Myocutaneous Flaps

• Nasolabial: interpolated flap that is transferred by pivotal movement and has a linear configuration; its base is not contiguous with defect; the pedicle ust pass over or under intervening tissue; if passed over intervening tissue, it requires second stage to divide pedicle and inset flap. The nasolabial flap is an axial flap but may be utilized as a random flap. The flap receives its blood supply from the angular artery (a branch of the facial artery), the infraorbital artery, and the transverse facial artery. Disadvantages of the nasolabial flap are that there is a limited amount of tissue available, the reconstruction may lead to asymmetry, and a ‘pincushioning’ effect of the cheek can occur when the flap is used for intraoral reconstruction.
• Palatal: pedicled, rotational flap
• Bilobed/Rhomboic: transpositional

Radial Forearm Flap

• Harvest is limited to 40% of radius circumference and 10-12cm of length
• Indicated for non-tooth bearing areas of the mandible, such as the angle and ramus
• The radial forearm osseocutaneous flap has recently enjoyed a resurgence in popularity based on Neal Futran’s work. He has found that prophylactic plating of the donor site has basically eliminated pathologic fractures of the residual radius. Harvest is still limited to 40 % of the radius’ circumference and 10-12 cm of length. It is primarily indicated for non-tooth bearing areas of the mandible, such as the angle and ramus.

Anterolateral Thigh Flap

• Advantage: donor site can be close primarily with an inconspicuous scar on the thigh
• Body habitus is main determinant of usefulness – excess fat may lead to excessive bulk and may require alternative flap
• The muscles first encountered when raising an ALT flap are: the vastus lateralis (laterally) and the rectus femoris (medially)

Latissimus Dorsi Flap

• Provides large bulk/large area of skin coverage; easy to harvest and can close primarily
• Can be both pedicled and free vascularized flap
• Disadvantage: frequent position change to harvest
• Blood supply: thoracodorsal artery from subscapular artery; secondary segmental pedicles come from perforating arterial branches of the posterior intercostals artery (lateral) and from lumbar artery (medial)

Platysma Flap

• Superiorly based flap – receives blood supply form submental branch of facial artery at or near the inferior border of the mandible
• Inferiorly based flap – transverse cervical artery
• Posteriorly based platysma flap – occipital artery
• Three different variations of the platysma flap are available based on the dominant blood supply. The inferiorly based flap, with no real application in oral/facial reconstruction, receives its arterial supply from the transverse cervical artery. The posteriorly based platysma flap receives its blood supply primarily from branches of the occipital artery. The superiorly based platysma flap receives its blood supply from the submental branch of the facial artery at or near the inferior border of the mandible.

Subscapular Flap

• Advantage: mobility of skin paddle relative to bone; extensive skin available; minimal donor site morbidity
• Disadvantage: frequent position change to harvest
• Blood supply: circumflex scapular artery; angular artery of thoracodorsal artery supplies inferior aspect of scapula and should be included if tip of scapula is required in reconstruction

Sternocleidomastoid Flap

• The blood supply to the skin paddle of the sternocleidomastoid myocutaneous flap must traverse through an intermediate muscular layer, the platysma muscle. The spinal accessory nerve should not be sacrificed as it also innervates the trapezius muscle and to do so would cause shoulder dysfunction. The arc of rotation of the SCM flap is inadequate to reconstruct anterior floor of mouth defects.

Trapezius Flap

• While in situ, the trapezius muscle receives minor contributions from the dorsal scapular artery, paraspinous perforators, and the occipital artery. However, once the flap is elevated, the transverse cervical artery is the primary nutrient vessel of this axial pattern flap. The transverse cervical artery is often sacrificed in patients who have undergone a neck dissection. If a trapezius myocutaneous flap is considered in one of these patients, the presence of the vessel must be confirmed by angiography.

Temporalis Flap

• The temporal muscle flap cannot be used to transfer overlying temporal skin due to a lack of myocutaneous perforators over the muscle. The muscle flap can successfully be grafted with a split thickness skin graft. The muscle flap can be used as a carrier of vascularized outer table calvarial bone for orbital or palatal reconstruction. The frontal branch of the facial nerve is located in the temporal parietal fascia, superficial to the temporal muscle fascia. This location is predictable and the flap can be elevated without damaging the frontal branch.