pedicled flaps used in head and neck surgery and their harvesting techniques are described in this power point presentation

1. PEDICLED FLAPS IN HEAD AND
NECK SURGERY
Dr . Rama raju

2. MYOCUTANEOUS FLAPS
• Commonest reconstructive option for head and neck defects
include:
1. Pectoralis major myocutaneous flap
2. Latissimus dorsi flap
3. Trapezius flap
4. Stenomastoid flap
5. Platysma flap
• PMMC flap and latissimus dorsi flaps still represent the
workhorses for some head and neck reconstructive surgeons
around the world

3. Blood supply to the muscles
• Random
• Axial
Random : perforators enters the
belly and immediately break up in
to branches (round muscles like
SCM)
Axial : major artery runs the entire
length of muscle giving
perforators (flat muscles like
PM,LD)

4. PECTORALIS MAJOR FLAP
ANATOMY :
• Orgin -clavicle, sternum, upper seven
ribs
• Insertion – bicipital groove
of humerus
• Blood supply –
Acromiothoracic artery branches
1) Superior clavicular branch
2) Main pectoral branch
a)Inferior thoracoacromial branch
b) Lateral thoracic trunk

5. ADVANTAGES OF PMMC FLAP
1. Large skin territory with rich vascular supply
2. Large arc of rotation
3. Can be harvested in supine position
4. Either muscle only or skin and muscle paddle can be used
5. Primary donor site closure is easily achieved

6. TECHNIQUE
SURFACE MARKING:
• A dotted line is marked from
acromion to xiphoid process and
another dotted line is drawn
perpendicular to first line from
sternal notch , this point represents
the location of vascular pedicle(
acromiothoracic artery)
• Skin island is drawn over distal part
of artery
• The border of skin island is stenum
medially and the nipple laterally

7. STEPS OF PMMC FLAP ELEVATION
Skin paddle has been marked
over the caudal , medial
portion of the chest wall

8. The lateral margin of the
pectoralis major is identified
through wide undermining of
the skin of lateral chest wall

9. A circumferential incision
around the skin paddle has
been completed, along with
exposure of entire pectoralis
major muscle.

10. • Pectoralis major muscle is
elevated off the chest wall by
sharp and blunt dissection

11. • Medial attachments of the
muscle are transected till the
level of clavicle.
• Careful attention should to
paid to stay lateral to
perforators of internal
mammary artery at the level
of 2nd and 3rd intercoastal
spaces to preserve blood
supply to deltopectoral flap

12. • Plane between pectoralis
major and minor is usually
avascular ,so blunt dissection
with finger is done.
• Pectoral branch of
thoracoacromial artery is
easily visualised in the
undersurface PM muscle
• Vascular pedicle is usually
located medial to pectoralis
minor

13. Muscular attachments to
humerus are transected
keeping vascular pedicle in
full view to prevent injury to
nutrient supply

14. • Tunnel is created for the
passage of PM flap in to the
neck
• Adequate underming is
required to prevent
compression of vascular
pedicle

15. • Flap has been transferred to
the neck superficial to the
clavicle , it is important to
avoid twisting or placing
excess tension to the pedicle
in this manoeuvre

16. Donor site closure should be
done by wide undermining of
chest wall skin

17. LATISSIMUS DORSI FLAP
• Large and triangular muscle
• ORGIN : sacrum, lumbar
vertebrae, thoracolumbar fascia,
posterior iliac crest , lower six
thoracic vertebrae
• INSERTION: intertubercular
groove of humerus
• Forms posterior wall of axilla

18. Blood supply:
• Major vascular supply-
thoracodorsal vessels
• It enters latissimus dorsi 10cm
from its humeral insertion
• Within LD muscle , thoracodorsal
vessels divide in to superior and
lateral branches which allow
muscle to split in to two.

19. • ADVANTAGES OF LD FLAP
1. Large amounts of tissue can
be transferred
2. Pedicled or free tissue
transfer
3. Cosmetic advantage
,especially in females
4. Versatile: may be
tubed/multiple/osseous
components
5. When pedicled , it can
reach upper face and scalp
• DISADVANTAGES OF LD
FLAP
1. It is very bulky
2. There is occasional donor
site dehiscence
3. There is reduction in upper
limb power
4. May require moving of
patient to harvest

20. STEPS OF HARVESTING LD FLAP
• Important landmarks – axilla ,
scapular tip, iliac crest
• Dotted line drawn from midpoint
of axilla to midpoint b/w anterior
and posteior iliac spine
represent anterior border of LD
• 8 to 10 cm below the midpoint
of axilla the thoracodorsal
artery and vein enters the
undersurface of LD muscle
• Divides into horizontal and
vertical branch

21. Initial incision is made at mid
point of axilla and runs along
the dashed line superiorly and
anterior edges of cutaneous
paddle inferiorly

22. • Anteior border of LD retracted
and branches of
thoracodorsal artery supplying
serratus anterior are exposed
and these are used to find
thoracodorsal vessels.
• Division of serratus anterior
branches allow near complete
mobilization of thoracodorsal
pedicle.

23. • An incision is made
circumferentially along
postero-medial portion of skin
paddle .
• This incision is made to the
level of fascia overlying
muscle

24. • Elevation of back skin off the
muscle provides exposure of
LD to posterior midline.

25. • LD is mobilised by blunt and
sharp dissection off the chest
wall ,external oblique ,
serratus anterior muscle
• The muscle and aponeurotic
attachment to iliac crest ,
vertebrae and ribs are sharply
transected

26. As the dissection proceeds
distally to proximally , the
vascular hilum identified ,
careful dissection along the
thoracodorsal vascular
pedicle requires division of
muscular and angular
branches.

27. • Passage of pedicled flap
requires preparation of tunnel
b/w pectoralis major and
minor
• The lateral edge of these
muscles are identified in
anterior axilla

28. • An incision parallel and
inferior to clavicle is required
to complete the tunnel . The
pectoralis major muscle
attachments to the clavicle
are incised
• A good tunnel must
accomdate atleast four of
surgeon’s fingers.

29. Under vision ,LD should be
passed through the tunnel
while being certain not to twist
the pedicle or to cause
shearing forces between skin
and the muscle.

30. Latissimus dorsi has been to
transferred to temporal region
without tension on vascular
leash

31. PLATYSMA FLAP
An island myocutaneous flap based on the
platysma muscle is ideal for reconstructing the
superficial lining defects of oral cavity
DISADVANTAGES OF PLATYSMA FLAP:
1) Blood supply can be unreliable.
2) Prior neck dissection or any neck surgeries precludes the
use of this flap
3) A proper neck dissection may damage the blood supply to
the flap
4) Removal of the platysma interferes with the blood supply to
the overlying skin and can lead to necrosis of skin.
5) Platysma flap is not advisable in patients with prior
irradiation to neck.

32. STERNOMASTOID FLAP
Advantages
The skin paddle of superiorly based sternomastoid flap is
hairless and thin and is an ideal reconstructive option
for medium sized cheek defects.
It does not produce excessive bulk in the face or mouth
Disadvantages
A proper neck dissection is likely to cause damage to the
vascular pedicle. Hence a previous neck surgery or
concurrent lymphadenectomy preclude the use of this
flap