Flaps in
otolaryngology
BALASUBRAMANIAN THIAGARAJAN
Ideal flap
"when a part of one's person is lost, it
should be replaced in kind, bone for
bone, muscle for muscle, hairless skin
for hairless skin, an eye for an eye, a
tooth for a tooth."
Ralph Millard
Introduction
The term "flap" first originated during the 16th century from the Dutch
word "flappe" meaning a structure that hung broad and loose,
fastened only on one side.
Flaps are usually used to repair structural defects following surgery i.e.
for malignant conditions of head and neck.
History

600 B.C. Susrutha performed nasal reconstruction using cheek flap

1440 A.D. Forehead rhinoplasty (India).

Pivotal flaps was preferred during early days. This involves rotation
of the flap around its vascular pedicle.

Advancement flap (French surgeons). This involves transfer of skin
from adjacent area without rotation.
History (contd)

McGregor - Who introduced the forehead flap during 1963

Bakamjian - Who introduced the deltopectoral flap during 1965


Ariyan - Who pioneered the Pectoralis major myocutaneous flap in
1979
Daniel & Taylor - Who pioneered the free flap in 1973
Flap surgery - Principles

Principle I : Replace like with like. This will go a long way in Camouflaging the
surgical defect.

Principle II: Reconstruction should be thought in terms of units. It was Millard who
divided the human body into 7 main parts (head, neck, body and extremities).
He subdivided each of these parts into units. Each unit is further divided into
subunits. These units and subunits should be considered and studied before the
process of reconstruction is begun.

The most important aspect of these units are their borders. These borders include
creases, margins and hair lines. Adherence to these borders during
reconstruction is very important. It is always better to convert a partial unit
defect into a whole unit defect before grafting. This will enable better
consmesis.

Principle III: There should be a pattern and a fall back option always at hand.

Principle IV: The graft should be sutured without any tension. The donor area
should not suffer excessive tissue loss.
Definition of flap / graft
Flap is a unit of tissue that can be transferred from one site (donor) to another
(recipient site) while maintaining its own blood supply. Flap is transferred with its
blood supply intact, whereas a graft is a transfer of tissue without its own blood
supply. Survival of graft depends entirely on the blood supply from the recipient
site.
Facial incision
Classification of flap
Flaps may be classified according to their:

1. Blood supply

2. Tissue to be transferred

3. Location of donor site
Blood supply
For any graft tissue to survive blood supply is a must. If the
blood supply is derived from unnamed blood vessels then it is
termed as "Random flap". Many local skin flaps fall in this
category. If blood supply to the flap is derived from named
vessel / vessels it is referred to as "Axial flap". Most muscle flaps
fall in this category
Types of axial flaps

Type I Axial flap: Has only one vascular pedicle e.g. Facia lata

Type II Axial flap: Has blood supply served by dominant and Minor
pedicles e.g. Gracilis flap

Type III Axial flap: Has blood supply served by two dominant
pedicles e.g. Gluteus maximus flap

Type IV Axial flap: Has blood supply via segmental blood vessels
e.g. Sartorious flap

Type V Axial flap: Derives blood supply from one dominant pedicle
and many segmental blood vessels e.g. Latissmus dorsi flap
Axial flaps (contd)
Classification – according to tissue
to be transferred

Skin

Fascia

Muscle

Bone

Viscera (colon, small intestine, omentum)

Composite – Fasciocutaneous, myocutaneous, Tendocutaneous
and osseocutaneous flaps
Classification - Location

Tissue could be transferred from an area adjacent to the defect. This
type of flap is known as local flap. They may be further subclassified
depending on its geometric design.

Pivotal flaps: are also known as geometric flaps. They include
rotation, transposition, and interpolation types.

Advancement flaps: This type include single pedicle / Bipedicle / VY flaps

Tissue transferred from non contiguous site i.e. distant flaps. These
flaps could either be pedicled or free flaps. The pedicled flaps are
still attached to their blood supply, while free flaps are totally
severed from their blood supply and are reattached to vessels at
the recipient site (microanastomosis).
Advancement flap (History)

Celsus of ancient Rome as the first to perform advancement flap

French surgeons in 1800 popularized this flap as sliding flaps

Used to cover skin defects close to an area of skin laxity

Initially it was commonly used in forehead, scalp, eyelid and upper
lip areas
Vascularity of advancement flaps



Critical blood supply – 1-2 ml / min / 100g of tissue is adequate.
Advancement flaps depend on random blood supply arising from
anastomoses within subdermal / dermal plexus
Flap length : width ratio in head and neck region is 4:1
Types of advancement flaps

Monopedicled flap

Bipedicled flap

V – Y flaps
Monopedicle flap

Usually rectangular and moves
forwards

Redundant tissue at the base of
the flap can be reduced by
creating Burow triangle
Bipedicle flap

Incisions are made on each side
of flap

These are random flaps (obtain
blood supply from capillaries
rather than named arteries

Commonly these flaps are
generally skin
V – Y Flap

V – shaped incision

Broad base of V is advanced into
the defect

Resultant defect is closed (Y
shaped closure)

If long flaps are needed delay
phenomenon can be made use
of. After raising the flap 1-3 weeks
time is given before advancing it.
Delay phenomenon works
because the choked blood vessels
open up if time is given.
Glabellar flap

Best suited for reconstruction of
defects involving the bridge or
upper half of the nose.

Axial flap

Blood supply – supratrochlear
artery / dorsal nasal branches

Upper portion of incision should be
carried up to the periosteum

Mobilisation around naso frontal
angle should be carried out by
blunt dissection. Supra trochlear
vessels should be preserved
Sliding rotation degloving nasal
flap

Helps to cover the lower half of
the front of the nasal cavity

The degloving flap is outlined in
such a fashion that the incision to
mobilize the flap is on the righthand side along the nasolabial
fold going up to the glabellar
region.

The apex of the flap is in the
midline, with symmetrical right and
left limbs

Blood supply is from the nasolabial
artery
Nasolabial flap

Axial flap

Blood supply – Nasolabial artery

Width to length ratio – 1:5

Useful in covering defects over
lower portion of nose and ala of
the nose
Inferiorly based nasolabial flap

Based on nasolabial artery

Logically suited because of its
blood supply

Suited for lateral aspect of lower
portion of nose reconstruction

Even though the defect to be
filled is circular its apex is made
triangular to facilitate primary
closure of donor site

Flap should be superficial to the
underlying facial musculature
Rhomboid flap

Geometric flap

Described by Limberg

Useful in pts with lax skin

Blood supply is from subdermal
plexus

Length to width ratio should not
exceed 2:1

Useful in reconstruction of lateral
nasal defects and cheek defects
Mustardé Advancement Rotation
Cheek Flap
1. Defects of infraorbital region / medial
part of cheek can be closed using
this cheek flap
2. Blood supply is from the terminal
branches of facial artery
3. Flap should be mobilized up to the
angle of the mandible to avoid
unnecessary tension to the flap
4. Superior aspect of incision is towards
the temple – prevents drooping of
lateral canthus of eye
Bilobed flap

Random flap

Can be used anywhere in the
body

Effective in covering defects over
zygoma and buccinators

Works best in pts with lax skin

First lobe fills the defect while the
second lobe fills up the defect
created by the first lobe
Cervical flap

Regional cutaneous flap

Useful to cover lower half of the
face and upper neck

Vascularity from subdermal
arterical plexus

Length to width ratio not to
exceed 3:1

Neck dissection if need be can be
performed via the same incision

Flap is to be elevated superficial to
platysma
Myocutaneous flaps

Includes skin, subcutaneous tissues
and muscles

1. Pectoralis major myocutaneous
flap

Useful in sealing large defects

2. Deltopectoral flap

Classified according to their
vascular patterns and locations

3. Radial forearm free flap

4. Temporalis flap
Pectoralis major myocutaneous
flap

Myocutaneous flap

Pectoral branch of
acromiothoracic artery

Enters the muscle just below
clavicle at the junction of middle
and outer thirds

Useful in reconstruction of oral
cavity, oropharynx, hypopharynx
and larynx
Pectoralis major myocutaneous
flap – elevation tips

1. The incision should be made above the nipple in male and below
the breast in the female patient.

2. Pedicle should be identified carefully to preserve the vascularity
of the flap

3. After repair of the defect rubber drains should be placed
Deltopectoral flap

Bakamjian in 1965

Axial flap

Supplied by perforating branches
of internal mammary artery

Can cover any site of the neck up
to the level of zygoma.

Advantage – Flap retraction
occurs from side to side and not
from end to end.
Deltopectoral flap (contd)

Flap is outlined in the anterior chest wall and shoulder

Dissection plane – deep to pectoral and deltoid muscle fascia

Muscle fibres should be seen as the flap is being elevated

Elevation of this flap should only be done up to 2cms lateral to the
sternal border taking care to avoid injury to perforating arteries

Donor site should be covered with split thickness skin graft
Radial forearm flap

Faciocutaneous flap based on
radial artery

Venous outflow is from the
superficial veins of forearm

Used to reconstruct oral cavity,
oropharynx and hypopharyx

This flap includes skin from the
anterior cubital fossa to the flexor
crease at the wrist. Skin should not
be elevated over the ulnar artery
Abbe Estlander flap

This flap is commonly used to
reconstruct defects involving lips
and commissures

Full thickness flap with skin /
muscle / mucous membrane are
used

The flap can be marked, rotated
and sutured leading to the
formation of new commissure
Temporoparietal flap

Based on superficial temporal
artery

Both anterior and posterior
branches of superficial temporal
artery should be included

Size of the flap should be the size
of temporalis muscle

The arch of the zygoma should be
fractured to deliver the flap into
the oral cavity

Donor site should be closed
primarily
Hadad Flap

Used for skull base reconstruction

Mucoperichondrial/periosteal flap

Based on nasoseptal artery

Commonly used for anterior skull
base reconstruction
Hadad flap - Indications

Skull base reconstruction after endonasal surgery

To prevent communication between brain and sinuses

To repair anterior skull base leak
Hadad flap - advantages

Robust blood supply

Superior arc of rotation

Provides enough area to cover entire anterior skull base

Can be safely stored in nasopharynx if the procedure needs to be
staged

Can be taken down and reused in revision cases