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  • Good afternoon ladies and gentlemen

Head Head Presentation Transcript

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