Produkt

KlappentextLocal and Regional Flaps in Head & Neck Reconstruction: A Practical Approach provides comprehensive, step-by-step instruction for flap raising and insetting for the head and neck region. Ideal for oral and maxillofacial surgeons, facial plastic surgeons, and head and neck surgeons, the book serves as a useful guide to planning reconstructive cases and an easily accessible reference prior to operation.

Local and Regional Flaps in Head & Neck Reconstruction is logically organized into 24 chapters, each focusing on a local or regional flap, or a special site reconstruction. Chapters focused on a particular flap will begin with a detailed description of the relevant anatomy and discuss potential applications of the flap before moving into a detailed step-by-step description of how to elevated and transfer the flap to the defect site. Potential complications will also be addressed.
Well-illustrated with more than 800 clinical photographs and with a website featuring surgical procedures, this book is an ideal reference for those new to practice and experts alike.

Rui Fernandes, DMD, MD, FACS, is Chief of the Head and Neck Service at the University of Florida College of Medicine. He maintains an active clinical practice in Jacksonville and serves as the program director for the microvascular reconstructive surgery fellowship. He is a fellow of the American Association of Oral & Maxillofacial Surgeons, American College of Oral & Maxillofacial Surgeons, American College of Surgeons, the American Head and Neck Society, the American Society of Clinical Oncology and is a founding fellow of the International Academy of Oral Oncology. He has authored more than 70 manuscripts and book chapters and has delivered numerous lectures both nationally and internationally.

Details

Weitere ISBN/GTIN9781118938386

ProduktartE-Book

EinbandartE-Book

FormatEPUB

Format Hinweis2 - DRM Adobe / EPUB

FormatFormat mit automatischem Seitenumbruch (reflowable)

Verlag

John Wiley & Sons

Erscheinungsjahr2014

Erscheinungsdatum15.10.2014

Auflage1. Auflage

Seiten272 Seiten

SpracheEnglisch

Dateigrösse394757 Kbytes

Artikel-Nr.3136702

Rubriken

Genre9201

Inhalt/Kritik

Inhaltsverzeichnis

Preface vii

Acknowledgments ix

About the companion website xi

1 Introduction 1

2 Flap classification 2

3 Bilobed flap 5

4 Rhomboid flap 12

5 Crescentic flap 20

6 Septal flap 31

7 Nasolabial flap 41

8 V to Y Advancement Flap 50

9 Keystone flap 57

10 Paramedian forehead flap 62

11 The temporoparietal fascia flap 75

12 Temporalis muscle flap 84

13 Cervicofacial advancement flap 92

14 Submental island flap 103

15 Pectoralis major myocutaneous flap 114

16 Latissimus dorsi myocutaneous flap 123

17 Sternocleidomastoid flap 133

18 Trapezius flap 140

19 The supraclavicular artery island flap 147

20 The internal mammary perforator flap 162

21 Ear reconstruction 170

22 Lip reconstruction 186

23 Nasal reconstruction 206

24 Scalp reconstruction 222

Index 243mehr

Leseprobe

Chapter 2
Flap classification
Introduction

The literature is replete with descriptions and various classifications of flaps. This ample classification can be confusing. The intent of this chapter is to provide a brief clarification of the systems commonly consulted for classification of skin and muscle flaps. The chapter is not intended to be a treatise on flap physiology or classification but simply to define some of the terms, which will be used in the remainder of the book.

Our understanding and improved success with the use of local and regional flaps is a direct consequence of a better understanding of the physiology of skin perfusion.

The understanding of the arterial supply has been a continuous process that had its foundation in pioneering works from the likes of Manchot,1 Cormack,2 and Salmon3 to Taylor4 and most recently Saint-Cyr.5 Continued advancements have been made in the entire reconstructive arena based on their work.

In general terms, we can classify flaps based on their vascularity, their composition, or their method of transfer.
Local flaps

Local flaps are flaps that are located adjacent to the defect site. They may be contiguous to the defect or a small amount of tissue may separate the flap from the defect. The surrounding tissue is transferred to repair the defect and therefore the flap tends to be similar in color and texture, and the thickness can often be tailored to the needs of the defect.
Local cutaneous flaps

Local flaps can also be classified based on the method of transfer. Broadly speaking, they can be pivot, advancement, or hinge flaps. The pivot flaps are further subdivided into: rotation, transposition, interpolated, and island flaps.

The rotational flap is a flap that is transferred to the recipient bed by pivoting around the base of the flap. The defect and the base of the flap have to be contiguous. Another form is to transpose a flap. This description entails the use of a flap with a geometric shaped design whereby the local tissue is undermined after elevation of the flap and then the flap is mobilized to fit the defect. At times, the design will include two shapes, as in a bilobed flap, so that the flap is transferred to the defect site and the smaller portion of the flap is transposed to the donor site. The area is closed after wide undermining.

The interpolated flap is where the defect is not intimately connected to the base of the flap. During transfer, the flap needs to cross over the intact portion of skin to reach the defect. There are two options for flap transfer. One is to develop a tunnel between the flap and the defect and then de-epithelialize the portion of the flap that will travel under the skin bridge and transfer the flap. The second and most commonly utilized method is to stage the reconstruction: transfer the flap over the tissue bridge, return after enough collateral blood supply to the flap has developed from the recipient bed, and then section the connecting portion of the flap between the recipient bed and donor site.

In the island flap design, the skin is circumferentially incised and the blood supply to the flap comes from the subcutaneous tissue or through the muscle or septum. A common design of the flap is with the pedicle composed mainly of the vasculature to the flap.
Regional flaps

Regional flaps are located at a significant distance from the donor site. Because of this distance, the flap usually has its own blood supply in the form of a named vessel. There are several potential disadvantages of regional flaps. The first and perhaps the most important is the arc of rotation of the flap. The ability to use a particular regional flap will be dependent on the reach of the flap based on its arc of rotation. The reliability of regional flaps is improved when the flap can reach the defect and the inset is performed without tension. Other disadvantages for regional flaps are that the skin color match and texture may be slightly different from that found at the recipient site.

The discovery between 1965 and 1975 of axial pattern skin flaps, such as the deltopectoral flap, with their advantageous length-to-breadth proportions marked the next milestone in reconstructive surgery.6 The term axial pattern was coined by McGregor and Morgan in 1973.7 In that publication they defined the terms as:

Axial Pattern Flap - A single flap which has an anatomically recognized arterio-venous system running along its long axias. Such a flap, because of the presence of its axial arterio-venous system, is not subject to many of the restrictions which apply to flaps in general.

Random Pattern Flap - A flap which lacks any significant bias in its vascular pattern. Such a flap, because it lacks an axial arterio-venous system, is subject to the restrictions hitherto generally accepted in flap practice.

The physiological basis for the survival of axial pattern flaps was elucidated by Smith's rabbit study published in 1973.8 In this study, Smith used flaps of varying length to width ratio and showed that the axial flaps survived as long as an 8#:#1 ratio. The ratio was limited to the flank length of the rabbit. In comparison, the random pattern flaps had a 1#:#1 ratio prior to developing distal tip necrosis.

Random pattern flaps can be classified according to their geometric configuration (rhombic, bilobed, V-Y, Z-plasties, or W-plasties) and by their method of transfer (rotation, advancement, interpolation, and island flaps).9
Distant (microvascular/free) flaps

The use of distant or free flaps will not be covered in this textbook in the procedure chapters. The use of various free flaps will be discussed in the site specific reconstruction found towards the end of the book. Unlike local or regional flaps, distant or microvascular free flaps require the detachment of the feeding vessels and transfer of the flap to the recipient site and anastomosing the vessels to a recipient artery and vein or veins. The advantage of this method of reconstruction is that the surgeon is no longer limited to the amount of tissue in the vicinity of the defect nor the art of rotation of the flap. It enables the use of small to large or simple to complex tissue transfer. The obvious disadvantage is that when the skin in the head and neck needs to be reconstructed, the color match and texture will be significantly different.
Flap classification (fasciocutaneous flap and muscle flap)

In 1984, Cormack and Lamberty, an anatomist and a plastic surgeon described a classification of fasciocutaneous flaps based on their vasculature. They described four different types.10 They described the flaps as follows:
Type A - A pedicled fasciocutaneous flap dependent on multiple fasciocutaneous perforators at the base and oriented with the long axis of the flap in the predominant direction of the arterial plexus at the deep fascia.
Type B - A pedicled or a free flap depending on a single sizeable and consistent fasciocutaneous perforator feeding a plexus at the level of the deep fascia.
Type C - The support of the skin is dependent upon the fascial plexus that is supplied by multiple small perforators along the length which reach it from a deep artery by passing along the fascial septum between the muscles.
Type D - The osteo-myo-fasciocutaneous free tissue transfer. An extension of type C, the fascial septum is taken in continuity with adjacent muscle and bone which derive their blood supply from the same artery.

The most commonly utilized classification system for muscle flaps is that of Mathis and Nahai, published in 1984.11 The classification was based on the vascular perfusion to the muscle. The classification had five types as follows:
Type I: One dominant vascular pedicle.
Type II: Dominant vascular pedicles and minor pedicles.
Type III: Two dominant pedicles.
Type IV: Segmental vascular pedicles.
Type V: One dominant vascular pedicle and secondary segmental vascular pedicles.

The most recent addition to the reconstructive surgeon's armamentarium has been the perforator flaps. The perforator flap concept was first described by Koshima in 1989.12 The basic premise of the technique was the harvest of a skin flap with dissection of the feeding vessels through the muscle down to the named source vessel. The Gent consensus defined a perforator as a vessel that has its origin in one of the axial vessels of the body and that passes through certain structural elements of the body, besides interstitial connective tissue and fat, before reaching the subcutaneous fat layer.13 In the consensus paper, they defined five types of perforators:
Direct perforators perforate the deep fascia only.
Indirect muscle perforators predominantly supply the subcutaneous tissues.
Indirect muscle perforators predominantly supply the muscle but have secondary branches to the subcutaneous tissues.
Indirect perimysium perforators travel within the perimysium between muscle fibers before piercing the deep fascia.
Indirect septal perforators travel through the intermuscular septum before piercing the deep...
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