Flap constructed of muscle, soft tissue, and overlying skin
Used when larger reconstruction site needs more volume (provided by muscle) to adequately fill surgical defect
Donor sites include pectoralis major, rectus abdominis, or latissimus dorsi muscles
Osteocutaneous flap
Flap constructed with bone, soft tissue, and overlying skin ± muscle
Also known as composite flap
Used when reconstruction requires bone replacement
Primarily employed in oral cavity squamous cell carcinoma (SCCa) reconstructions
Portion of mandible or maxilla removed during tumor treatment surgery
Muscle added to osteocutaneous flap if more volume needed for larger surgical defects
Donor site usually fibula or scapula
Flaps most commonly used to reconstruct tumor resection cavity
Also used to repair posttraumatic defects in extracranial head and neck
Osteocutaneous flap may be used to repair mandibular or maxillary osteonecrosis
IMAGING
General Features
Imaging Recommendations
CT Findings
MR Findings
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
General Features
Staging, Grading, & Classification
CLINICAL ISSUES
Presentation
Demographics
Natural History & Prognosis
DIAGNOSTIC CHECKLIST
Consider
Image Interpretation Pearls
Reporting Tips
Selected References
Patel SA et al: Principles and practice of reconstructive surgery for head and neck cancer. Surg Oncol Clin N Am. 24(3):473-489, 2015
Glastonbury CM et al: Ossification of the vascular pedicle in microsurgical fibular free flap reconstruction of the head and neck. AJNR Am J Neuroradiol. 35(10):1965-9, 2014
Wehage IC et al: Complex reconstructions in head and neck cancer surgery: decision making. Head Neck Oncol. 3:14, 2011
Chan JW et al: Three- and four-dimensional computed tomographic angiography studies of the supraclavicular artery island flap. Plast Reconstr Surg. 125(2):525-31, 2010
González-García R et al: Transport osteogenesis in the maxillofacial skeleton: outcomes of a versatile reconstruction method following tumor ablation. Arch Otolaryngol Head Neck Surg. 136(3):243-50, 2010
Jacobson AS et al: Reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular free flap. Laryngoscope. 120(2):273-5, 2010
Kalavrezos N et al: Current trends and future perspectives in the surgical management of oral cancer. Oral Oncol. 46(6):429-32, 2010
Kruse AL et al: Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review. Microsurgery. 30(3):242-8, 2010
Lee JT et al: Reconstruction of extensive composite oromandibular defects with simultaneous free anterolateral thigh fasciocutaneous and fibular osteocutaneous flaps. J Reconstr Microsurg. 26(3):145-51, 2010
Nelson JA et al: The vastus lateralis muscle flap in head and neck reconstruction: an alternative flap for soft tissue defects. Ann Plast Surg. 64(1):28-30, 2010
Pattani KM et al: What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope. 120(4):717-23, 2010
Sader C et al: Fat graft pedicle stabilization in head and neck microvascular reconstruction. Plast Reconstr Surg. 125(3):893-5, 2010
Smith JE et al: Temporalis muscle flap for reconstruction of skull base defects. Head Neck. 32(2):199-203, 2010
Abdel-Galil K et al: Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques--part I. Non-invasive techniques. Br J Oral Maxillofac Surg. 47(5):351-5, 2009
Chien SH et al: Reconstruction of extensive head and neck defects with multiple simultaneous free flaps. Plast Reconstr Surg. 124(1):318, 2009
Corten EM et al: Clinical outcome after pedicled segmental pectoralis major island flaps for head and neck reconstruction. Ann Plast Surg. 63(3):292-6, 2009
Ethier JL et al: Pectoralis major myofascial flap in head and neck reconstruction: indications and outcomes. J Otolaryngol Head Neck Surg. 38(6):632-41, 2009
Iseli TA et al: Functional outcomes following secondary free flap reconstruction of the head and neck. Laryngoscope. 119(5):856-60, 2009
Nuara MJ et al: Prospective analysis of outcomes and complications of 300 consecutive microvascular reconstructions. Arch Facial Plast Surg. 11(4):235-9, 2009
Sumer BD et al: Microvascular flap reconstruction of major pharyngeal resections with the intent of laryngeal preservation. Arch Otolaryngol Head Neck Surg. 135(8):801-6, 2009
Ayad T et al: Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation. Head Neck. 30(4):437-45, 2008
Cordeiro PG: Frontiers in free flap reconstruction in the head and neck. J Surg Oncol. 97(8):669-73, 2008
Dassonville O et al: Head and neck reconstruction with free flaps: a report on 213 cases. Eur Arch Otorhinolaryngol. 265(1):85-95, 2008
Kramer M et al: Vascular mapping of head and neck: computed tomography angiography versus digital subtraction angiography. J Oral Maxillofac Surg. 66(2):302-7, 2008
Murray DJ et al: Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature. J Plast Reconstr Aesthet Surg. 61(10):1148-56, 2008
Oliver C et al: Interpretability of PET/CT imaging in head and neck cancer patients following composite mandibular resection and osteocutaneous free flap reconstruction. Head Neck. 30(2):187-93, 2008
Thorwarth M et al: Free flap transfer in cranio-maxillofacial surgery: a review of the current data. Oral Maxillofac Surg. 12(3):113-24, 2008
Bokhari WA et al: Tongue reconstruction: recent advances. Curr Opin Otolaryngol Head Neck Surg. 15(4):202-7, 2007
Kelly AM et al: Preoperative MR angiography in free fibula flap transfer for head and neck cancer: clinical application and influence on surgical decision making. AJR Am J Roentgenol. 188(1):268-74, 2007
Resto VA et al: Pectoralis major flap in composite lateral skull base defect reconstruction. Arch Otolaryngol Head Neck Surg. 133(5):490-4, 2007
Richmon JD et al: Reconstruction of the hypopharynx: current trends. Curr Opin Otolaryngol Head Neck Surg. 15(4):208-12, 2007
Smith RB et al: Scapula osteocutaneous free flap reconstruction of the head and neck: impact of flap choice on surgical and medical complications. Head Neck. 29(5):446-52, 2007
Spiegel JH et al: Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques. Laryngoscope. 117(3):485-90, 2007
Podrecca S et al: Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. J Plast Reconstr Aesthet Surg. 59(2):122-9, 2006
Morimoto Y et al: Instability of background fat intensity suppression using fat-saturated (FS) MR imaging techniques according to region and reconstruction procedure in patients with oral cancer. Oral Oncol. 40(3):332-40, 2004
Hudgins PA: Flap reconstruction in the head and neck: expected appearance, complications, and recurrent disease. Semin Ultrasound CT MR. 23(6):492-500, 2002
Tomura N et al: MR imaging of recurrent head and neck tumours following flap reconstructive surgery. Clin Radiol. 57(2):109-13, 2002
Chong J et al: MR imaging of the muscular component of myocutaneous flaps in the head and neck. AJNR Am J Neuroradiol. 22(1):170-4, 2001
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Imaging
Diagnostic Checklist
TERMINOLOGY
Definitions
Flap: Soft tissue ± muscle ± bone surgical site reconstruction
Also known as microvascular reconstruction
Soft tissue or autologous bone used to reconstruct postoperative resection defect in H&N
Fasciocutaneous flap
Flap constructed of deep muscle fascia with its overlying skin
Used for smaller surgical reconstructions in H&N
Allows harvesting of fasciocutaneous arterial perforators that pass along fascial septa between adjacent muscles
Results in larger flap size survival at reconstruction site as needed
Sensory cutaneous nerves also harvested when sensory reinnervation desired
Flap constructed of muscle, soft tissue, and overlying skin
Used when larger reconstruction site needs more volume (provided by muscle) to adequately fill surgical defect
Donor sites include pectoralis major, rectus abdominis, or latissimus dorsi muscles
Osteocutaneous flap
Flap constructed with bone, soft tissue, and overlying skin ± muscle
Also known as composite flap
Used when reconstruction requires bone replacement
Primarily employed in oral cavity squamous cell carcinoma (SCCa) reconstructions
Portion of mandible or maxilla removed during tumor treatment surgery
Muscle added to osteocutaneous flap if more volume needed for larger surgical defects
Donor site usually fibula or scapula
Flaps most commonly used to reconstruct tumor resection cavity
Also used to repair posttraumatic defects in extracranial head and neck
Osteocutaneous flap may be used to repair mandibular or maxillary osteonecrosis
IMAGING
General Features
Imaging Recommendations
CT Findings
MR Findings
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
General Features
Staging, Grading, & Classification
CLINICAL ISSUES
Presentation
Demographics
Natural History & Prognosis
DIAGNOSTIC CHECKLIST
Consider
Image Interpretation Pearls
Reporting Tips
Selected References
Patel SA et al: Principles and practice of reconstructive surgery for head and neck cancer. Surg Oncol Clin N Am. 24(3):473-489, 2015
Glastonbury CM et al: Ossification of the vascular pedicle in microsurgical fibular free flap reconstruction of the head and neck. AJNR Am J Neuroradiol. 35(10):1965-9, 2014
Wehage IC et al: Complex reconstructions in head and neck cancer surgery: decision making. Head Neck Oncol. 3:14, 2011
Chan JW et al: Three- and four-dimensional computed tomographic angiography studies of the supraclavicular artery island flap. Plast Reconstr Surg. 125(2):525-31, 2010
González-García R et al: Transport osteogenesis in the maxillofacial skeleton: outcomes of a versatile reconstruction method following tumor ablation. Arch Otolaryngol Head Neck Surg. 136(3):243-50, 2010
Jacobson AS et al: Reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular free flap. Laryngoscope. 120(2):273-5, 2010
Kalavrezos N et al: Current trends and future perspectives in the surgical management of oral cancer. Oral Oncol. 46(6):429-32, 2010
Kruse AL et al: Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review. Microsurgery. 30(3):242-8, 2010
Lee JT et al: Reconstruction of extensive composite oromandibular defects with simultaneous free anterolateral thigh fasciocutaneous and fibular osteocutaneous flaps. J Reconstr Microsurg. 26(3):145-51, 2010
Nelson JA et al: The vastus lateralis muscle flap in head and neck reconstruction: an alternative flap for soft tissue defects. Ann Plast Surg. 64(1):28-30, 2010
Pattani KM et al: What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope. 120(4):717-23, 2010
Sader C et al: Fat graft pedicle stabilization in head and neck microvascular reconstruction. Plast Reconstr Surg. 125(3):893-5, 2010
Smith JE et al: Temporalis muscle flap for reconstruction of skull base defects. Head Neck. 32(2):199-203, 2010
Abdel-Galil K et al: Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques--part I. Non-invasive techniques. Br J Oral Maxillofac Surg. 47(5):351-5, 2009
Chien SH et al: Reconstruction of extensive head and neck defects with multiple simultaneous free flaps. Plast Reconstr Surg. 124(1):318, 2009
Corten EM et al: Clinical outcome after pedicled segmental pectoralis major island flaps for head and neck reconstruction. Ann Plast Surg. 63(3):292-6, 2009
Ethier JL et al: Pectoralis major myofascial flap in head and neck reconstruction: indications and outcomes. J Otolaryngol Head Neck Surg. 38(6):632-41, 2009
Iseli TA et al: Functional outcomes following secondary free flap reconstruction of the head and neck. Laryngoscope. 119(5):856-60, 2009
Nuara MJ et al: Prospective analysis of outcomes and complications of 300 consecutive microvascular reconstructions. Arch Facial Plast Surg. 11(4):235-9, 2009
Sumer BD et al: Microvascular flap reconstruction of major pharyngeal resections with the intent of laryngeal preservation. Arch Otolaryngol Head Neck Surg. 135(8):801-6, 2009
Ayad T et al: Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation. Head Neck. 30(4):437-45, 2008
Cordeiro PG: Frontiers in free flap reconstruction in the head and neck. J Surg Oncol. 97(8):669-73, 2008
Dassonville O et al: Head and neck reconstruction with free flaps: a report on 213 cases. Eur Arch Otorhinolaryngol. 265(1):85-95, 2008
Kramer M et al: Vascular mapping of head and neck: computed tomography angiography versus digital subtraction angiography. J Oral Maxillofac Surg. 66(2):302-7, 2008
Murray DJ et al: Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature. J Plast Reconstr Aesthet Surg. 61(10):1148-56, 2008
Oliver C et al: Interpretability of PET/CT imaging in head and neck cancer patients following composite mandibular resection and osteocutaneous free flap reconstruction. Head Neck. 30(2):187-93, 2008
Thorwarth M et al: Free flap transfer in cranio-maxillofacial surgery: a review of the current data. Oral Maxillofac Surg. 12(3):113-24, 2008
Bokhari WA et al: Tongue reconstruction: recent advances. Curr Opin Otolaryngol Head Neck Surg. 15(4):202-7, 2007
Kelly AM et al: Preoperative MR angiography in free fibula flap transfer for head and neck cancer: clinical application and influence on surgical decision making. AJR Am J Roentgenol. 188(1):268-74, 2007
Resto VA et al: Pectoralis major flap in composite lateral skull base defect reconstruction. Arch Otolaryngol Head Neck Surg. 133(5):490-4, 2007
Richmon JD et al: Reconstruction of the hypopharynx: current trends. Curr Opin Otolaryngol Head Neck Surg. 15(4):208-12, 2007
Smith RB et al: Scapula osteocutaneous free flap reconstruction of the head and neck: impact of flap choice on surgical and medical complications. Head Neck. 29(5):446-52, 2007
Spiegel JH et al: Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques. Laryngoscope. 117(3):485-90, 2007
Podrecca S et al: Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. J Plast Reconstr Aesthet Surg. 59(2):122-9, 2006
Morimoto Y et al: Instability of background fat intensity suppression using fat-saturated (FS) MR imaging techniques according to region and reconstruction procedure in patients with oral cancer. Oral Oncol. 40(3):332-40, 2004
Hudgins PA: Flap reconstruction in the head and neck: expected appearance, complications, and recurrent disease. Semin Ultrasound CT MR. 23(6):492-500, 2002
Tomura N et al: MR imaging of recurrent head and neck tumours following flap reconstructive surgery. Clin Radiol. 57(2):109-13, 2002
Chong J et al: MR imaging of the muscular component of myocutaneous flaps in the head and neck. AJNR Am J Neuroradiol. 22(1):170-4, 2001
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