# Local and Regional Flaps of the Head and Neck

## Introduction

Reconstruction of head and neck defects following oncologic resection, trauma, or Mohs surgery demands an understanding of tissue transfer principles. The **reconstructive ladder** and **reconstructive elevator** guide the surgeon from simple closure to complex flap reconstruction. Local and regional flaps offer the advantage of matching tissue **color, texture, and thickness** better than distant or free flaps in the head and neck.

## Fundamental Principles

### Reconstructive Ladder

Healing by secondary intention, Primary closure, Skin grafts (split-thickness and full-thickness), Local flaps, Regional flaps, Distant/pedicled flaps, Free tissue transfer.

### Flap Classification

| Classification | Types |
|---------------|-------|
| By blood supply | Random pattern (subdermal plexus) vs. Axial pattern (named vessel) |
| By tissue | Cutaneous, fasciocutaneous, musculocutaneous, osseous |
| By movement | Advancement, rotation, transposition, interpolation |
| By location | Local (adjacent) vs. Regional (same region) vs. Distant |

**By blood supply**: Random pattern (subdermal plexus) vs. axial pattern (named vessel). **By tissue composition**: Cutaneous, fasciocutaneous, musculocutaneous, osseous. **By movement**: Advancement, rotation, transposition, interpolation. **By location**: Local (adjacent tissue) vs. regional (same body region) vs. distant.

### Key Design Principles

Respect **aesthetic subunits** of the face (forehead, nose, cheeks, lips, chin, eyelids). Place incision lines along **relaxed skin tension lines (RSTLs)** whenever possible. Maintain adequate blood supply; length-to-width ratios of **3:1** for random flaps (up to 4:1 on the face). Minimize tension on wound closure; distribute tension evenly. Preserve critical **landmarks** (eyelids, nasal ala, lip vermilion) to prevent distortion.

## Local Flaps

### Advancement Flaps

Tissue moves directly forward into the defect without rotation or lateral movement. **V-Y advancement**: Island pedicle flap advanced into the defect; V-shaped incision closed as Y. **Y-V advancement**: Opposite direction; used to lengthen tissue. **Bilateral advancement (H-plasty/Burow's)**: Two opposing advancement flaps with Burow's triangles to reduce standing cutaneous deformities.

### Rotation Flaps

Semicircular flap rotated about a pivot point into an adjacent triangular defect. Arc of rotation should be **4-8 times** the diameter of the defect. **Back-cut** or Burow's triangle may be needed to reduce tension. Excellent for scalp and cheek defects.

### Transposition Flaps

Rectangular flap that moves laterally over intervening tissue to fill an adjacent defect. **Rhombic (Limberg) flap**: Classic transposition flap designed on a 60-degree rhombus; four possible orientations allow strategic placement of scars. **Dufourmentel flap**: Modification allowing closure of rhomboid defects with angles other than 60 degrees. **Z-plasty**: Two triangular flaps transposed to redirect a scar, release contracture, or lengthen tissue; central limb placed along the scar; standard 60-degree angles provide 75% length increase. **Bilobed flap**: Two lobes of progressively smaller size rotated into a defect; workhorse for nasal tip and alar defects (Zitelli modification).

![Design and execution of a rhombic (Limberg) transposition flap for cheek reconstruction](images/rhombic-flap-design.jpg)

### Interpolation Flaps

Pedicle passes over or under intervening tissue; requires a second stage for pedicle division. **Paramedian forehead flap**: Gold standard for nasal reconstruction of defects >1.5 cm. Based on the **supratrochlear artery**. Provides excellent skin color and texture match. Two or three stages: Flap inset, pedicle division (3 weeks), optional thinning. **Melolabial (nasolabial) interpolation flap**: Used for alar and lateral nasal wall defects. Based on the angular artery. Pedicle divided at 2-3 weeks.

## Regional Flaps

### Cervicofacial Advancement-Rotation Flap

Large rotation-advancement flap for cheek and periorbital defects. Based on the **subdermal plexus** and perforators from the facial artery. Provides excellent tissue match for large cheek defects, Deep plane elevation below the SMAS for safe mobilization.

### Submental Flap

Axial flap based on the **submental artery** (branch of the facial artery). Provides a large skin paddle with variable inclusion of the anterior belly of the digastric. Useful for floor of mouth, tongue, and lower face reconstruction. **Contraindicated** when level I nodes are positive for malignancy.

### Deltopectoral Flap

Axial fasciocutaneous flap based on **perforating branches of the internal mammary artery**. Used for pharyngeal and cervical skin defects. Largely replaced by free flaps but remains a reliable backup option. Requires staged division of the pedicle.

### Pectoralis Major Myocutaneous Flap

Workhorse regional pedicled flap for head and neck reconstruction. Based on the **thoracoacromial artery** (pectoral branch). Provides bulk for oral cavity, oropharyngeal, and neck defects. Can include a segment of rib for mandibular reconstruction. Disadvantages: Bulky in obese patients, limited arc for superior defects, donor site morbidity.

![Paramedian forehead flap based on the supratrochlear artery for nasal reconstruction](images/paramedian-forehead-flap.jpg)

## Skin Grafts

**Split-thickness skin graft (STSG)**: 0.008-0.012 inches; heals donor site by re-epithelialization; greater contraction. **Full-thickness skin graft (FTSG)**: Includes entire dermis; less contraction; better color match. Common FTSG donor sites: Preauricular, postauricular, supraclavicular, upper eyelid. Grafts require a **vascularized wound bed**; will not take over bare bone, cartilage without perichondrium, or irradiated tissue. Bolster dressings immobilize the graft for 5-7 days to facilitate plasmatic imbibition and inosculation.

![Full-thickness skin graft harvested from the preauricular region for nasal sidewall reconstruction](images/ftsg-preauricular-harvest.jpg)

## Key Clinical Pearls

Always consider aesthetic subunits when planning facial reconstruction; replacing an entire subunit often yields a better result than patching a partial defect. The paramedian forehead flap is the gold standard for nasal defects larger than 1.5 cm and provides the best color and texture match. The bilobed flap (Zitelli modification) is the workhorse for nasal tip and distal nasal defects smaller than 1.5 cm. The pectoralis major flap remains an essential backup when free tissue transfer is not feasible or has failed. A Z-plasty with standard 60-degree angles achieves 75% lengthening of the central limb.

## References

1. Baker SR. *Local Flaps in Facial Reconstruction*. 3rd ed. Elsevier; 2014.
2. Menick FJ. Nasal reconstruction with a forehead flap. *Clin Plast Surg*. 2009;36(3):443-459.
3. Zitelli JA. The bilobed flap for nasal reconstruction. *Arch Dermatol*. 1989;125(7):957-959.
4. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck. *Plast Reconstr Surg*. 1979;63(1):73-81.