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  • Good afternoon ladies and gentlemen
  • Transcript

    • 1. 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
      • In Slide Show, click on the right mouse button
      • Select “Meeting Minder”
      • Select the “Action Items” tab
      • Type in action items as they come up
      • Click OK to dismiss this box
      • This will automatically create an Action Item slide at the end of your presentation with your points entered.
    • 2. Introduction
      • Goals of Reconstruction
        • Ablative cure
        • Restoration of function
        • Restoration of form
    • 3. Introduction
      • Functional Objectives
        • Restore sensation
        • Maintain oral continence
        • Facilitate swallowing
        • Prevent aspiration
        • Preserve speech
        • Protect vital structures
        • Achieve primary wound healing
        • Obtain cosmesis
    • 4. 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
    • 5. 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
    • 6. 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
    • 7. 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
    • 8. 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
    • 9. 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
    • 10.  
    • 11. 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
    • 12. 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
    • 13.  
    • 14. 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
    • 15. 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
    • 16. 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
    • 17. 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
    • 18. 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
    • 19.  
    • 20. 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
    • 21. 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
    • 22.  
    • 23. 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
    • 24. 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
    • 25. 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
    • 26. 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
    • 27. 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
    • 28. 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
    • 29. 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
    • 30. 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
    • 31. 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)
    • 32. 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
    • 33. 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
    • 34.  
    • 35. 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
    • 36. 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
    • 37. 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
    • 38. 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
    • 39. Reconstructive options
      • Musculocutaneous flaps
        • LDMF
          • Advantages:
            • Large size
            • Wide excursion
            • Donor site morbidity negligible
          • Disadvantages:
            • Positioning
            • Intricate dissection
            • Complexity of tunneling
    • 40. 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
    • 41. 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
    • 42. 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
    • 43. 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
    • 44. 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
    • 45. 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
    • 46. 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
    • 47. Reconstructive options
      • Musculocutaneous flaps
        • Platysma flap
          • Contraindications
            • previous irradiation to the neck
            • Surgery in the head and neck
            • Neoadjuvant chemotherapy
            • Nodal disease
            • Large defects
    • 48. 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
    • 49. 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
    • 50. 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
    • 51. 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
    • 52.  
    • 53. 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
    • 54. 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
    • 55. 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
    • 56. 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
    • 57. 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%
    • 58. Regional reconstruction
      • Outline
        • Oral cavity
          • Floor of mouth
          • Soft palate
          • Hard palate
          • Tongue
        • Oropharynx
        • Hypopharynx and esophagus
        • Mandible
    • 59. 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
    • 60. Regional reconstruction
      • Oral cavity
        • Six contiguous mucosal vascular territories
          • Labial
          • Buccal
          • Inferior alveolar
          • Lingual
          • Ascending pharyngeal
          • Ascending palatine
    • 61. 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
    • 62. Regional reconstruction
      • Oral cavity
        • Soft palate
          • Traditionally non surgical
          • Lateral pharyngeal walls
            • Skin graft
            • Flap
            • Obturator
          • Sensation helps initiate oral phase of deglutition
    • 63. 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
    • 64. 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
    • 65. 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
    • 66. 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
    • 67. Regional reconstruction
      • Oral cavity
        • Tongue
          • Options
            • PMMF
              • Problems with excessive bulk
              • Good short term results
              • Muscle atrophy and gravity diminish outcome
    • 68. 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
    • 69. 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
    • 70. 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
    • 71. 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
    • 72. 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
    • 73. 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
    • 74. 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
    • 75. Regional reconstruction
      • Oropharynx
        • Radial forearm flap cont’d
          • Donor site morbidity
            • Distal skin island
              • 33% graft failure
              • Exposed wrist tendons
    • 76. 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
    • 77. 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
    • 78. 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
    • 79.  
    • 80. 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
    • 81. 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
    • 82. 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
    • 83.  
    • 84. 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
    • 85. 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
    • 86. 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
    • 87. 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
    • 88. Regional reconstruction
      • Hypopharynx and esophagus
        • Fasciocutaneous flaps
          • Radial forearm flap
            • Thin and pliable
            • Ample vascular supply
            • Large paddle to form circumferential segment reconstruction
    • 89. 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
    • 90. 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
    • 91. 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
    • 92. 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
    • 93. 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
    • 94. 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
    • 95. 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
    • 96. 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
    • 97. 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
    • 98. 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
    • 99. Regional reconstruction
      • Hypopharynx and esophagus
        • Pedicled viscera
          • Colon interposition
            • Historical use
            • No longer used
            • Multiple complications
    • 100. 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
    • 101. 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
    • 102. 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%
    • 103. Regional reconstruction
      • Mandible
        • Requires replacement of missing mandibular segment of bone
        • Vascularized bone
          • Promotes primary healing
          • Resists radiotherapy
          • Allows dental reconstruction with osseointegrated implants
    • 104. 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
    • 105.  
    • 106. 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
    • 107. 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
    • 108. 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
    • 109. 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
    • 110. 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
    • 111. 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
    • 112. Regional reconstruction
      • Mandible
        • Alloplasts
          • Temporary spacers pending definitive reconstruction with vascularized bone
          • High extrusion rates
            • Anterior mandibular defects
            • Poor quality lining
            • Irradiated soft tissues
    • 113. 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
    • 114. 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
    • 115.  
    • 116. 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
    • 117. 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
    • 118. 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
    • 119. 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
    • 120. 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
    • 121. 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
    • 122. 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
    • 123. 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
    • 124. 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
    • 125. 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
    • 126. Regional reconstruction
      • Mandible
        • Vascularized bone
          • Trapezius osseomusculocutaneous flap
          • Sternocleidomastoid musculoosseus flap
          • Free rib
          • Sternum and muscle flap
          • Temporalis myoosseus flap
    • 127. Regional reconstruction
      • Mandible
        • Composite mandibular defects
          • Defect encompasses oral mucosa or overlying soft tissue
          • Dual free flaps versus composite free flaps
          • Combinations endless

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