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Head and Neck Reconstruction Drs. N. Afridi and S. Morris <ul><li>This presentation will probably involve audience discuss...
Introduction <ul><li>Goals of Reconstruction </li></ul><ul><ul><li>Ablative cure </li></ul></ul><ul><ul><li>Restoration of...
Introduction <ul><li>Functional Objectives </li></ul><ul><ul><li>Restore sensation </li></ul></ul><ul><ul><li>Maintain ora...
Introduction <ul><li>Multidisciplinary team </li></ul><ul><ul><li>Head and neck surgeon </li></ul></ul><ul><ul><li>Plastic...
Introduction <ul><li>Preoperative Evaluation </li></ul><ul><ul><li>Tumor histology/TNM and prognosis </li></ul></ul><ul><u...
Introduction <ul><li>Procedure selection </li></ul><ul><ul><li>Always tailor to patient </li></ul></ul><ul><ul><li>Reduce ...
Introduction <ul><li>Procedure selection </li></ul><ul><ul><li>Reconstructive ladder </li></ul></ul><ul><ul><ul><li>Primar...
Introduction <ul><li>Procedure Selection </li></ul><ul><ul><li>Reconstructive ladder cont’d </li></ul></ul><ul><ul><ul><li...
Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Tongue flap </li></ul></ul><ul><ul><ul><li>Lexer 1909 </l...
 
Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Tongue flap cont’d </li></ul></ul><ul><ul><ul><li>Variati...
Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Nasolabial flap </li></ul></ul><ul><ul><ul><li>Cohen and ...
 
Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Masseter crossover flap </li></ul></ul><ul><ul><ul><li>Ti...
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Forehead flap </li></ul></ul><ul><ul><ul><li>McGregor </l...
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Superficial temporal artery fascial flap </li></ul></ul><...
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Temporalis muscle flap </li></ul></ul><ul><ul><ul><li>Bra...
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Deltopectoral flap </li></ul></ul><ul><ul><ul><li>Bakamji...
 
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Deltopectoral flap cont’d </li></ul></ul><ul><ul><ul><li>...
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Facial artery musculomucosal flap (FAMM) </li></ul></ul><...
 
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Buccinator musculomucosal flap </li></ul></ul><ul><ul><ul...
Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Submental flap </li></ul></ul><ul><ul><ul><li>Musculocuta...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Neck flaps </li></ul></ul><ul><ul><ul><li>Pote...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Pectoralis major musculocutaneous flap (PMMF) ...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Pectoral b...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Disadvanta...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modificati...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Flap witho...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modificati...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modificati...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modificati...
 
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Complicati...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Latissimus dorsi flap (LDMF) </li></ul></ul><u...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Three angi...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Skin islan...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Advantages...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Potential ...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Complicati...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Sternocleidomastoid flap (SCMF) </li></ul></ul...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Sternocleidomastoid flap (SCMF) </li></ul></ul...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Sternocleidomastoid flap (SCMF) </li></ul></ul...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Platysma flap </li></ul></ul><ul><ul><ul><li>C...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Platysma flap </li></ul></ul><ul><ul><ul><li>A...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Platysma flap </li></ul></ul><ul><ul><ul><li>C...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Infrahyoid flap </li></ul></ul><ul><ul><ul><li...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>...
 
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>...
Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Serratus anterior flap </li></ul></ul><ul><ul>...
Reconstructive options <ul><li>Free tissue transfer </li></ul><ul><ul><li>High success rates </li></ul></ul><ul><ul><li>Su...
Regional reconstruction <ul><li>Outline </li></ul><ul><ul><li>Oral cavity </li></ul></ul><ul><ul><ul><li>Floor of mouth </...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Frequently repaired by skin graft or local flap </li></u...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Six contiguous mucosal vascular territories </li></ul></...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Floor of mouth </li></ul></ul><ul><ul><ul><li>Primary cl...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Soft palate </li></ul></ul><ul><ul><ul><li>Traditionally...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Soft palate </li></ul></ul><ul><ul><ul><li>Thin fasciocu...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Hard palate </li></ul></ul><ul><ul><ul><li>Difficult are...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Most common site o...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Priorities of tong...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options </li></ul>...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </l...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </l...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </l...
Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </l...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap </li></ul></ul><ul><ul><ul><li>1981 Y...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d </li></ul></ul><ul><ul><ul><li...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d  </li></ul></ul><ul><ul><ul><l...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d </li></ul></ul><ul><ul><ul><li...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d </li></ul></ul><ul><ul><ul><li...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Large defects with mandibulectomy </li></ul></ul><ul><ul>...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Scapular flap </li></ul></ul><ul><ul><ul><li>Subscapular ...
 
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Scapular flap </li></ul></ul><ul><ul><ul><li>Thoma et al ...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Rectus abdominis musculocutaneous flap </li></ul></ul><ul...
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Lateral arm free flap </li></ul></ul><ul><ul><ul><li>Post...
 
Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Lateral arm free flap cont’d </li></ul></ul><ul><ul><ul><...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Cervical esophagus difficult to repair </l...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Partial esophageal defects </li></ul></ul>...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Skin flaps </li></ul></ul><ul><ul><ul><li>...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Fasciocutaneous flaps </li></ul></ul><ul><...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Fasciocutaneous flaps </li></ul></ul><ul><...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Fasciocutaneous flaps </li></ul></ul><ul><...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Musculocutaneous flaps </li></ul></ul><ul>...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul...
Regional Reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><u...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><u...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><u...
Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><u...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Requires replacement of missing mandibular segment of bone ...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Defect classification </li></ul></ul><ul><ul><ul><li>C = ce...
 
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Bardenheuer 1892 </li></ul></ul><ul><ul><ul><li>Composite f...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Non vascularized bone grafts </li></ul></ul><ul><ul><ul><li...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Sterilized autogenous bone </li></ul></ul><ul><ul><ul><li>S...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>1976 Boyne and Za...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>Temporary spacers...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>Titanium coated H...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>Temporary spacers...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Transfer o...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Improves f...
 
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free fibul...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free fibul...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free fibul...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free circu...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>CIOCF </li...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>CIOCF </li...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free radia...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Iliac cres...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free scapu...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free dorsa...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Trapezius ...
Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Composite mandibular defects </li></ul></ul><ul><ul><ul><li...
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  • Good afternoon ladies and gentlemen
  • Transcript of "Head "

    1. 1. Head and Neck Reconstruction Drs. N. Afridi and S. Morris <ul><li>This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation </li></ul><ul><li>In Slide Show, click on the right mouse button </li></ul><ul><li>Select “Meeting Minder” </li></ul><ul><li>Select the “Action Items” tab </li></ul><ul><li>Type in action items as they come up </li></ul><ul><li>Click OK to dismiss this box </li></ul><ul><li>This will automatically create an Action Item slide at the end of your presentation with your points entered. </li></ul>
    2. 2. Introduction <ul><li>Goals of Reconstruction </li></ul><ul><ul><li>Ablative cure </li></ul></ul><ul><ul><li>Restoration of function </li></ul></ul><ul><ul><li>Restoration of form </li></ul></ul>
    3. 3. Introduction <ul><li>Functional Objectives </li></ul><ul><ul><li>Restore sensation </li></ul></ul><ul><ul><li>Maintain oral continence </li></ul></ul><ul><ul><li>Facilitate swallowing </li></ul></ul><ul><ul><li>Prevent aspiration </li></ul></ul><ul><ul><li>Preserve speech </li></ul></ul><ul><ul><li>Protect vital structures </li></ul></ul><ul><ul><li>Achieve primary wound healing </li></ul></ul><ul><ul><li>Obtain cosmesis </li></ul></ul>
    4. 4. Introduction <ul><li>Multidisciplinary team </li></ul><ul><ul><li>Head and neck surgeon </li></ul></ul><ul><ul><li>Plastic surgeon </li></ul></ul><ul><ul><li>Radiation oncologist </li></ul></ul><ul><ul><li>Medical oncologist </li></ul></ul><ul><ul><li>Maxillofacial prosthodontist </li></ul></ul><ul><ul><li>Dentist </li></ul></ul><ul><ul><li>Radiologist </li></ul></ul><ul><ul><li>Pathologist </li></ul></ul><ul><ul><li>Speech and occupational therapists </li></ul></ul><ul><ul><li>Dietician </li></ul></ul><ul><ul><li>Psychologist </li></ul></ul><ul><ul><li>Social worker </li></ul></ul>
    5. 5. Introduction <ul><li>Preoperative Evaluation </li></ul><ul><ul><li>Tumor histology/TNM and prognosis </li></ul></ul><ul><ul><li>Ablative procedure </li></ul></ul><ul><ul><li>Size of defect </li></ul></ul><ul><ul><li>Types of tissue involved </li></ul></ul><ul><ul><li>History of cigarettes and ETOH </li></ul></ul><ul><ul><li>Previous limb surgery </li></ul></ul><ul><ul><li>Peripheral vascular disease </li></ul></ul><ul><ul><li>Cerebrovascular disease </li></ul></ul><ul><ul><li>Medical comorbidities – DM, CPD </li></ul></ul><ul><ul><li>Nutritional state </li></ul></ul>
    6. 6. Introduction <ul><li>Procedure selection </li></ul><ul><ul><li>Always tailor to patient </li></ul></ul><ul><ul><li>Reduce operative time </li></ul></ul><ul><ul><ul><li>Synchronous resection and flap elevation </li></ul></ul></ul><ul><ul><ul><li>Avoid multiple flaps </li></ul></ul></ul><ul><ul><ul><li>Use flaps not requiring positioning changes </li></ul></ul></ul><ul><ul><li>Dental rehabilitation </li></ul></ul><ul><ul><ul><li>Use bone graft of adequate height to accommodate osseointegrated implants </li></ul></ul></ul>
    7. 7. Introduction <ul><li>Procedure selection </li></ul><ul><ul><li>Reconstructive ladder </li></ul></ul><ul><ul><ul><li>Primary closure </li></ul></ul></ul><ul><ul><ul><ul><li>Restricted to small lesions lateral tongue, buccal mucosa, larynx-hypopharynx </li></ul></ul></ul></ul><ul><ul><ul><li>Split thickness skin grafts </li></ul></ul></ul><ul><ul><ul><ul><li>Maxilla, alveolar ridge, anterior buccal mucosa, dorsal surface of tongue, posterior esophageal wall </li></ul></ul></ul></ul><ul><ul><ul><li>Flaps </li></ul></ul></ul><ul><ul><ul><ul><li>Indicated when thick, pliable, self supporting tissue is needed </li></ul></ul></ul></ul>
    8. 8. Introduction <ul><li>Procedure Selection </li></ul><ul><ul><li>Reconstructive ladder cont’d </li></ul></ul><ul><ul><ul><li>Musculocutaneous or fasciocutaneous flaps </li></ul></ul></ul><ul><ul><ul><ul><li>Maintain tongue mobility in floor of mouth defects </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Allow mandibular excursion in retromolar trigone and posterolateral oropharynx </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Protect the great vessels of neck from salivary pool </li></ul></ul></ul></ul><ul><ul><ul><li>Free tissue transfer </li></ul></ul></ul><ul><ul><ul><ul><li>Precise match of appropriate tissue for specific area </li></ul></ul></ul></ul>
    9. 9. Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Tongue flap </li></ul></ul><ul><ul><ul><li>Lexer 1909 </li></ul></ul></ul><ul><ul><ul><li>Posteriorly based pedicle tongue flap </li></ul></ul></ul><ul><ul><ul><li>Reconstruction of retromolar trigone, tonsillar area, and palate </li></ul></ul></ul><ul><ul><ul><li>Blood supply: lingual artery, enters the undersurface of tongue near posterior aspect </li></ul></ul></ul><ul><ul><ul><li>20-40% of lateral tongue elevated </li></ul></ul></ul><ul><ul><ul><li>Donor site closed primarily </li></ul></ul></ul>
    10. 11. Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Tongue flap cont’d </li></ul></ul><ul><ul><ul><li>Variations </li></ul></ul></ul><ul><ul><ul><ul><li>Base anteriorly on marginal artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Preserve dorsolingual branch of lingual artery and detach hemitongue posteriorly </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Can advance flap significantly </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Venous drainage </li></ul></ul></ul><ul><ul><ul><ul><li>Hypoglossal nerve vein > epiglottic valleculate vein > lingual nerve vein > lingual root vein > accompanying vein of lingual artery </li></ul></ul></ul></ul>
    11. 12. Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Nasolabial flap </li></ul></ul><ul><ul><ul><li>Cohen and Edgerton </li></ul></ul></ul><ul><ul><ul><li>Inferiorly based flaps to anterior floor of mouth </li></ul></ul></ul><ul><ul><ul><li>5 mm below the medial canthus to oral commissure </li></ul></ul></ul><ul><ul><ul><li>Tunneled through cheek mucosa </li></ul></ul></ul><ul><ul><ul><li>Two staged when based on skin pedicle </li></ul></ul></ul><ul><ul><ul><li>Single stage if subcutaneous or arteriovenous pedicle </li></ul></ul></ul><ul><ul><ul><li>Flap viability relies on transverse facial artery </li></ul></ul></ul><ul><ul><ul><ul><li>Viable when anterior facial artery divided </li></ul></ul></ul></ul>
    12. 14. Reconstructive options <ul><li>Local flaps </li></ul><ul><ul><li>Masseter crossover flap </li></ul></ul><ul><ul><ul><li>Tiwari and Snow </li></ul></ul></ul><ul><ul><ul><li>Inferiorly based flap </li></ul></ul></ul><ul><ul><ul><li>Small to moderate defects of oropharynx </li></ul></ul></ul><ul><ul><ul><ul><li>Palatoglossal fold </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tonsillar fossa </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tonsillolingual sulcus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lateral base of tongue </li></ul></ul></ul></ul><ul><ul><ul><li>Blood supply: masseteric branches of transverse facial artery, facial artery, maxillary artery, or external carotid artery </li></ul></ul></ul>
    13. 15. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Forehead flap </li></ul></ul><ul><ul><ul><li>McGregor </li></ul></ul></ul><ul><ul><ul><li>Superficial temporal vessels </li></ul></ul></ul><ul><ul><ul><li>Folded and tunneled through cheek below zygomatic arch </li></ul></ul></ul><ul><ul><ul><li>Pedicle divided at second stage </li></ul></ul></ul><ul><ul><ul><li>Entire forehead as aesthetic unit </li></ul></ul></ul><ul><ul><ul><ul><li>Delay procedure mandatory </li></ul></ul></ul></ul><ul><ul><ul><ul><li>5-15% distal tip necrosis </li></ul></ul></ul></ul><ul><ul><ul><li>Poor cosmetic option </li></ul></ul></ul>
    14. 16. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Superficial temporal artery fascial flap </li></ul></ul><ul><ul><ul><li>Double layered fascial flap </li></ul></ul></ul><ul><ul><ul><ul><li>Temporoparietal fascia and temporalis muscle fascia </li></ul></ul></ul></ul><ul><ul><ul><li>Superficial temporal artery </li></ul></ul></ul><ul><ul><ul><li>Cover parotid bed after parotidectomy </li></ul></ul></ul><ul><ul><ul><li>Decreased incidence of gustatory sweating (Frey’s syndrome) </li></ul></ul></ul><ul><ul><ul><li>Decreased post parotidectomy hollow </li></ul></ul></ul>
    15. 17. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Temporalis muscle flap </li></ul></ul><ul><ul><ul><li>Bradley and Brockbank </li></ul></ul></ul><ul><ul><ul><li>Floor of mouth defects </li></ul></ul></ul><ul><ul><ul><li>Muscle used for soft tissue fill </li></ul></ul></ul><ul><ul><ul><li>Increased mobility of flap </li></ul></ul></ul><ul><ul><ul><ul><li>Temporarily remove zygomatic arch </li></ul></ul></ul></ul>
    16. 18. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Deltopectoral flap </li></ul></ul><ul><ul><ul><li>Bakamjian 1965 </li></ul></ul></ul><ul><ul><ul><li>Pharyngoesophageal reconstruction with medially based flap </li></ul></ul></ul><ul><ul><ul><ul><li>Transferred in two stages </li></ul></ul></ul></ul><ul><ul><ul><li>McGregor and Jackson 1970 </li></ul></ul></ul><ul><ul><ul><ul><li>Extended range </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Undelayed flap </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Skin paddle in deltoid portion distal to cephalic groove 1:1 ratio </li></ul></ul></ul></ul></ul>
    17. 20. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Deltopectoral flap cont’d </li></ul></ul><ul><ul><ul><li>Three main vascular contributions </li></ul></ul></ul><ul><ul><ul><ul><li>1 st four perforating branches of internal mammary artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thoracoacromial artery supplies upper midportion of deltopectoral flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Perforating vessels from deltoid muscle </li></ul></ul></ul></ul><ul><ul><ul><li>Deltoid portion is random flap </li></ul></ul></ul><ul><ul><ul><li>Pectoral skin axial blood supply </li></ul></ul></ul><ul><ul><ul><li>Delay procedure raises tip of flap lateral to D of deltopectoral groove </li></ul></ul></ul><ul><ul><ul><li>15-25% incidence of tip necrosis </li></ul></ul></ul>
    18. 21. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Facial artery musculomucosal flap (FAMM) </li></ul></ul><ul><ul><ul><li>Mucosa, submucosa, buccinatory, buccal fat and facial artery </li></ul></ul></ul><ul><ul><ul><li>Superior or inferior based </li></ul></ul></ul><ul><ul><ul><li>Oropharyngeal reconstruction </li></ul></ul></ul><ul><ul><ul><ul><li>Small to medium sized defects </li></ul></ul></ul></ul><ul><ul><ul><li>Narrow flap with wide arc of rotation </li></ul></ul></ul><ul><ul><ul><li>Anterior to parotid duct </li></ul></ul></ul>
    19. 23. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Buccinator musculomucosal flap </li></ul></ul><ul><ul><ul><li>Buccal artery principal arterial pedicle </li></ul></ul></ul><ul><ul><ul><li>Supplies posterior half of muscle </li></ul></ul></ul><ul><ul><ul><li>All incisions intraoral </li></ul></ul></ul><ul><ul><ul><li>Mean dimensions </li></ul></ul></ul><ul><ul><ul><ul><li>3.5 cm width and 7 cm length </li></ul></ul></ul></ul><ul><ul><ul><li>Anterior and lateral floor of the mouth </li></ul></ul></ul><ul><ul><ul><li>Must preserve facial artery with neck dissection </li></ul></ul></ul><ul><ul><ul><li>Ipsilateral molars should be extracted </li></ul></ul></ul>
    20. 24. Reconstructive options <ul><li>Axial flaps </li></ul><ul><ul><li>Submental flap </li></ul></ul><ul><ul><ul><li>Musculocutaneous island flap </li></ul></ul></ul><ul><ul><ul><li>Submental artery </li></ul></ul></ul><ul><ul><ul><li>Skin paddle </li></ul></ul></ul><ul><ul><ul><ul><li>7 x 18 cm </li></ul></ul></ul></ul><ul><ul><ul><li>Ipsilateral oral cavity and face </li></ul></ul></ul><ul><ul><ul><li>Scar hidden under mandible </li></ul></ul></ul>
    21. 25. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Neck flaps </li></ul></ul><ul><ul><ul><li>Potential involvement of metastatic spread </li></ul></ul></ul><ul><ul><ul><li>Risk of circulatory interruption by the excisional surgery </li></ul></ul></ul><ul><ul><ul><li>Damage inflicted by preoperative irradiation </li></ul></ul></ul><ul><ul><li>Chest flaps </li></ul></ul><ul><ul><ul><li>Not affected by treatment of 1 º disease </li></ul></ul></ul><ul><ul><ul><li>Wider and more extensive surgical dissection </li></ul></ul></ul><ul><ul><ul><li>Pectoralis major and latissimus dorsi are workhorses </li></ul></ul></ul>
    22. 26. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Pectoralis major musculocutaneous flap (PMMF) </li></ul></ul><ul><ul><ul><li>Ariyan 1979 </li></ul></ul></ul><ul><ul><ul><li>Mathes and Nahai type V </li></ul></ul></ul><ul><ul><ul><ul><li>Thoracoacromial major pedicle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Secondary segmental parasternal perforators from internal mammary artery </li></ul></ul></ul></ul>
    23. 27. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Pectoral branch of thoracoacromial </li></ul></ul></ul><ul><ul><ul><ul><li>Exits subclavian at midclavicle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Medial to insertion of pectoralis minor tendon </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Runs with lateral pectoral nerve </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Line from tip of should through xiphoid </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Skin island can be centered over lower portion of muscle in line of pedicle </li></ul></ul></ul>
    24. 28. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Disadvantages of classic design: </li></ul></ul></ul><ul><ul><ul><ul><li>Disfiguring donor site in women </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hair bearing skin paddle in men </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bulky skin paddle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Limited arc of rotation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Muscle pedicle bulges in the neck </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Occasional shoulder dysfunction </li></ul></ul></ul></ul>
    25. 29. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modifications </li></ul></ul></ul><ul><ul><ul><ul><li>Women </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Skin flap medial beyond edge of muscle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Skin flap placed under the breast </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Vertical parasternal paddle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sickle shaped parasternal paddle into IMF </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Men </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Replace cutaneous portion of skin paddle with STSG </li></ul></ul></ul></ul></ul>
    26. 30. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Flap without skin paddle </li></ul></ul></ul><ul><ul><ul><ul><li>Pectoralis major musculofascial flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Leave outer surface raw </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mucosalizes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ideal for small to medium sized oral cavity and pharyngeal defects </li></ul></ul></ul></ul>
    27. 31. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modifications </li></ul></ul></ul><ul><ul><ul><ul><li>Bulk </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Parasternal skin paddle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Prefabricated with STSG over muscle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Arc of rotation </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Skin paddle lower portion of muscle onto rectus abdominis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Resect medial half of clavicle (2.5 – 3 cm of length to flap) </li></ul></ul></ul></ul></ul>
    28. 32. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modifications </li></ul></ul></ul><ul><ul><ul><ul><li>Muscle bulk in neck </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Transect medial and lateral pectoral nerves </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Exteriorize and later resect muscle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Shoulder function </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sternocostal portion leaves functioning muscle on chest with clavicular head </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Bone </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Incorporate 5 th rib </li></ul></ul></ul></ul></ul>
    29. 33. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Modifications </li></ul></ul></ul><ul><ul><ul><ul><li>Splitting muscle </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Split longitudinally </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Double skin paddles </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sternal portion blood supply from pectoral branch of thoracoacromial artery </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Lateral portion perfused by lateral thoracic artery </li></ul></ul></ul></ul></ul>
    30. 35. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>PMMF </li></ul></ul><ul><ul><ul><li>Complications </li></ul></ul></ul><ul><ul><ul><ul><li>Kroll et al. MD Anderson </li></ul></ul></ul></ul><ul><ul><ul><ul><li>63% of cases </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Most self limiting </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Increased in smokers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Total flap loss 2.4%, most were women </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thicker adipose tissue between muscle and skin </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Overall hospital cost 30% more than free flap </li></ul></ul></ul></ul>
    31. 36. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Latissimus dorsi flap (LDMF) </li></ul></ul><ul><ul><ul><li>Tansini 1896 chest wall reconstruction </li></ul></ul></ul><ul><ul><ul><li>1 st musculocutaneous flap described in the literature </li></ul></ul></ul><ul><ul><ul><li>Head and neck reconstruction 1978 </li></ul></ul></ul><ul><ul><ul><li>Type V muscle </li></ul></ul></ul><ul><ul><ul><ul><li>Dominant vascular pedicle thoracodorsal artery and runs with thoracodorsal nerve </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thoracodorsal artery branches </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Anterior branch runs 2.5 cm medial to free border </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Segmental pedicles from intercostal perforators and lumbar vessels </li></ul></ul></ul></ul>
    32. 37. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Three angiosomes </li></ul></ul></ul><ul><ul><ul><ul><li>Proximal portion supplied by thoracodorsal artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Medial portion supplied by posterior intercostals </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Caudal portion supplied by lumbar vessels </li></ul></ul></ul></ul><ul><ul><ul><li>Muscle and skin can be harvested from adjacent angiosomes by crossing one system of choke vessels </li></ul></ul></ul><ul><ul><ul><li>Flap elevation </li></ul></ul></ul><ul><ul><ul><ul><li>Division of collateral branches of thoracodorsal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Muscle detached from insertion on humerus </li></ul></ul></ul></ul>
    33. 38. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Skin islands placed over upper 2/3 of muscle consistently survive </li></ul></ul></ul><ul><ul><ul><li>Thoracodorsal pedicle divides into medial and lateral branches </li></ul></ul></ul><ul><ul><ul><ul><li>Can design two separate skin paddles </li></ul></ul></ul></ul>
    34. 39. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Advantages: </li></ul></ul></ul><ul><ul><ul><ul><li>Large size </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Wide excursion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Donor site morbidity negligible </li></ul></ul></ul></ul><ul><ul><ul><li>Disadvantages: </li></ul></ul></ul><ul><ul><ul><ul><li>Positioning </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intricate dissection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Complexity of tunneling </li></ul></ul></ul></ul>
    35. 40. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Potential problems: </li></ul></ul></ul><ul><ul><ul><ul><li>Marginal fat necrosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Compression or twisting of pedicle when tunneled between pectoralis major and minor pedicles </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nerve injury </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Long thoracic nerve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Antebrachial cutaneous nerve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Brachial plexus with positioning </li></ul></ul></ul></ul></ul>
    36. 41. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>LDMF </li></ul></ul><ul><ul><ul><li>Complications </li></ul></ul></ul><ul><ul><ul><ul><li>26% with failure rate of 5% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Greater in men than in women </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Radiotherapy, site of reconstruction, type of flap and age not significant risk factors </li></ul></ul></ul></ul>
    37. 42. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Sternocleidomastoid flap (SCMF) </li></ul></ul><ul><ul><ul><li>Moderately useful </li></ul></ul></ul><ul><ul><ul><li>Partial flap loss in 50% of patients </li></ul></ul></ul><ul><ul><ul><li>Most reliable when based on the occipital artery and retained skin bridge </li></ul></ul></ul><ul><ul><ul><li>Arc of rotation determined by the course of the spinal accessory nerve within the muscle </li></ul></ul></ul><ul><ul><ul><li>Improved vascularity with preservation of superior thyroid artery and vein </li></ul></ul></ul><ul><ul><ul><li>Can include clavicle in the flap </li></ul></ul></ul>
    38. 43. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Sternocleidomastoid flap (SCMF) </li></ul></ul><ul><ul><ul><li>Advantages: </li></ul></ul></ul><ul><ul><ul><ul><li>One stage immediate reconstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rapid and technical ease of elevation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Option to use contralateral flap to malignancy resection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Modification using SCM musculoperiosteal flap for tracheal reconstruction </li></ul></ul></ul></ul>
    39. 44. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Sternocleidomastoid flap (SCMF) </li></ul></ul><ul><ul><ul><li>Disadvantages: </li></ul></ul></ul><ul><ul><ul><ul><li>Loss of protection of great vessels </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Contraindicated ipsilateral flap in clinically positive neck </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Contour deformity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Unreliable distal skin paddle </li></ul></ul></ul></ul>
    40. 45. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Platysma flap </li></ul></ul><ul><ul><ul><li>Contains lower cervical skin on superiorly based platysma </li></ul></ul></ul><ul><ul><ul><li>Turned to resurface anterior floor of mouth or cheek </li></ul></ul></ul><ul><ul><ul><li>Intact facial artery not crucial to survival of flap </li></ul></ul></ul><ul><ul><ul><li>External jugular and anterior communicating veins should be included to improve venous drainage </li></ul></ul></ul>
    41. 46. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Platysma flap </li></ul></ul><ul><ul><ul><li>Advantages </li></ul></ul></ul><ul><ul><ul><ul><li>Thin and pliable muscle skin paddle </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ideal for floor of mouth where bulk undesirable </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Negligible functional impairment of deglutition, speech and denture fitting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cosmetic donor site </li></ul></ul></ul></ul>
    42. 47. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Platysma flap </li></ul></ul><ul><ul><ul><li>Contraindications </li></ul></ul></ul><ul><ul><ul><ul><li>previous irradiation to the neck </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgery in the head and neck </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Neoadjuvant chemotherapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nodal disease </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Large defects </li></ul></ul></ul></ul>
    43. 48. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Infrahyoid flap </li></ul></ul><ul><ul><ul><li>Modification of midline cervical flap </li></ul></ul></ul><ul><ul><ul><li>Includes strap muscles </li></ul></ul></ul><ul><ul><ul><ul><li>Sternohyoid and sternothyroid </li></ul></ul></ul></ul><ul><ul><ul><li>Includes main trunk of superior thyroid artery </li></ul></ul></ul><ul><ul><ul><li>Useful in closure of medium sized defects </li></ul></ul></ul><ul><ul><ul><ul><li>Floor of mouth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tongue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Buccal mucosa </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lateral pharyngeal wall </li></ul></ul></ul></ul><ul><ul><ul><li>Motor capability useful in swallowing and speech </li></ul></ul></ul>
    44. 49. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>McGraw </li></ul></ul></ul><ul><ul><ul><ul><li>Based on proximal occipital artery </li></ul></ul></ul></ul><ul><ul><ul><li>Mathes and Vasconez </li></ul></ul></ul><ul><ul><ul><ul><li>Cervicohumeral modification included transverse cervical artery </li></ul></ul></ul></ul><ul><ul><ul><li>Demergasso and Piazza </li></ul></ul></ul><ul><ul><ul><ul><li>Designed skin island over the acromioclavicular joint </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Carried on transverse cervical artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Muscle kept attached proximally </li></ul></ul></ul></ul>
    45. 50. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>Bertotti </li></ul></ul></ul><ul><ul><ul><ul><li>Only included muscle under skin island </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Based on superficial ascending branch of transverse cervical artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Deep descending branch divided to increase reach </li></ul></ul></ul></ul>
    46. 51. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>Yang and Morris </li></ul></ul></ul><ul><ul><ul><ul><li>Three main vascular sources </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Transverse cervical artery (TCA) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dorsal scapular artery (DSA) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Posterior intercostal arterial branches </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>TCA dominant pedicle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>TCA and DSA supply most of muscle </li></ul></ul></ul></ul>
    47. 53. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>Advantages: </li></ul></ul></ul><ul><ul><ul><ul><li>Proximity to the operative field </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thin, pliable skin of deltoid area </li></ul></ul></ul></ul><ul><ul><ul><li>Disadvantages </li></ul></ul></ul><ul><ul><ul><ul><li>Variable vasculature </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Limited by neck dissection or irradiation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Donor site morbidity </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Shoulder drop </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Must ensure transverse cervical artery intact if neck dissection previously done </li></ul></ul></ul>
    48. 54. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>Modification </li></ul></ul></ul><ul><ul><ul><ul><li>Lower trapezius flap </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Deep (descending) branch of transverse cervical artery </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Innervated by posterior branch of spinal accessory nerve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Posterior and lateral head and neck defects </li></ul></ul></ul></ul></ul>
    49. 55. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Trapezius flap </li></ul></ul><ul><ul><ul><li>Modification </li></ul></ul></ul><ul><ul><ul><ul><li>Advantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Skin between posterior midline and scapula carried </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Upper trapezius remains innervated and functional therefore no shoulder drop </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inconspicuous donor site </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Disadvantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Shorter pedicle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Limited reach </li></ul></ul></ul></ul></ul>
    50. 56. Reconstructive options <ul><li>Musculocutaneous flaps </li></ul><ul><ul><li>Serratus anterior flap </li></ul></ul><ul><ul><ul><li>Fasciocutaneous extension of serratus anterior muscle from 6 th to 8 th ribs </li></ul></ul></ul><ul><ul><ul><li>Long pedicle 15-20 cm </li></ul></ul></ul><ul><ul><ul><li>Rib can be included </li></ul></ul></ul><ul><ul><ul><li>Latissimus dorsi flap can be included in same pedicle </li></ul></ul></ul><ul><ul><ul><ul><li>Can cover large soft tissue defects </li></ul></ul></ul></ul>
    51. 57. Reconstructive options <ul><li>Free tissue transfer </li></ul><ul><ul><li>High success rates </li></ul></ul><ul><ul><li>Superior aesthetic and functional results </li></ul></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>Vascular pedicle anastomosed to most appropriate recipient </li></ul></ul></ul><ul><ul><ul><li>Ease of flap insetting and orientation </li></ul></ul></ul><ul><ul><ul><li>Closure of massive defects feasible </li></ul></ul></ul><ul><ul><ul><li>Option of restoration of sensation </li></ul></ul></ul><ul><ul><ul><ul><li>Sensory nerve harvest </li></ul></ul></ul></ul><ul><ul><li>95% flap survival </li></ul></ul><ul><ul><li>Complication rate approximately 20% </li></ul></ul><ul><ul><ul><li>Salivary fistula 12% </li></ul></ul></ul>
    52. 58. Regional reconstruction <ul><li>Outline </li></ul><ul><ul><li>Oral cavity </li></ul></ul><ul><ul><ul><li>Floor of mouth </li></ul></ul></ul><ul><ul><ul><li>Soft palate </li></ul></ul></ul><ul><ul><ul><li>Hard palate </li></ul></ul></ul><ul><ul><ul><li>Tongue </li></ul></ul></ul><ul><ul><li>Oropharynx </li></ul></ul><ul><ul><li>Hypopharynx and esophagus </li></ul></ul><ul><ul><li>Mandible </li></ul></ul>
    53. 59. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Frequently repaired by skin graft or local flap </li></ul></ul><ul><ul><li>Large defects require regional or distant flaps </li></ul></ul><ul><ul><li>Key to success </li></ul></ul><ul><ul><ul><li>Preservation of tongue mobility </li></ul></ul></ul>
    54. 60. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Six contiguous mucosal vascular territories </li></ul></ul><ul><ul><ul><li>Labial </li></ul></ul></ul><ul><ul><ul><li>Buccal </li></ul></ul></ul><ul><ul><ul><li>Inferior alveolar </li></ul></ul></ul><ul><ul><ul><li>Lingual </li></ul></ul></ul><ul><ul><ul><li>Ascending pharyngeal </li></ul></ul></ul><ul><ul><ul><li>Ascending palatine </li></ul></ul></ul>
    55. 61. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Floor of mouth </li></ul></ul><ul><ul><ul><li>Primary closure </li></ul></ul></ul><ul><ul><ul><li>Palatal mucoperiosteal grafts </li></ul></ul></ul><ul><ul><ul><ul><li>Useful for medium sized defects </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Little contracture allows good tongue mobility </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thick graft prevents contour deformity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Donor site left to granulate </li></ul></ul></ul></ul>
    56. 62. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Soft palate </li></ul></ul><ul><ul><ul><li>Traditionally non surgical </li></ul></ul></ul><ul><ul><ul><li>Lateral pharyngeal walls </li></ul></ul></ul><ul><ul><ul><ul><li>Skin graft </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Obturator </li></ul></ul></ul></ul><ul><ul><ul><li>Sensation helps initiate oral phase of deglutition </li></ul></ul></ul>
    57. 63. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Soft palate </li></ul></ul><ul><ul><ul><li>Thin fasciocutaneous free flaps useful </li></ul></ul></ul><ul><ul><ul><li>Cutaneous segment of free flap should be placed tightly across soft palate </li></ul></ul></ul><ul><ul><ul><ul><li>Eliminates redundancy </li></ul></ul></ul></ul><ul><ul><ul><li>Velopharyngeal competency requires redundant tissue to meet posterior pharyngeal wall </li></ul></ul></ul><ul><ul><ul><ul><li>Reconstructed tissues have no dynamic activity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Can deepithelialize opposing surfaces of midportion of flap and suture raw surfaces </li></ul></ul></ul></ul>
    58. 64. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Hard palate </li></ul></ul><ul><ul><ul><li>Difficult area to reconstruct </li></ul></ul></ul><ul><ul><ul><li>Prosthesis as an obturator </li></ul></ul></ul><ul><ul><ul><ul><li>Large </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Difficult to stabilize unless osseointegrated </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Insensible </li></ul></ul></ul></ul><ul><ul><ul><li>Alternatives to obturator </li></ul></ul></ul><ul><ul><ul><ul><li>Osseocutaneous radial forearm free flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Osseocutaneous scapular flap </li></ul></ul></ul></ul>
    59. 65. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Most common site of oral cavity cancer </li></ul></ul></ul><ul><ul><ul><li>Frequent locus of invasion </li></ul></ul></ul><ul><ul><ul><ul><li>Floor of mouth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Oropharyngeal cancer </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypopharyngeal cancer </li></ul></ul></ul></ul><ul><ul><ul><li>Reconstruction of tongue in total or near total glossectomy difficult </li></ul></ul></ul>
    60. 66. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Priorities of tongue reconstruction </li></ul></ul></ul><ul><ul><ul><ul><li>Airway protection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Swallowing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Articulation </li></ul></ul></ul></ul><ul><ul><ul><li>Donor tissue should be bulky </li></ul></ul></ul><ul><ul><ul><li>Need to create shelf above laryngeal inlet to direct food bolus down the posterior pharyngeal wall </li></ul></ul></ul><ul><ul><ul><li>Tissue should be pliable and capable of movement </li></ul></ul></ul><ul><ul><ul><ul><li>Sensory innervation ideal </li></ul></ul></ul></ul>
    61. 67. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options </li></ul></ul></ul><ul><ul><ul><ul><li>PMMF </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Problems with excessive bulk </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Good short term results </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Muscle atrophy and gravity diminish outcome </li></ul></ul></ul></ul></ul>
    62. 68. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </li></ul></ul></ul><ul><ul><ul><ul><li>Musculocutaneous free flap </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cylindrical in shape </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Obliterate oral cavity with jaw closed </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Anterior sulcus shallower than lateral sulci to enhance salivary drainage and prevent pooling </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Lower lip sutured over wide base to improve support, decrease inner lip height and tighter oral seal </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Can support the flap with bone on oral floor </li></ul></ul></ul></ul></ul>
    63. 69. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </li></ul></ul></ul><ul><ul><ul><ul><li>Innervated latissimus dorsi </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Muscle fibers transverse to axis of skin </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Create contractile muscle sling </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Suspend by suturing tendinous inscriptions to the mandible for support </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Reinnervate by coaptation to hypoglossal nerve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Peroneal fasciocutaneous flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sensory radial forearm/ iliac crest combination </li></ul></ul></ul></ul>
    64. 70. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </li></ul></ul></ul><ul><ul><ul><ul><li>Radial forearm with brachioradialis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Medial or lateral antebrachial cutaneous nerves coapted to lingual nerve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sensation improved </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>No major advantage with intraoral function </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Free groin flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rectus abdominis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Harvest 10 th intercostal nerve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Ulnar forearm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Iliac crest </li></ul></ul></ul></ul>
    65. 71. Regional reconstruction <ul><li>Oral cavity </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Options cont’d </li></ul></ul></ul><ul><ul><ul><ul><li>Vastus lateralis musculocutaneous free flap </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Long, high caliber vascular pedicle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Innervated gracilis musculocutaneous flap </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Obturator nerve coapted to hypoglossal nerve </li></ul></ul></ul></ul></ul><ul><ul><ul><li>All patients should be followed by a speech pathologist </li></ul></ul></ul>
    66. 72. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap </li></ul></ul><ul><ul><ul><li>1981 Yang et al </li></ul></ul></ul><ul><ul><ul><li>Fasciocutaneous flap </li></ul></ul></ul><ul><ul><ul><li>Arterial supply: radial artery </li></ul></ul></ul><ul><ul><ul><li>Venous drainage: venae comitantes or superficial vein ie cephalic </li></ul></ul></ul><ul><ul><ul><li>Can be used as a conduit for blood to a second flap </li></ul></ul></ul><ul><ul><ul><li>Radius can be harvested </li></ul></ul></ul><ul><ul><ul><ul><li>Small portion of FPL muscle required </li></ul></ul></ul></ul>
    67. 73. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d </li></ul></ul><ul><ul><ul><li>Tubed flap useful in laryngeal reconstruction </li></ul></ul></ul><ul><ul><ul><ul><li>Partial laryngectomy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Helps with speech rehabilitation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stiffer resonating chamber for speech production </li></ul></ul></ul></ul><ul><ul><ul><ul><li>No peristalsis or mucus secretion as with visceral flaps </li></ul></ul></ul></ul><ul><ul><ul><li>More reliable than PMMF </li></ul></ul></ul><ul><ul><ul><li>Large series </li></ul></ul></ul><ul><ul><ul><ul><li>Infection fistula rate 24% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Revisional surgery required in 19% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>19% had donor site complications </li></ul></ul></ul></ul>
    68. 74. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d </li></ul></ul><ul><ul><ul><li>Applications </li></ul></ul></ul><ul><ul><ul><ul><li>Every site of oral cavity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Palatal reconstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Upper lip reconstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>brachioradialis muscle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Total lower lip reconstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sensory flap with palmaris longus tendon </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Vascularized nerve graft </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vascularized bone graft </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pharyngoesophageal reconstruction </li></ul></ul></ul></ul>
    69. 75. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d </li></ul></ul><ul><ul><ul><li>Donor site morbidity </li></ul></ul></ul><ul><ul><ul><ul><li>Distal skin island </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>33% graft failure </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Exposed wrist tendons </li></ul></ul></ul></ul></ul>
    70. 76. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Radial forearm flap cont’d </li></ul></ul><ul><ul><ul><li>Decrease morbidity </li></ul></ul></ul><ul><ul><ul><ul><li>Improved graft take if proximally based flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Shorter vascular pedicle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Can use turnover flaps of FPL and FDS to cover FCR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May also preserve deep fascia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ulnar transposition flap and V-Y closure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Skin grafted fascial forearm flap no donor skin </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Full thickness skin graft to forearm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bevel osteotomy, use 1/3 of radial diameter </li></ul></ul></ul></ul>
    71. 77. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Large defects with mandibulectomy </li></ul></ul><ul><ul><ul><li>Radial forearm and iliac crest free flaps </li></ul></ul></ul><ul><ul><ul><li>Separate tissue units advocated </li></ul></ul></ul><ul><ul><ul><ul><li>No single large area of anaesthesia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Allows better oral function </li></ul></ul></ul></ul><ul><ul><ul><li>Can anastomose lingual nerve to antebrachial cutaneous nerve of forearm </li></ul></ul></ul>
    72. 78. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Scapular flap </li></ul></ul><ul><ul><ul><li>Subscapular artery </li></ul></ul></ul><ul><ul><ul><li>Scapular, parascapular, latissimus dorsi and serratus muscles </li></ul></ul></ul><ul><ul><ul><ul><li>Can support vascularized bone from border of scapula </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Circumflex scapular artery supplies lateral border of scapula </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Can harvest 14 cm bone segment </li></ul></ul></ul></ul></ul>
    73. 80. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Scapular flap </li></ul></ul><ul><ul><ul><li>Thoma et al </li></ul></ul></ul><ul><ul><ul><ul><li>Medial ridge of scapula </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Abundant hairless skin and soft tissue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inconspicuous donor site </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Longer vascular pedicle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Independent of parascapular artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thinner bone </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>? Placement of osseointegrated implants </li></ul></ul></ul></ul></ul>
    74. 81. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Rectus abdominis musculocutaneous flap </li></ul></ul><ul><ul><ul><li>Inferior epigastric vessels </li></ul></ul></ul><ul><ul><ul><li>Same bulk as pectoralis major, latissimus, trapezius </li></ul></ul></ul><ul><ul><ul><li>Kroll compared the two </li></ul></ul></ul><ul><ul><ul><ul><li>Complications </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>PMMF 44% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rectus 13% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Flap loss </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>PMMF 10% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rectus none </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Can harvest segment of peritoneum at lateral border of rectus abdominis </li></ul></ul></ul>
    75. 82. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Lateral arm free flap </li></ul></ul><ul><ul><ul><li>Posterior radial collateral artery (profunda brachii) </li></ul></ul></ul><ul><ul><ul><li>Sensory soft tissue </li></ul></ul></ul><ul><ul><ul><ul><li>Good quality for head and neck reconstruction </li></ul></ul></ul></ul><ul><ul><ul><li>Donor defect closed with linear scar </li></ul></ul></ul><ul><ul><ul><li>Versatile </li></ul></ul></ul><ul><ul><ul><li>Low donor site morbidity </li></ul></ul></ul><ul><ul><ul><li>Thin skin of proximal forearm and thick skin of the upper arm </li></ul></ul></ul><ul><ul><ul><ul><li>Thin skin useful for posterior oral cavity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thicker portion in tongue base </li></ul></ul></ul></ul>
    76. 84. Regional reconstruction <ul><li>Oropharynx </li></ul><ul><ul><li>Lateral arm free flap cont’d </li></ul></ul><ul><ul><ul><li>Osseocutaneous flap </li></ul></ul></ul><ul><ul><ul><ul><li>Harvest segment of humerus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>1 x 10 cm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Septal perforators extend to the periosteum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Muscular cuff of triceps and brachioradialis is necessary </li></ul></ul></ul></ul><ul><ul><ul><li>Sensation </li></ul></ul></ul><ul><ul><ul><ul><li>Posterior cutaneous nerve of the arm and forearm allow for sensory neurotization </li></ul></ul></ul></ul>
    77. 85. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Cervical esophagus difficult to repair </li></ul></ul><ul><ul><ul><li>Narrow lumen </li></ul></ul></ul><ul><ul><ul><li>Compressed position in the neck </li></ul></ul></ul><ul><ul><ul><li>Skeletal restrictions at the thoracic outlet and posterior to larynx </li></ul></ul></ul>
    78. 86. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Partial esophageal defects </li></ul></ul><ul><ul><ul><li>Skin flaps </li></ul></ul></ul><ul><ul><ul><li>Musculocutaneous flaps </li></ul></ul></ul><ul><ul><ul><li>Myoplasty with skin graft </li></ul></ul></ul><ul><ul><li>Complete esophageal defects </li></ul></ul><ul><ul><ul><li>Skin flaps </li></ul></ul></ul><ul><ul><ul><li>Fasciocutaneous flaps/musculocutaneous flaps </li></ul></ul></ul><ul><ul><ul><li>Microvascular bowel transfers or pedicled viscera </li></ul></ul></ul>
    79. 87. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Skin flaps </li></ul></ul><ul><ul><ul><li>Historical interest </li></ul></ul></ul><ul><ul><ul><li>Bakamjian 1965 </li></ul></ul></ul><ul><ul><ul><li>Medially based deltopectoral flap for pharyngo-esophageal reconstruction </li></ul></ul></ul><ul><ul><ul><li>Two operative stages </li></ul></ul></ul><ul><ul><ul><li>Temporary pharyngocutaneous fistula </li></ul></ul></ul><ul><ul><ul><li>Useful in partial esophageal reconstruction </li></ul></ul></ul><ul><ul><ul><li>Late stricture at lower anastomosis in circumferential replacement </li></ul></ul></ul>
    80. 88. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Fasciocutaneous flaps </li></ul></ul><ul><ul><ul><li>Radial forearm flap </li></ul></ul></ul><ul><ul><ul><ul><li>Thin and pliable </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ample vascular supply </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Large paddle to form circumferential segment reconstruction </li></ul></ul></ul></ul>
    81. 89. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Fasciocutaneous flaps </li></ul></ul><ul><ul><ul><li>Lateral thigh flap </li></ul></ul></ul><ul><ul><ul><ul><li>Baek 1983 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Third perforator of profunda femoris artery </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Runs in the lateral intermuscular septum between vastus lateralis and biceps femoris </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Sensory restoration </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Medial and lateral femoral cutaneous nerves of the thigh </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Largest cutaneous surface area flap available </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thin, pliable and often hairless </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Proximal fat portion used for bulk </li></ul></ul></ul></ul>
    82. 90. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Fasciocutaneous flaps </li></ul></ul><ul><ul><ul><li>Lateral thigh flap </li></ul></ul></ul><ul><ul><ul><ul><li>Advantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thin, pliable and hairless </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>8-12 cm long pedicle, 2-3 mm diameter </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pedicle enters midportion of skin paddle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Allows two team ablation and harvest </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Minimal donor site morbidity </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Disadvantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Occasionally need to include 2 nd or 4 th perforator </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Atherosclerosis in profunda femoris branches </li></ul></ul></ul></ul></ul>
    83. 91. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Musculocutaneous flaps </li></ul></ul><ul><ul><ul><li>Latissimus dorsi and pectoralis major </li></ul></ul></ul><ul><ul><ul><li>PMMF </li></ul></ul></ul><ul><ul><ul><ul><li>Useful </li></ul></ul></ul></ul><ul><ul><ul><ul><li>High success rate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Useful in concerns with wound breakdown </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Advantage of single stage closure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Reliable blood supply </li></ul></ul></ul></ul>
    84. 92. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul><ul><li>Segmental jejunum </li></ul></ul></ul><ul><ul><ul><ul><li>Most popular </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Regarded as method of choice </li></ul></ul></ul></ul><ul><ul><ul><ul><li>85% success rate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>>80% patients resume oral feeding </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Used for cervical esophagus as well as after subtotal laryngopharyngectomy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Can harvest additional mesentery for coverage of exposed vessels and STSG </li></ul></ul></ul></ul>
    85. 93. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul><ul><li>Segmental jejunum </li></ul></ul></ul><ul><ul><ul><ul><li>Lower risk for fistula formation than free radial forearm </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fewer suture lines </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Preoperative radiotherapy preferable </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Decreased radiation mucositis, late stricture or fistula </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Maximum usable length of jejunum is 20 cm </li></ul></ul></ul></ul>
    86. 94. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul><ul><li>Segmental jejunum </li></ul></ul></ul><ul><ul><ul><ul><li>Lowest median hospital stay </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Shortest time to resumption of oral intake </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Complications </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>17% in neck </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>2.5% abdomen </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Average time to swallowing 11days </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>No coordinated peristaltic activity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Passive conduit with time after diminution of peristalsis </li></ul></ul></ul></ul>
    87. 95. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul><ul><li>Segmental jejunum </li></ul></ul></ul><ul><ul><ul><ul><li>Stricture </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Minimize by incising distal end 2cm anteriorly </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increase size of distal anatomosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Avoid autostaples </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Avoid end to side anastomoses </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Monitoring </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>May exteriorize segment or create surgical window </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Look for peristalsis and color </li></ul></ul></ul></ul></ul>
    88. 96. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul><ul><li>Gastric omental flaps </li></ul></ul></ul><ul><ul><ul><ul><li>Papachristou </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Antral segment from greater curvature of stomach </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Avoids parietal cell acid secretion </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Gastroepiploic vessels </li></ul></ul></ul></ul><ul><ul><ul><ul><li>10 x 10 cm flaps </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pedicle 30 cm in length </li></ul></ul></ul></ul>
    89. 97. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul><ul><li>Gastric omental flaps </li></ul></ul></ul><ul><ul><ul><ul><li>Omentum used to fill dead space and contouring in radical neck dissection </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Atrophies to 50% of size </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Drawbacks </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mucosal hypersecretion </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Possible aspiration </li></ul></ul></ul></ul></ul>
    90. 98. Regional Reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Free visceral flaps </li></ul></ul><ul><ul><ul><li>Free jejunum and gastric antrum </li></ul></ul></ul><ul><ul><ul><ul><li>Partial defects of cervical esophagus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Circumferential defects extending into nasopharynx </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Total cervical esophageal replacement when larynx is preserved </li></ul></ul></ul></ul>
    91. 99. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><ul><li>Colon interposition </li></ul></ul></ul><ul><ul><ul><ul><li>Historical use </li></ul></ul></ul></ul><ul><ul><ul><ul><li>No longer used </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Multiple complications </li></ul></ul></ul></ul>
    92. 100. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><ul><li>Gastric esophagoplasty </li></ul></ul></ul><ul><ul><ul><ul><li>1960 Ong and Lee </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Advanced gastric fundus into cervical area to replace thoracic esophagus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Ample blood supply, mobility and length </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Modern technique </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dividing left gastric, left gastroepiploic and short gastric arteries </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Kocher maneuver, vagotomy and pyloroplasty </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thoracic esophagus is anastomosed to hypopharynx </li></ul></ul></ul></ul></ul>
    93. 101. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><ul><li>Gastric esophagoplasty </li></ul></ul></ul><ul><ul><ul><ul><li>Advantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Easy to prepare and use </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Excellent blood supply </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Away from irradiated field </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>One anastomosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Disadvantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Infection, bleeding, anastomotic leaks </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Operative mortality 31% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Procedure of choice for replacement of thoracic esophagus </li></ul></ul></ul></ul>
    94. 102. Regional reconstruction <ul><li>Hypopharynx and esophagus </li></ul><ul><ul><li>Pedicled viscera </li></ul></ul><ul><ul><ul><li>Gastric esophagoplasty </li></ul></ul></ul><ul><ul><ul><ul><li>Free jejunum </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>94% success </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Satisfactory swallowing 88% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Discharge several days sooner </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fistula rate 16% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Late stricture 22% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Gastric pull up </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>87% success </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>87% swallowing </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>20% fistula rate </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Late stricture 13% </li></ul></ul></ul></ul></ul>
    95. 103. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Requires replacement of missing mandibular segment of bone </li></ul></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Promotes primary healing </li></ul></ul></ul><ul><ul><ul><li>Resists radiotherapy </li></ul></ul></ul><ul><ul><ul><li>Allows dental reconstruction with osseointegrated implants </li></ul></ul></ul>
    96. 104. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Defect classification </li></ul></ul><ul><ul><ul><li>C = central segment </li></ul></ul></ul><ul><ul><ul><ul><li>Between two canines </li></ul></ul></ul></ul><ul><ul><ul><li>L = lateral segment </li></ul></ul></ul><ul><ul><ul><li>H = hemimandible </li></ul></ul></ul><ul><ul><ul><ul><li>Similar to lateral segment but includes the condyle on the affected side </li></ul></ul></ul></ul><ul><ul><ul><li>Variable combinations </li></ul></ul></ul><ul><ul><ul><ul><li>LC, HC, LCL </li></ul></ul></ul></ul>
    97. 106. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Bardenheuer 1892 </li></ul></ul><ul><ul><ul><li>Composite flap of skin, periosteum and bone from forehead to replace missing jaw </li></ul></ul></ul><ul><ul><li>Sykoff 1900 </li></ul></ul><ul><ul><ul><li>First non-vascularized bone graft </li></ul></ul></ul><ul><ul><li>Risdon and Waldron 1919 </li></ul></ul><ul><ul><ul><li>Iliac crest grafts to the mandible </li></ul></ul></ul>
    98. 107. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Non vascularized bone grafts </li></ul></ul><ul><ul><ul><li>Rib or iliac crest </li></ul></ul></ul><ul><ul><ul><li>Balance of cortical and cancellous bone </li></ul></ul></ul><ul><ul><ul><li>1969 Millard </li></ul></ul></ul><ul><ul><ul><ul><li>Immediate rib bone grafts </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>30% failure rate </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Recommended delaying bone grafting to 6 weeks after soft tissue reconstruction </li></ul></ul></ul></ul>
    99. 108. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Sterilized autogenous bone </li></ul></ul><ul><ul><ul><li>Sterilizing resected mandibular segment </li></ul></ul></ul><ul><ul><ul><li>Replaced biologically inert mandible </li></ul></ul></ul><ul><ul><ul><ul><li>Scaffold for new bone growth </li></ul></ul></ul></ul><ul><ul><ul><li>Freeze dried </li></ul></ul></ul><ul><ul><ul><ul><li>-50 º C to –60 º C with liquid nitrogen </li></ul></ul></ul></ul><ul><ul><ul><li>Alternate technique is irradiation </li></ul></ul></ul><ul><ul><ul><li>All such methods abandoned </li></ul></ul></ul>
    100. 109. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>1976 Boyne and Zarem </li></ul></ul></ul><ul><ul><ul><ul><li>Titanium mesh tray and cancellous bone chips </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Postponed if postoperative radiation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Metallic tray increases absorbed radiation by 29-36% </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increased risk to soft tissue envelope </li></ul></ul></ul></ul></ul><ul><ul><ul><li>1972 Leake and Rappoport </li></ul></ul></ul><ul><ul><ul><ul><li>Dacron urethane mesh </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Biocompatible and malleable alternative </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Easy to handle, simple fixation, no heat conduction or radiation scatter </li></ul></ul></ul></ul>
    101. 110. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>Temporary spacers – Kellman and Gullane </li></ul></ul></ul><ul><ul><ul><ul><li>AO stainless steel plates </li></ul></ul></ul></ul><ul><ul><ul><ul><li>23 patients; 90% irradiated </li></ul></ul></ul></ul><ul><ul><ul><ul><li>17% exposure rate in lateral mandibular reconstructions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>48% exposure rate with anterior arch </li></ul></ul></ul></ul>
    102. 111. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>Titanium coated Hollow Screw and Reconstruction Plate (THORP) system </li></ul></ul></ul><ul><ul><ul><ul><li>Raveh </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use of hollow screws </li></ul></ul></ul></ul><ul><ul><ul><ul><li>New bone is integrated into the prosthesis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>“ Integrated osteosynthesis” </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Greater stability </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Less need for direct contact between plate and mandibular cortex </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>85% success rate </li></ul></ul></ul></ul></ul>
    103. 112. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Alloplasts </li></ul></ul><ul><ul><ul><li>Temporary spacers pending definitive reconstruction with vascularized bone </li></ul></ul></ul><ul><ul><ul><li>High extrusion rates </li></ul></ul></ul><ul><ul><ul><ul><li>Anterior mandibular defects </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Poor quality lining </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Irradiated soft tissues </li></ul></ul></ul></ul>
    104. 113. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Transfer of vascularized bone by microanastomoses </li></ul></ul></ul><ul><ul><ul><li>Low morbidity </li></ul></ul></ul><ul><ul><ul><li>Negligible mortality </li></ul></ul></ul><ul><ul><ul><li>Tolerated in any age group </li></ul></ul></ul><ul><ul><ul><li>Primary healing </li></ul></ul></ul><ul><ul><ul><li>Tolerates radiotherapy </li></ul></ul></ul><ul><ul><ul><li>Allows dental restoration with osseointegrated implants </li></ul></ul></ul>
    105. 114. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Improves facial for and quality of life </li></ul></ul></ul><ul><ul><ul><li>96% success rates, low complication rate </li></ul></ul></ul><ul><ul><ul><li>Most common sources </li></ul></ul></ul><ul><ul><ul><ul><li>Fibula </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Iliac crest </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Radius </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lateral scapular border </li></ul></ul></ul></ul><ul><ul><ul><li>Less common </li></ul></ul></ul><ul><ul><ul><ul><li>Rib </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Second metatarsal </li></ul></ul></ul></ul>
    106. 116. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free fibular flap </li></ul></ul></ul><ul><ul><ul><ul><li>Hidalgo </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Published initial 12 cases </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Half were anterior arch </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Peroneal artery and vein </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Can include a skin paddle </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Reliability increased if include cuff of soleus and FHL preserved around bone </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Considered method of choice in most mandibular reconstruction </li></ul></ul></ul></ul>
    107. 117. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free fibular flap </li></ul></ul></ul><ul><ul><ul><ul><li>Advantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Up to 25 cm of bone to span defect any size </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Supine flap dissection </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Two team ablation harvest possible </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Segmental perforators from peroneal vessels allow multiple osteotomies </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Adequate bone stock for osseointegrated implants </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Disadvantage </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Contraindicated in severe PVD </li></ul></ul></ul></ul></ul>
    108. 118. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free fibular flap </li></ul></ul></ul><ul><ul><ul><ul><li>Complications </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Exposure of bone and hardware </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Orocutaneous fistula </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Osteoradionecrosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Partial or complete flap loss </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cervical contracture </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>MD Anderson large series </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>42% cases had one complication </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Radiotherapy equivocal </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Free fibular preserved bone mass best compared to other techniques </li></ul></ul></ul></ul></ul>
    109. 119. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free circumflex iliac osseocutaneous flap (CIOCF) </li></ul></ul></ul><ul><ul><ul><ul><li>Taylor et al 1979 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Deep circumflex iliac vessels </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Groin skin and iliac crest </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Useful in reconstruction of a hemimandible </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Jewer et al </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>60 cases </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>95% flap survival </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>86% patients returning to previous activities </li></ul></ul></ul></ul></ul>
    110. 120. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>CIOCF </li></ul></ul></ul><ul><ul><ul><ul><li>Advantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Good caliber of vessels </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Broad surface of bone for contouring mandible </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Segmental nutrient vessels allow osteotomies </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Disadvantages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bulky skin paddle can be unreliable with multiple osteotomies </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Abdominal wall weakness and hernia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Contour deformity at donor site </li></ul></ul></ul></ul></ul>
    111. 121. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>CIOCF </li></ul></ul></ul><ul><ul><ul><ul><li>Shenaq et al </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Modified flap to avoid donor site morbidity </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Split inner cortex iliac crest free flap </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inner cortex of iliac crest used </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>No abdominal wall weakness or hernias </li></ul></ul></ul></ul></ul>
    112. 122. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free radial forearm flap </li></ul></ul></ul><ul><ul><ul><ul><li>Segment of radius for mandibular reconstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inner volar cortex of radius divided </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Available segment of bone </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Distal to insertion of pronator teres </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Maximum length of bone 10-12 cm in adults </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Use 1/3 thickness of bone </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Should use full length plaster cast for 3-4 weeks </li></ul></ul></ul></ul>
    113. 123. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Iliac crest versus radial forearm </li></ul></ul></ul><ul><ul><ul><ul><li>Boyd et al </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Iliac crest </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ideal for massive defects </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Natural curvature follows mandibular contour </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Obstacle in small defects </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Higher incidence of intraoral wound breakdown and bone exposure </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Radial forearm </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Better skin paddle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Useful in smaller defects less than 9 cm </li></ul></ul></ul></ul></ul>
    114. 124. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free scapular flap </li></ul></ul></ul><ul><ul><ul><ul><li>Teot et al 1981 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lateral border of scapula transferred with muscle cuff </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Circumflex scapular vessels </li></ul></ul></ul></ul><ul><ul><ul><ul><li>7 cm of bone safely harvested </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cutaneous paddle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Protects from shoulder immobility with pedicled trapezius </li></ul></ul></ul></ul>
    115. 125. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Free dorsalis pedis osseocutaneous flap </li></ul></ul></ul><ul><ul><ul><ul><li>2 nd metatarsal 4-7 cm of bone </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Segmental blood supply allows osteotomies </li></ul></ul></ul></ul><ul><ul><ul><li>Masseter osseomuscular flap </li></ul></ul></ul><ul><ul><ul><ul><li>Central mandible segment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Preserves bone viability </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Maintains form and function of mandible </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Local flap </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Low donor site morbidity and short operative time </li></ul></ul></ul></ul>
    116. 126. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Vascularized bone </li></ul></ul><ul><ul><ul><li>Trapezius osseomusculocutaneous flap </li></ul></ul></ul><ul><ul><ul><li>Sternocleidomastoid musculoosseus flap </li></ul></ul></ul><ul><ul><ul><li>Free rib </li></ul></ul></ul><ul><ul><ul><li>Sternum and muscle flap </li></ul></ul></ul><ul><ul><ul><li>Temporalis myoosseus flap </li></ul></ul></ul>
    117. 127. Regional reconstruction <ul><li>Mandible </li></ul><ul><ul><li>Composite mandibular defects </li></ul></ul><ul><ul><ul><li>Defect encompasses oral mucosa or overlying soft tissue </li></ul></ul></ul><ul><ul><ul><li>Dual free flaps versus composite free flaps </li></ul></ul></ul><ul><ul><ul><li>Combinations endless </li></ul></ul></ul>
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