Local Flaps

Local flaps consist of tissue that is mostly detached from surrounding tissue but retains enough connec

Figure 18-6. A, A patient with dermatofibrosarcoma of the scalp was reconstructed with pericranial flap and split-thickness skin graft which have healed well. B, Tissue expander in place and scalp fully expanded. C, Appearance after excision of skin graft, removal of tissue expander and advancement of expanded scalp.

tion to preserve an adequate blood supply to the entire flap. These are mostly cutaneous flaps that are used very often for reconstruction of small- to moderate-sized cutaneous defects of the head and neck.10 Local flaps may be transposed, rotated or advanced, and the donor site closed primarily. Examples of local flaps frequently used for reconstruction of facial defects include the Limberg or rhomboid (transposition), V-Y (advancement) and Imre (rotation) flap (Figure 18-8). Rearrangement of existing tissue in one area (ie, Z-plasty) is another technique frequently used to change the orientation of a scar or lengthen a scar contracture (Figure 18-9).

Moderate-sized composite defects requiring specialized tissues, such as those of the eyelids or lips, can often be reconstructed using switch flaps from their opposite, intact counterparts.1112 The borrowed tissue is mobilized and left attached to the defect for 3 weeks. At this time collateral neovascularization to

Figure 18-6. A, A patient with dermatofibrosarcoma of the scalp was reconstructed with pericranial flap and split-thickness skin graft which have healed well. B, Tissue expander in place and scalp fully expanded. C, Appearance after excision of skin graft, removal of tissue expander and advancement of expanded scalp.

Figure 18-7. A, Defect in temporal region. B, Late follow-up after repair with full-thickness skin graft. Note reasonable color match.

the flap is developed at the recipient site, the original vascular pedicle is divided and both defects closed primarily (Figure 18-10).

Random Flaps

A random flap is a cutaneous flap (ie, skin and subcutaneous tissue) that receives its blood supply through the subdermal capillary plexus rather than from named vessels. Random flaps for head and neck reconstruction are transposition, rotation or advancement flaps that are used mostly to resurface superficial defects after excision of skin cancers. Due to the nonspecific blood supply, these flaps tend to have a marginal viability at the distal tip; thus its length-to-width ratio limits the size of a random flap. According to experimental studies, this ratio should be no larger than 3 to 1 so that the entire flap can survive.13 Occasionally, the flap vascularity may be augmented using a so-called delay procedure, which consists of partially raising the skin flap and suturing it back to its vascular bed for 2 to 3 weeks.1415 Although the mechanism of the delay phenomenon is not completely understood, it is felt that partially elevating the flap results in a degree of local ischemia which in turn augments the remaining blood supply to the tissue. In general, delaying a flap allows for the successful transfer of a larger flap with an increased length-to-width ratio. Expanding adjacent tissue to obtain larger skin flaps with the same color and texture as the recipient site functions also as a gradual delay phenomenon. Tissue expansion has been extremely useful for head and neck reconstruction achieved in a delayed fashion16 (see Figure 18-2).

Figure 18-8. A, Transposition flap. B, V-Y advancement flap. C, Rhomboid flap.
Figure 18-9. Z-plasty.

Axial Flaps

Axial flaps are skin and subcutaneous tissue segments designed to parallel the major axis of a named vessel. If required, an axial flap may be designed such that all tissue may be raised, except at the connection with the vascular pedicle. This allows further mobilization of the cutaneous segment, as opposed to a random flap that has a more significant soft-tissue attachment to the donor site. Due to an identifiable blood supply,

Figure 18-10. A, Design of excision of lip lesion and lip switch flap for repair. B, C, Flap elevated and transposed into defect. D, Flap inset into upper lip. Pedicle is left attached for 10 to 21 days.

length-to-width ratio of axial flaps is not a concern and survival is increased when compared to random flaps.

Axial flaps most frequently used for head and neck reconstruction are based on the supratrochlear vessels (median or paramedian forehead flap) and the labial marginal artery and vein (nasolabial flap). Following are examples of axial flaps used in head and neck reconstruction.

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