Locoregional Flap in Head and Neck Cancermedinfo2.psu.ac.th/surgery/Edu_be_document/document...

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1 10 Locoregional flap in head and neck cancer Safety margin 3-6 basal cell carcinoma 1 squamous cell carcinoma grading stage (reconstruction) flap (cutaneous flap) (myocutaneous flap) (osteomyocutaneous flap) (skin graft) flap flap flap flap (pedicle) flap Cutaneous flap 2 random pattern flap dermal subdermal plexus flap ( 1) cutaneous flap 1:1, 1:1½, 1:3, 1:4 1:5 design flap 1:3 1:5 flap design flap 1:1 1:1½ flap cutaneous flap axial pattern flap flap subdermal dermal plexus ( 2) groin flap superficial circumflex iliac flap iliac crest anterior superior iliac spine iliac vascularized bone graft flap random pattern flap 1 cutaneous flap 1

Transcript of Locoregional Flap in Head and Neck Cancermedinfo2.psu.ac.th/surgery/Edu_be_document/document...

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Locoregional flap in head and neck cancer

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��������� ����!����"� #$� %&���' (�����������!�)���� ��&� ���#��*+�*�' �$�)��������&����� ��%&���'��$,�����%!)�����-�'������%&���'������&�������.#)��/'� Safety margin 3-6 ��!!���� �+���* basal cell carcinoma �!� 1 �C������ �+���* squamous cell carcinoma ���������'-����� ��!���������#+��F�GF� grading -���C!!���� � !���I��������-���C!!���� ��!����*&� stage -����� �'��� '������ �!��)���%&���'������� ��������JK����'�*��F,� ��%&���'�������� (reconstruction) ���JK����'�*�� ��&�JK����*��GF�#NIO��)���%&���'����)����*%P�JQ����!&���� �+�)����������,GP���'���/J /'��*������-F�����'���)������G�+�������,/'�J��� �!���PJ!���I���,J����+�)��%P�JQ������G)��������!�*�-���P&���#�/'����$��#�J��� ��%&���'������������������ �����+� flap #$� %&���'�����$����$,���,J���*/J'���%������/-��� (cutaneous flap) %������/-����!�����$�� (myocutaneous flap) �$�%������/-����!�����$�� �!���'P� (osteomyocutaneous flap) �$�JS''����%&�%������ (skin graft) �-��/J�����'�����������,GP���'��� '������ �!�������F������+�#���P�����!��-��)���* flap ��!&����)��'� ��$,�����G%&���')��/'�%!'�/�&��-�����C���������+� flap ��&� flap ���/'� flap #$� ��$����$,���,J���*'���%������/-����JK���&������ �$����������&���$,�&��'��� ��&� �!�����$���!���'P�.'���-��� (pedicle) CF,��+��!$�'/J�!���� flap Cutaneous flap �*&����!���I�-���!�'�!$�'��,/J�!�������� 2 ���' /'���& random pattern flap CF,�%&���'*���I)'-��&������ /'������!$�'��� dermal �!� subdermal plexus �-��/J�!���� flap (PJ��, 1) cutaneous flap ���������'�&��#���������&�#�������JK� 1:1, 1:1½, 1:3, 1:4 �$� 1:5 -F����**���I���� ] �&����!$�'���!�������������&�)' ��&� *���I)*���� ����� design flap )����#���������&�#�������JK� 1:3 GF� 1:5 /'�.'� flap /�&��� ��&*���I�-� -� !+���� ������� design )�� flap ��#���������&�#������ �JK� 1:1 �$� 1:1½ �F���J!�'O�� ��&��/� ��� �����J�����$,������,�&��)�� flap �'CF,����� F���#���P����,����� cutaneous flap ������'#$� axial pattern flap �������-�� flap �JK��!�'�!$�'�'�'+� CF,��+�)���!$�'/J�!���� subdermal �!� dermal plexus �!�'#������-������!�'�!$�' (PJ��, 2) ��&� groin flap *���I-����*�����!�'�!$�'�'�'+� superficial circumflex iliac �JK����-�� flap ����!�'/JGF� iliac crest *���I anterior superior iliac spine �+�)������G�+������'P� iliac /J)���JK� vascularized bone graft /'��!��������G����** flap �&�/J����JK����' random pattern flap /'�

������ 1 ���'-�� cutaneous flap �*&����!���I�-���!�'�!$�'��,/J�!����1

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������ 2 Groin flap1

Myocutancous �$� musculocutaneous flap �����!�����$�� �!��!�'�!$�'��,���!�����!�����$�� ���� ] �JK�-��� )��!�����$��� ���� intramuscular vessels �!��� perforator vessels ��!N fascia -���!�����$��-F��/J)�����/-��� subdernal plexus �!� dermal plexus ��$,��!����%��������,��P&*���I����/'� Mathes �!� Nahai /'��*&����'-���!�����$�����PJ�**-���!�'�!$�'��,���!����CF,��*&��JK� 5 �** (PJ��, 3)

������ 3 Vascular pedicle types of muscle according to Mathes and Nahai2

�NJ#$� random pattern flap ���!$�'���!�������-�����,�� dermal subdermal plexus �-��/J)� flap )���+���*%&���'JS'���%!*���I)*�����!����%&���'���������$�������� ���� axial pattern flap ���!�'�!$�'�'�'+� �JK����-�� flap CF,�����G�+�/J)��/'������-�����&� random pattern flap ��#����&���$,�G$������&� �!�/�&-F����*��'�&��-��#���������&�#����� myocutancous flap �������!�'�!$�'�!��!�����$��CF,�����+�/J)����$,�������,���,������/'������&� random pattern flap ��%&���'������� �*���I�&��J�� �N-������)��&��J���!�f��JK���,����+�#�������+�������I� �!�)�����������,�����'��� ��&� %P�JQ����,���N-������)��&��J��'�GF�'���� �&����%&���'��-P'���JP� ���N'f���,%N� ���������� �+���*%P�JQ����,�� poor oral hygiene ����+�)���+� dental clearance ��$,��!���!�,�������'�������*��'��$����,�%!%&���' �$� flap �!�G��%P�JQ������/'��*��(�����������!��%&���'� ���JK�J�.������&���%P�JQ��������'��� ��%&���'JS' defect �+��JK�����#�')���JK� step ladder pattern #$� G������G�� *JS'�%!/'�)�� undermine �%!�!��� *JS' G���%!������� *JS'/�&GF�)���+� skin graft �����-������)���JS'�%&�%�������$���-��*&����)����+� flap )������I��+� local flap �JK�!+�'�*�� ���/�&����G�+�/'�)��)�� distant flap G�����)��/�&/'����)������I��+� free flap G�� �!�������F'G$��!��Jg�*�����&������!��+�%&���'JS' defect �!�����'-�����C��� ��&� flap ��� �%!��� �������,)����*%P�JQ��� ���#���P&)����h�������� �!��������G�!$��)����"��$,� ] ��,�JK�-�������&�/J/'����.'�/�&�+�)���P�������$����$,�-��%P�JQ��.'�/�&�+��JK�

Arterial portion Cutaneous portion

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Cutaneous flap �*&����PJ&�� �$���"����!$,�� flap �-��/JJS' defect /'���& rotation flap, transposition flap, v-y advancement flap �!� bilobe flap �������������� flap ��,��!���I��(������ ��&� Rhomboid �$� Limberg flap �!� Dufourmental flap �$� LLL flap (PJ��, 4) ���+�%&���' random pattern flap #�)��-���-�� flap ����-�������)����+�)�� flap /�&*�� ����/�!�����-���!$�''+� �!���+���!$�� �!�*�-���P&���)�/'���'����&� �N���,���'-F��������!$,�� flap/J����/�&���� 90 �� � �� design flap ��&!�#���� �������'����)�������%�)��%!�N'�������%!%&���'�&��)��&��-��� �$��(���/�&����(����* skin line �$�)�����%!%&���'-�����* contour line � ���+�)���%!�JK���,���'-F����������-���%!%&���'��/�&�JK���,������

Transposition flap

Rhomboid �$� Limberg flap

Dufourmental flap �$� LLL flap

������ 4 Cutaneous flap �*&����PJ&�� �$���"����!$,�� flap �-��/JJS' defect3

��%&���'���������� ���,���� �����������#�'#$� G������%&���'������� ����!�������� ���� 2 �C������ �!����������G�!������ loose plane -������ ���)��������+�)������G�� *JS'�%!/'���&����,�)� ��� defect ���� 2 �C������ �����+� galeal incision ��$,��$'���� ����!��� *JS'/'� *��#����������)�� Towel clips 'F����-�*���� ������-���)������'��� �!��� *JS'/'� ��� defect �������&��������!$��)����"�JS''����%&�%������ (skin graft) G��*���I��.�!� ����� pericranium #!N���P& ���/�&�� pericranium #!N��$�������JS' defect ��$,�����%!'���#����������$����*���'��*� ����I��+� rotation flap ���+� rotation flap *���I���� ����+��JK����� design )���� arch of rotation �������� ] ��$,�����*���I���� �����/�&�$'��N&� (supple) ���$��%������*���I�$,� *��#�����������+� galeal incision (PJ��, 5) ��$,��$'���� ���)������G�� *�%!JS'/'�

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������ 5 Rotation flap3

Defect *���I����%��� ��&��������G undermine )����� loose plane )���!�����$�� frontalis )�� �������� ] �+�)���� *�%!JS'/'� ���-�*�%!���/�&����G�����/'�����+�)��)�� Towel clips 'F����-�*�%!�$'%������*���I����%��)������'����!��� *JS'/'� �%!�JK���,*���I�����$,���'���/J�����F,����JK���, �&���)���&����� /�&����+�JS''����%&�%������ ����� *JS'/�&/'��������I��+� rotation flap (PJ��, 6)

������ 6 Rotation flap *���I����%��3

Defect *���I periocular area ����!���I��(�����,)��)���JS'�%!)�*���I��� CF,����*&��JK�

defect ��,�P�����*���&��-���������!��!�'#������-�������� Spinelli �!� Jelks /'�������"���%&���'��������*���I periocular ��&�����** (PJ��, 7) ��%&���'JS' defect �!�'#������-��������!&�� �+��JK�����)�� composite graft �����'P��&���!� mucosa �����$,�������P� ��$,���� conjunctiva, tarsal plate �!��!$,�� flap ���*���I����.'�)�� Mustade flap �!$,���-��/JJS' Ian Mc. Gregor /'� modify .'��+� Z-plasty ��, lateral canthal area ��$,�����G�!$,��%������/-��������������!&��/'� (PJ��, 8)

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������ 7 �NJ������)���%&���'��������������*���I�*!P����������,�JK� partial-thickness defect (PT) �!� Full-thickness defect (FT) 5

������ 8 Mustade check flap4

Guo L, Priba JR �!� Pribaz JJ /'�����-������)���%&���'����������$,�JS' defect -��'�! �*���I��P�'��� local flap ��&� glabella flap, miter flap, bilobe flap, nasolabial flap �!� forehead flap .'��*&�*���I��P��JK� 4 zone #$� proximal third, middle third, distal third �!� distal subunits CF,�/'���& ala, domal alar grove, dome, central, columella �!� nasal sill (PJ��, 9 �!� 10)

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������ 9 ��P��*&��JK� 4 .C�6

������ 10 Flap ���'�&�� ] *���I��P�6

��%&���'���������� �*���I��xyJ��CF,��&��)��&�JK� squamous cell carcinoma GF����!� 95 ����#+��F�GF�!���I��(���-����!N�!��-����� �CF,���!�����/J'���-����!�!�!F�)���xyJ�� '��������%&���'�+��JK�����%&���'�JK�PJ��� V �$� W �$��JK� block !�/J�!�'#������-����xyJ�� �!�����)���&�����-�*������� �-���!� 1 �C������'��� %P�JQ���F�����.�������-�'/'� ��%&���'JS'�%!��,��xyJ���!�����%&���'���������� ���� ���!��������I�#$� G�� defect ���'-F�������/�&������F,�)����-��#������-����xyJ��*��$�!&��)���� *JS'/'�)����� mucosa, �!�����$��, dermis �!�%������ ��� defect ������F,�)������&/�&�������)����%&���'JS'�%!'��� Abbe|s flap �$� Estlander|s flap ��� defect �������)�������)�� Karapandzic|s flap CF,��JK� functional flap �$� Mc. Huge|s flap ��JS'/'� �&�� defect ��,��xyJ��!&�����/J������'����+�)��)�� bilateral Mc. Huge|s flap CF,�����GJS'�%!�!�������xyJ��!&��/'�'� (PJ��, 11,12)

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������ 11 Abbe|s flap4

������ 12 Bilateral Mc. Huge|s flap4

Locoregional flap �$,� ] �+���*��%&���'����������,�&���)� #$� submental flap (PJ��, 13) supraclavicular flap (PJ��, 14) deltopectoral flap �$� Bakamjian|s flap (PJ��, 15) Pectoralis major myocutancous flap (PJ��, 16) �!� Trapezius myocutaneous flap (PJ��, 17) ��&�!$��&���%&���'������� ����� �!��)���������� ��������JK����'�*��F,� ��%&���'�����������JK����&��)��%!-��������%P�JQ����!&����'�-F����#NIO�����-F�� �!���� �!�����������#�'��,��J��N�����"�%&���'���������)�����+�)��%!��%&���'�������'���,���+�)��%P�JQ������G)��������-���P&���#�/'���&����,�)� ��&� #�J���

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���� 8 ��� 10

������ 13 Submental flap8, 9

������ 14 Supraclavicular flap10

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������ 15 Deltopectoral flap �$� Bakamjian|s flap4

������ 16 Pectoralis major myocutancous flap12, 13

������17 Trapezius myocutaneous flap14

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���� 10 ��� 10

Reference:

1. Jankauskas S, Cohen IK, Grabb WC. Basic technique of plastic surgery. In: Smith JW and Aston SJ, editors. Grabb and Smith|s plastic surgery. 4th ed. Little Brown, 1991.

2. Ariyan S. Reconstruction of the oropharyngeal area. In: Ariyan S, editor. Cancer of the head and neck, CV Mosby, 1987.

3. Jackson IT. Local flaps in head and neck reconstruction. 1st ed. Quality Medical Publishing, 2002.

4. Sultan M. Local and regional flap. In: Close LG, Larson DL, Shah JP. Editors, Essentials of head and neck oncology. Thiem, 1998.

5. Spinelli HM, Jelks GW. Periocular reconstruction: A systematic approach. Plast. Reconstr. Surg., 1993, 91; 1017-1024.

6. Guo L, Pribaz JR and Pribaz JJ. Nasal reconstruction with local flaps: A simple algorithm for management of small defects. 2008, 122; 130-139.

7. Rojananin S, Igarashi T, Ratanavichitrasin A, Lertakayamanee N, Ruksamanee A. experimental study of the facial artery: Relevance to its reverse flow competence and cutaneous blood supply of the neck for clinical use as a new flap. Head neck, 1996, 18; 17.

8. Pistre V, Pelissier P, Martin D, Lim A, Baudet J. Ten years of experience with the submental Flap. Plast. Reconstr. Surg. 2001, 108; 1576-1581.

9. Tan O, Atik B, Parmaksizoglu D. Soft-tissue augmentation of the middle and lower face using the deepithelialized submental flap. Plast. Reconstr. Surg. 2007, 119; 873-879.

10. Vinhv Q , Ogawa R, Anh TV, Hyakusoku H. Reconstruction of neck scar contractures using supraclavicular flaps: Retrospective study of 30 cases. Plast. Reconstr. Surg. 2007, 119; 130-135.

11. Pallua N, Noah ME. The tunneled supraclavicular island flap: An optimized technique for head and neck reconstruction. Plast. Reconstr. Surg. 2000, 105; 842.

12. Koh KS, Eom JS, Kirk I, Kim SY, Nam s. Pectoralis major musculocutaneous flap in oropharyngeal reconstruction: Revisited. Plast. Reconstr. Surg. 2006, 118; 1145-1149.

13. Rikimaru H, Kiyokawa K, Inoue Y, Tai Y. Three-dimensional anatomical vascular distribution in the pectoralis major myocutaneous flap. Plast. Reconstr. Surg. 2005, 115; 1342-1352.

14. Guillamondegui OM, Larson DL. The lateral trapezius musculocutaneous flap: Its use in head and neck reconstruction. Plast. Reconstr. Surg. 1981, 67; 143-150.