VASCULAR FLAP SURGERY Popper/Palva Flap Middle Temporal ... · VASCULAR FLAP SURGERY Popper/Palva...

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VASCULAR FLAP SURGERY Popper/Palva Flap Middle Temporal Flap Wing Flap © Bruce Black MD

Transcript of VASCULAR FLAP SURGERY Popper/Palva Flap Middle Temporal ... · VASCULAR FLAP SURGERY Popper/Palva...

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VASCULAR FLAP SURGERY

Popper/Palva Flap

Middle Temporal Flap

Wing Flap © Bruce Black MD

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Pinna-based periosteal flap (Popper 1935, Palva 1961). Popper’s design was periosteal; Palva’s incorporated the

superficial tissues also, for obliteration purposes. © Bruce Black MD

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Anteriorly based Popper periosteal flap, Rt ear. These flaps are comprised of relatively avascular mastoid

periosteum, without major supply vessels. © Bruce Black MD

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Palva flap, mastoid surgery, Rt ear. The Palva pattern incorporates the post-auricular muscle and soft tissue in

addition to the Popper periosteum, to increase bulk during obliteration procedures. © Bruce Black MD

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Plan of the middle temporal flap that derives vascular supply from the combined superficial and deep temporal

arteries, plus the post-auricular (if not previously sectioned). © Bruce Black MD

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Middle temporal flap (MTF) series 1, Rt ear. The post-auricular mastoid tissues are below, right. The temporalis has been elevated revealing the middle temporal artery (MTA) and accompanying dual veins in the squamous

temporal pericranium. © Bruce Black MD

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Greater detail of the previous frame. The artery is fine and difficult to visualise, but the “railway line” of the veins is evident. These vary from vertical to nearly horizontal. © Bruce Black MD

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The outline of the flap is cut on to bone as long as possible with a #15 blade. The anterior border begins 1 cm above

the zygomatic root, avoiding the MTA as it emerges at this point. © Bruce Black MD

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The flap is elevated by fine retrograde strokes of a tympanoplasty first incision knife and rolls up like a carpet.

The MTA sulcus is seen as a vertical line. © Bruce Black MD

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Completed elevation of the squamous pericranial upper half of the MTF. This part is vascular and will fold into the EAC

in a mastoid reconstruction case, forming the vascular stroma of the new canal. © Bruce Black MD

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Detail of the unfolded MTF. Note the relatively avascular mastoid tissues, right, as compared to the vascular

squamous section, left. © Bruce Black MD

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The MTF is elevated and reflected forwards, secured with forceps to permit access to the mastoid, avoiding flap

trauma. © Bruce Black MD

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Entry into the mastoid cavity from behind, during mastoidectomy reconstruction. The cavity will be cleared of

disease preparatory to EAC wall repair. © Bruce Black MD

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Exposure of the cavity lining prior to clearance and EAC wall repair.

© Bruce Black MD

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The MTF, turned into the mastoid cavity to line the new EAC. The flap needs length to reach the anterior attic as

considerable contraction occurs upon elevation. © Bruce Black MD

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MTF creation, series 2, Rt ear. Preliminary flap exposure. The temporalis fascia has been divided along the supra-

mastoid crest and the temporalis muscle elevated. © Bruce Black MD

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Detail of the squamous pericranium, showing the MTA and accompanying vessels passing posterosuperiorly.

© Bruce Black MD

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Detail of the MTA vessels. These are surrounded by a web of vessels creating a very vascular tissue layer.

Uncommonly, the MTA cannot be identified, but this does not affect the efficacy of the flap. © Bruce Black MD

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High detail of the artery, its veins and the vascular web of the pericranium.

© Bruce Black MD

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Progressive MTF elevation, showing the arterial sulcus in the temporal bone above.

© Bruce Black MD

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Elevation of the pericranial section of the MTF. Attachment to the bone is tenuous; elevation is simple. Create the flap

5cm above the crest and 5cm to the rear of the EAC. © Bruce Black MD

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Similar view. A Langenbeck retractor aids visualisation, but the upper flap elevation is done by blind dissection.

© Bruce Black MD

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Completion of the flap down to the crest. The anterior edge should not cross the zygomatic root, as the MTA emerges

from the infra-temporal fossa just above the EAC. © Bruce Black MD

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Progressive elevation of the thicker mastoid periosteum, this part of the MTF used to obliterate the mastoid tip cells.

© Bruce Black MD

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Completion of the MTF elevation and initial entry into the mastoid cavity, preparatory to clearance and EAC re-

creation. © Bruce Black MD

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Plan of a Wing flap. This is an oversize MTF pattern deriving supply from the MTA and the post-auricular. The pattern may be fascia or pericranium (cavity lining role) or

full thickness as an obliterating flap. © Bruce Black MD

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A wing flap teased out to full extent, showing the dimensions of flap for lining a cavity or other roles.

© Bruce Black MD

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Post-aural approach to the mastoid after elevation of a wing flap. The tissues are held forwards by artery clips to permit

mastoid exenteration without flap trauma. © Bruce Black MD