Novel flaps for head and neck reconstruction.

The head and neck region is important both functionally and aesthetically and its reconstruction poses a formidable challenge for plastic surgeons. A perforator flap is a flap of skin or subcutaneous tissue supplied by a vessel that perforates the deep fascia to gain access to flap. With improvement in our knowledge of the anatomy of blood supply to the skin, the perforator flaps have opened a whole new horizon for the plastic surgeon to choose flaps with better function and cosmesis. The locally available perforators enable flaps to be designed with excellent match in tissue characteristics. Perforator flaps limit donor site morbidity and as they are islanded complete insetting is possible in a single stage. The principal perforator flaps such as facial artery perforator flap, platysma flap and its variant the submental flap and supra-clavicular artery flap used in the head and neck reconstruction are discussed. The more commonly used flaps are the free radial artery forearm flap and the anterolateral thigh flap while the novel ones are the thoracodorsal artery perforator flap, medial sural artery perforator flap and the toe-web flap for commissure reconstruction. The indications, reach and drawbacks of these flaps have been discussed in this review.

Managing venous discrepancy: simple method.

Microvascular anastomosis is an essential technique for free flap transfer and replantation surgery. Size discrepancy in microvascular anastomosis is a common issue in free flap transfer. Different methods are used by microvascular surgeons to solve the problem of vascular discrepancies. We describe a simple technique using Ligaclips (TM) that effectively narrows the wider vein in such discrepancy.

Use of the submental island flap in orofacial reconstruction--a review of 20 cases.

The submental flap, though not a widely used flap, is extremely useful in orofacial reconstruction. We present our experience with this flap particularly in the post oncological setting and describe its technique, complications and precautions adopted in its use. Between January 2001 and January 2007 we performed 20 submental flaps for primary reconstruction of post tumour excision defects in the intraoral and facial region. The procedure was successful in all cases without any complete flap loss. The complications encountered were partial flap loss in one case, haematoma in two cases and venous congestion in one case which was salvaged. Marginal mandibular nerve function was preserved in all cases.

Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases.

We present a series of reconstruction of 47 patients with large full thickness cheek defects secondary to cancer ablative surgery. All patients were reconstructed primarily by bipaddle pectoralis major myocutaneous (PMMC) flap. The age of patients ranged from 25 to 85 years (mean 49.5 years). All patients were male. The size of the paddle used for mucosal defect repair ranged from 5 x 3 to 9 x 7 cm and the size of the paddle used for skin cover ranged from 4 x 4 to 9 x 8 cm. The total flap size ranged from 10 x 5 to 17 x 7 cm. One patient had complete loss of flap (2.12%). Sixteen patients had minor complications all of which settled with conservative management. The follow up period varied from 1 month to 4 years. The modification adopted in bipaddling the flap was based on anatomical location of perforators to ensure good blood supply to both paddles of flap. Placing the flap horizontally with inclusion of nipple and areola increased the reach and size of available flap. We found the technique to be anatomically sound, technically easy and reliable. Precautions taken included proper assessment of reach of the paddle, placing not more than one-third of the paddle outside the muscle and securing the skin paddle to the muscle to avoid shearing of perforators during flap raising. We conclude that this technique is a useful alternative where microsurgical free tissue transfer is not possible or as a salvage procedure in selected large full thickness oral cavity lesions. However, the disadvantages of this method include loss of nipple and areola and technical difficulty in obese patients and females.