAMM flap

48. NASO LABIAL FLAP
 Melolabial crease
 SMAS layer insertion
 Most important facial aesthetic boundaries
 Vascularity - Facial artery
medial cheek skin
superiorly based
inferiorly based
Sufficient skin available
unilaterally / bilaterally
closure parallel - melolabial crease

49.  Color, texture & skin – LIPS & LATERAL NOSE
 Pivotal + advancement
 Rotation not used
 Transposition – most common
Limited donor tissue
Extremely difficult to use in dentate patient
Uses
closure of oro-antral fistula
small defect of anterior floor of the mouth in edentulous patient
Oral submucous fibrosis
NASO LABIAL FLAP

50. NASO LABIAL FLAP

51. BUCCAL FAT PAD
 Heister (1727) - “Glandula molaris.”
 Bichat (1801) - True nature of the BFP. ‘‘boule de
Bichat,’’ sucking pad, sucking cushion, masticatory fat
pad, or buccal pad of fat.
 Scammon - Anatomy of the BFP .
 Egyedi (1977) – BFP as a versatile pedicled graft.
 Neder described the use of buccal pad fat as free
graft to close oral defects.
 Tideman et al. (1986) described its detailed anatomy,
vascular supply and operative technique.
 Yenwas the first to succeed in covering the buccal
defect with a split thickness skin graft in treating a case
of OSMF.

52. The possible functions of the BFP
 Sucking in newborns
 Separating the masticator muscles from one another
and from the adjacent bony structures,
 Enhancement of intermuscular motion, (syssacosis)
 Protection of neurovascular bundles.
Advantages of BFP as a pedicled graft are
 Easy harvest
 Low morbidity
 High success rate
 Elimination of donor-site skin scars.

53. ANATOMY
 The buccal fat pad located anterior
to the masseter muscle and deep to
the buccinator muscle.
 Acc to Traditional anatomic
descriptions Buccal fat pad has a
central body and 4 processes:
buccal, pterygoid,pterygopalatine,
superficial, and deep temporal.
 Recently, Buccal fat pad was
described as having 3 lobes
anterior, intermediate, posterior.
The 4 processes described are
from the posterior lobe
Atlas Oral Maxillofacial Surg
Clin N Am 15 (2007) 23–32

54. ANATOMY
•The main body lies on the anterior border of the masseter
muscle and extends deeply to lie on the posterior maxilla and
forward along the buccal vestibule.
•Buccal process - located deep to the superficial
musculoaponeurotic system at the anterior border of the
masseter and partially responsible for cheek contour.
•Pterygopalatine process - extends into the pterygopalatine
fossa encapsulating the pterygopalatine vessels.

55. ANATOMY
•Pterygoid extension - posteriorly extends in to
pterygomandibular space.
•Temporal extension can be divided further into 2 parts:
•Superficial part - between the deep temporal fascia,
temporalis muscle, and tendon.
•Deep part - behind the lateral orbital wall and frontal process
of the zygoma and into the infratemporal space.
•Blood supply
•Buccal and deep temporal branches of the maxillary artery,
Transverse facial branch of the superficial temporal artery,
Branches of the facial artery such as the inferior buccinator
artery.

56. LIGAMENTS ATTACHED FROM ATTACHED TO
Maxillary ligament
(fibrous condensation)
Anterior lobe Maxilla
Posterior zygomatic
ligament
Intermediate lobe Zygomatic process
Medial and lateral
infraorbital ligaments
Intermediate lobe
(Medial and lateral
side)
Infraorbital rim
Temporalis tendon
ligament
Posterior lobe Temporalis tendon
posteriorly.
Buccinator ligament Anterior lobe Buccinator
membrane.
Each process has its own capsule and is anchored to
the surrounding structures by ligaments.

57.  The buccal and zygomatic
branches of the facial nerve
and the parotid duct lie lateral
to the fat pad and should not
be injured during flap
mobilization.
 The parotid duct courses with
the buccal branches of the
facial nerve anteriorly
(superficial), and on the lateral
surface of the BFP, it
penetrates the buccinator
muscles, entering the oral
cavity.

58. •The buccal extension and main body together constitute 55%-
70% of total weight.
•BFP seems to be constant throughout life, usually with no direct
relationship to the total body fat present.
•The mean volume in males was 10.2 ml (7.8–11.2 ml), and in
females it was 8.9 ml (7.2–10.8 ml).The mean thickness was 6
mm, and mean weight of 9.7 g.
•Blunt surgical dissection reveals that the fat pad may be
estimated between 7 to 9.34 cm with reproducible vascularity as
long as the flap is tension-free.

59. SURGICAL PROCEDURE
 The BFP was approached via the posterior- superior margin of the
created buccal defect or by placing 2 cm horizontal vestibular
incision extending backwards from above the maxillary second
molar tooth, and then dissected with an index finger.
 Blunt dissection through the buccinator and loose surrounding
fascia, allowed the buccal fat pad to herniate into the mouth.
 The body and the buccal extension of BFP were gently mobilised by
blunt dissection, taking care not to disrupt the delicate capsule.
 After the pad had been dissected free from the surrounding tissues,
it was grasped with vascular forceps, gently teased out, advanced,
and expanded over the defect.
 The BFP was teased out gently until a sufficient amount was
obtained to cover the defect without tension .

60.  HEALING OF THE BFP
 Clinically, in the typical course, the surface of the
orally exposed fat becomes yellowish-white in 3 days
and then gradually becomes red within 1 week,
which is most likely due to the formation of young
granulation tissue. This changes into firmer
granulation tissue during the 2nd week, and becomes
completely epithelialized with a slight contraction of
the wound by 3 weeks after the operation.
 The BFP healed in 2 weeks and completely epithelized
in 6 weeks.5

61.  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; warmth.
Muscle – Dark; dark red bleeding; skin graft not
adherent.
Fascia – Dark; greyish, doppler signal may remain
normal for a longer period
Monitoring of Flaps

62.  Inflow
 Arterial kinking
 Inset too tight
 Damage to pedicle
 Arterial insufficiency
 Thrombosis in extremity.
 Outflow
 Venous occlusion
 Tunnel too tight.
 Venous thrombosis in major veins.
 Kinking of pedicle.
 Hematoma under flap
Possible causes of impaired
perfusion

63. Conclusion
Anatomic structure Flap used for reconstruction
Floor of the mouth Deltopectoral flap
FAMM flap
Forehead flap
PMMC flap
Lower vertical trapezius
Platysma flap
Buccal mucosal defects Temporo parietal flap
PMMC flap
Soft palate defects BFP, FAMM flap,
Temporalis muscle flap
Hard palate defects and
Retromolar trigone
FAMM flap
Temporalis muscle flap
BFP

64. Flap Anatomic structures
reconstructed
PMMC flap Oral cavity, oropharynx,
Face and neck defects
Trapezius flap Lower 2/3rd of face, neck,
Temporal fossa defects
Sternocledo mastoid flap Resurfacing oral cavity,
Protecting pharyngeal
reconstruction and greater vessels
Platysma flap Intra oral defects,
oropharyngeal defects.
Lattismus dorsi flap Oral cavity, oropharynx,
face and neck defects.
Temporalis flap Cheek and orbital defects,
Dynamic facial reconstruction.

65.  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
References