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  1. 1. Reconstruction of the Oral Cavity Michael Underbrink, M.D. Anna Pou, M.D.
  2. 2. Introduction <ul><li>Difficult challenge </li></ul><ul><li>Complex anatomy and function </li></ul><ul><li>Goals </li></ul><ul><ul><li>Restore preoperative function </li></ul></ul><ul><ul><li>Cosmesis </li></ul></ul><ul><li>Patient status is important consideration </li></ul><ul><li>Variety of reconstruction options </li></ul>
  3. 3. Anatomy <ul><li>Vermilion to junction of hard and soft palate superiorly </li></ul><ul><li>Inferiorly to circumvallate papillae </li></ul><ul><li>Structures: lips, alveolar ridges, buccal mucosa, retromolar trigone, hard palate, floor of mouth, mobile tongue </li></ul><ul><li>Functions: speech, mastication, bolus preparation and initiation of deglutition </li></ul>
  4. 4. Functional Considerations <ul><li>Oral sphincter </li></ul><ul><ul><li>Speech, mastication and deglutition </li></ul></ul><ul><ul><li>Provides a watertight closure for bolus preparation </li></ul></ul><ul><ul><li>Prevents escape of saliva </li></ul></ul>
  5. 5. Functional Considerations <ul><li>Alveolar Ridges </li></ul><ul><ul><li>Covered with thin, adherent mucosa </li></ul></ul><ul><ul><li>Elevated above floor of mouth </li></ul></ul><ul><ul><li>Lingual and buccal sulci direct the flow of food and saliva during bolus processing </li></ul></ul>
  6. 6. Functional Considerations <ul><li>Floor of the mouth </li></ul><ul><ul><li>Allows unrestricted mobility of the oral tongue </li></ul></ul><ul><ul><li>Collects food and saliva (bolus preparation) </li></ul></ul>
  7. 7. Functional Considerations <ul><li>Oral (mobile) tongue </li></ul><ul><ul><li>Speech and deglutition </li></ul></ul><ul><ul><li>Mobility allows for: </li></ul></ul><ul><ul><ul><li>Articulation of speech </li></ul></ul></ul><ul><ul><ul><li>Bolus manipulation in preparation for deglutition </li></ul></ul></ul><ul><ul><li>Sensory functions: proprioception, pain, taste </li></ul></ul><ul><ul><ul><li>Assists in mastication and bolus processing </li></ul></ul></ul>
  8. 8. Functional Considerations <ul><li>Hard palate </li></ul><ul><ul><li>Opposes tongue </li></ul></ul><ul><ul><li>Important for speech and bolus preparation </li></ul></ul>
  9. 9. Functional Considerations <ul><li>Buccal Mucosa </li></ul><ul><ul><li>Lines the cheek </li></ul></ul><ul><ul><li>Functions in mastication and deglutition </li></ul></ul><ul><ul><li>Allows expansion for mastication </li></ul></ul><ul><ul><li>Thin to avoid restriction of dental closure </li></ul></ul>
  10. 10. Functional Considerations <ul><li>Base of tongue </li></ul><ul><ul><li>Often involved with oral cavity defects </li></ul></ul><ul><ul><li>Participates in taste, deglutition and speech </li></ul></ul><ul><ul><li>Must occlude oropharynx during deglutition </li></ul></ul><ul><ul><li>Some consonants require BOT to touch hard palate </li></ul></ul>
  11. 11. Patient Factors <ul><li>Individualize options </li></ul><ul><ul><li>Type of tissue </li></ul></ul><ul><ul><li>Anticipated functional gain </li></ul></ul><ul><ul><li>Anticipated donor morbidity </li></ul></ul><ul><ul><li>Need for innervation </li></ul></ul><ul><ul><li>Success rate </li></ul></ul><ul><ul><li>Intraoperative positioning </li></ul></ul><ul><ul><li>Operative time </li></ul></ul><ul><ul><li>Dental restoration </li></ul></ul><ul><ul><li>Overall medical status </li></ul></ul>
  12. 12. Patient Factors <ul><li>Preoperative counseling </li></ul><ul><li>Complete medical history </li></ul><ul><ul><li>Diabetes, atherosclerosis, previous radiation </li></ul></ul><ul><ul><li>Cardiopulmonary status (operating time, aspiration risk) </li></ul></ul><ul><li>Smoking history </li></ul><ul><li>Patient expectations and motivation are very important </li></ul>
  13. 13. Floor of Mouth Reconstruction <ul><li>Requires soft and mobile tissue </li></ul><ul><li>Allow mobility of oral tongue </li></ul><ul><li>Avoid scar contracture (i.e., secondary intention) </li></ul><ul><li>Avoid bulk (glossoptosis, obliteration of lower lip sulcus) </li></ul>
  14. 14. Floor of Mouth Reconstruction <ul><li>Smaller defects </li></ul><ul><ul><li>Split thickness skin graft </li></ul></ul><ul><ul><ul><li>Harvest from lateral thigh at 0.017 in </li></ul></ul></ul><ul><ul><ul><li>Provides water-tight closure, no hair </li></ul></ul></ul><ul><ul><ul><li>Stabilize with bolster </li></ul></ul></ul><ul><ul><ul><li>Survives over muscle and cancellous bone (via imbibition and neovascularization) </li></ul></ul></ul><ul><ul><ul><li>Also good for lateral FOM and retromolar trigone </li></ul></ul></ul>
  15. 15. Floor of Mouth Reconstruction
  16. 16. Floor of Mouth Reconstruction <ul><li>Moderate defects involving a larger portion of mylohyoid </li></ul><ul><ul><li>Nasolabial flap </li></ul></ul><ul><ul><ul><li>Based on angular artery </li></ul></ul></ul><ul><ul><ul><li>Better for older patients with lax skin </li></ul></ul></ul><ul><ul><ul><li>Requires two stages and temporary fistula </li></ul></ul></ul><ul><ul><ul><li>Bite block necessary </li></ul></ul></ul>
  17. 17. Floor of Mouth Reconstruction
  18. 18. Floor of Mouth Reconstruction <ul><li>Moderate defects (continued) </li></ul><ul><ul><li>Regional flaps </li></ul></ul><ul><ul><ul><li>Forehead flap (rarely used) </li></ul></ul></ul><ul><ul><ul><li>Platysma flap </li></ul></ul></ul><ul><ul><ul><li>Facial artery musculomucosal flap (FAMM) </li></ul></ul></ul><ul><ul><ul><li>Deltopectoral flap (historical significance) </li></ul></ul></ul>
  19. 19. Floor of Mouth Reconstruction <ul><li>Forehead flap </li></ul><ul><ul><li>Superficial temporal artery </li></ul></ul><ul><ul><li>Reliable 2/3 across the forehead </li></ul></ul><ul><ul><li>Tunneled into cheek below zygoma </li></ul></ul><ul><ul><li>Requires orocutaneous fistula </li></ul></ul><ul><ul><li>Obvious donor site (skin graft) </li></ul></ul><ul><ul><li>Second stage to inset flap </li></ul></ul>
  20. 20. Floor of Mouth Reconstruction <ul><li>Submental artery island flap </li></ul><ul><ul><li>Thin, supple skin </li></ul></ul><ul><ul><li>Submental branch of facial artery </li></ul></ul><ul><ul><li>Primary closure of donor site </li></ul></ul><ul><ul><li>Poor reliability if: </li></ul></ul><ul><ul><ul><li>Facial artery sacrificed </li></ul></ul></ul><ul><ul><ul><li>Irradiated necks </li></ul></ul></ul>
  21. 21. Floor of Mouth Platysma Flap Reconstruction
  22. 22. Floor of Mouth Reconstruction <ul><li>FAMM flap </li></ul><ul><ul><li>Branch of facial artery </li></ul></ul><ul><ul><li>Contains mucosa, buccinator muscle, and fat </li></ul></ul><ul><ul><li>2 x 8 cm flap without injury to facial nerve </li></ul></ul>
  23. 23. Floor of Mouth Reconstruction
  24. 24. Floor of Mouth Reconstruction <ul><li>Deltopectoral Flap </li></ul><ul><ul><li>Axial distant flap </li></ul></ul><ul><ul><li>First four perforators of internal mammary </li></ul></ul><ul><ul><li>Deltoid portion is random </li></ul></ul><ul><ul><li>Preliminary delay procedure </li></ul></ul><ul><ul><li>Creates dependent orocutaneous fistula </li></ul></ul>
  25. 25. Floor of Mouth Reconstruction <ul><li>Fasciocutaneous free flaps </li></ul><ul><ul><li>Thin nature and pliability </li></ul></ul><ul><ul><li>Radial forearm has low incidence of failure to this site </li></ul></ul><ul><ul><li>Provides tongue mobility and free movement of food during deglutition </li></ul></ul>
  26. 26. Floor of Mouth Reconstruction <ul><li>Radial forearm free flap </li></ul><ul><ul><li>Based on radial artery </li></ul></ul><ul><ul><li>Outflow: two venae comitantes, basilic vein, cephalic vein </li></ul></ul><ul><ul><li>Long vascular pedicle with dependable supply </li></ul></ul><ul><ul><li>Potential sensation (posterior cutaneous nerve anastomosed to lingual) </li></ul></ul><ul><ul><li>Disadvantage: donor site morbidity (STSG, potential loss of thumb and index finger, potential decreased forearm function) </li></ul></ul>
  27. 27. Floor of Mouth Reconstruction
  28. 28. Anterior Tongue Reconstruction <ul><li>Very difficult to reconstruct </li></ul><ul><li>Complex intrinsic musculature and function </li></ul><ul><li>Redundancy is advantageous </li></ul><ul><ul><li>Near hemiglossectomy does not significantly alter function </li></ul></ul>
  29. 29. Anterior Tongue Reconstruction <ul><li>Defects <50% can be closed primarily +/- STSG </li></ul><ul><li>Larger or composite defects require more bulk (i.e, fasciocutaneous free flap) </li></ul><ul><li>Lateral arm free flap is good for defects including posterior aspect of tongue/FOM </li></ul>
  30. 30. Anterior Tongue Reconstruction
  31. 31. Anterior Tongue Reconstruction
  32. 32. Anterior Tongue Reconstruction <ul><li>Lateral Arm free flap </li></ul><ul><ul><li>Posterior radial collateral artery </li></ul></ul><ul><ul><li>Paired venae comitantes </li></ul></ul><ul><ul><li>12 x 18 cm paddle possible (6 x 8 cm allows for primary closure) </li></ul></ul><ul><ul><li>Potential sensate flap (posterior cutaneous nerve) </li></ul></ul><ul><ul><li>Disadvantages: donor site appearance, hair growth, elbow pain, lateral forearm numbness </li></ul></ul>
  33. 33. Anterior Tongue Reconstruction
  34. 34. Buccal Cavity Reconstruction <ul><li>Small defects – primary closure possible </li></ul><ul><li>Larger superficial defects </li></ul><ul><ul><li>Quilted skin/mucosal grafts </li></ul></ul><ul><ul><li>Temporoparietal fascial flap (STSG for lining) </li></ul></ul><ul><li>Large full-thickness defects </li></ul><ul><ul><li>Pectoralis major myocutaneous flap </li></ul></ul><ul><ul><li>Latissimus dorsi myocutaneous flap </li></ul></ul><ul><ul><li>Fasciocutaneous free flaps </li></ul></ul>
  35. 35. Buccal Cavity Reconstruction
  36. 36. Mandibular Reconstruction <ul><li>Goals </li></ul><ul><ul><li>Reconstitute mandibular continuity </li></ul></ul><ul><ul><li>Allow for future dental restoration </li></ul></ul><ul><li>Anterior defects </li></ul><ul><ul><li>Worst functional defects </li></ul></ul><ul><ul><li>“ Andy Gump” deformity </li></ul></ul><ul><li>Lateral defects </li></ul><ul><ul><li>Easier to reconstruct </li></ul></ul><ul><ul><li>Less functional problems </li></ul></ul>
  37. 37. Mandibular Reconstruction <ul><li>Fibula osseocutaneous free flap ideal for anterior defects (minimal soft tissue defect) </li></ul><ul><ul><li>Based on peroneal vessels </li></ul></ul><ul><ul><li>Multiple osteotomies allowable (for contouring) </li></ul></ul><ul><ul><li>25 cm of bone available (entire defects) </li></ul></ul><ul><ul><li>Sensate (lateral cutaneous nerve) </li></ul></ul><ul><ul><li>Reliable for osseointegrated dental implants </li></ul></ul>
  38. 38. Fibula Free Flap
  39. 39. Fibula Free Flap
  40. 40. Mandibular Reconstruction <ul><li>Scapular free flap for anterior defects with massive soft tissue loss (i.e., total glossectomy) </li></ul><ul><ul><li>Circumflex scapular artery and vein </li></ul></ul><ul><ul><li>14 cm of bone available (lateral aspect) </li></ul></ul><ul><ul><li>Allows osseointegrated implants </li></ul></ul><ul><ul><li>Long pedicle to axillary artery </li></ul></ul><ul><ul><li>Multiple fasciocutaneous/musculocutaneous flaps available (scapular, parascapular, latissimus dorsi, serratus anterior) </li></ul></ul><ul><ul><li>Major drawback: patient positioning </li></ul></ul>
  41. 41. Scapula Free Flap
  42. 42. Mandibular Reconstruction <ul><li>Lateral mandible defects </li></ul><ul><ul><li>Regional/Distant/Free flap with mandibular swing </li></ul></ul><ul><ul><li>Low profile reconstruction plate with soft tissue coverage </li></ul></ul><ul><ul><ul><li>Patient factors which prevent dental restoration </li></ul></ul></ul><ul><ul><ul><li>Plate exposure rate of about 5% </li></ul></ul></ul><ul><ul><ul><li>Compared to anterior exposure rate near 20% </li></ul></ul></ul><ul><ul><li>Osseocutaneous free flaps (iliac, scapular, fibula) </li></ul></ul>
  43. 43. Mandibular Reconstruction
  44. 44. Mandibular Reconstruction <ul><li>Iliac crest free flap for lateral defects </li></ul><ul><ul><li>Internal oblique musculature included </li></ul></ul><ul><ul><li>Contour similar to native mandible </li></ul></ul><ul><ul><li>Reliable for osseointegrated implants </li></ul></ul><ul><ul><li>Deep circumflex iliac artery </li></ul></ul><ul><ul><li>Disadvantages (difficult harvest, donor site deformity, abdominal weakness, postoperative hematoma, lateral thigh pain/anesthesia) </li></ul></ul><ul><ul><li>Split inner cortex modification reduces morbidity </li></ul></ul>
  45. 45. Mandibular Reconstruction
  46. 46. Mandibular Reconstruction
  47. 47. Special Considerations <ul><li>Total Glossectomy Defects </li></ul><ul><ul><li>Often accompany oral cavity defects with extensive disease </li></ul></ul><ul><ul><li>Require bulk for reconstruction </li></ul></ul><ul><ul><li>Goals </li></ul></ul><ul><ul><ul><li>Direct secretions laterally </li></ul></ul></ul><ul><ul><ul><li>Provide contact of neo-tongue with palate </li></ul></ul></ul><ul><ul><li>Use flaps which will not atrophy over time </li></ul></ul><ul><ul><li>Palatal drop prosthesis </li></ul></ul>
  48. 48. Special Considerations <ul><li>Total Glossectomy Defects </li></ul><ul><ul><li>Rectus abdominis free flap </li></ul></ul><ul><ul><ul><li>Inferior and superior epigastric arteries </li></ul></ul></ul><ul><ul><ul><li>Motor nerve (intercostal) anastomosis retains bulk </li></ul></ul></ul><ul><ul><li>Latissimus dorsi myocutaneous free flap </li></ul></ul><ul><ul><ul><li>Thoracodorsal artery </li></ul></ul></ul><ul><ul><ul><li>Motor nerve (thoracodorsal) </li></ul></ul></ul><ul><ul><li>Pedicled flaps (PMMF, latissimus dorsi) </li></ul></ul>
  49. 49. Special Considerations <ul><li>Total glossectomy with laryngeal preservation </li></ul><ul><ul><li>Select patients </li></ul></ul><ul><ul><ul><li>Good health without cardiopulmonary disease </li></ul></ul></ul><ul><ul><ul><li>Can tolerate aspiration </li></ul></ul></ul><ul><ul><ul><li>Disease does not involve valleculae or preepiglottic space </li></ul></ul></ul><ul><ul><li>Must maintain intact superior laryngeal nerve </li></ul></ul><ul><ul><li>Laryngeal suspension lessens aspiration </li></ul></ul>
  50. 50. Decision Making in Oral Cavity Reconstruction Defect Type Soft Tissue Bone Floor of Mouth Tongue Buccal Mucosa Anterior Defect Lateral Defect Small STSG Moderate Regional Flaps Fasciocutaneous Free Flaps Large Pedicled Fasciocutaneous flap Fasciocutaneous free flaps Superficial Primary Closure Skin/Mucosal Grafts Full Thickness Regional Flaps Fasciocutaneous Free Flaps Large Full Thickness Fasciocutaneous Free Flaps Pedicled musculocutaneous flaps Osseocutaneous free flaps Regional/Distant Flap and Mandibular Swing Reconstruction Plate and Regional/Distant Flaps Osseocutaneous Free Flaps <50% Loss Primary Closure Skin Graft Combined Defects Fasciocutaneous free flaps Total Glossectomy Myocutaneous free flaps Pedicled musculocutaneous flaps
  51. 51. Conclusion <ul><li>Multitude of reconstructive options </li></ul><ul><li>Remember functional characteristics of tissue involved </li></ul><ul><li>Various patient factors to consider </li></ul><ul><li>Preoperative counseling essential </li></ul><ul><li>High success rates possible with proper patient selection </li></ul>
  52. 52. References <ul><li>Fong BP, Funk GF. Osseous free tissue transfer in head and neck reconstruction. Facial Plast Surg. 1999; 15(1): 45-59 </li></ul><ul><li>  </li></ul><ul><li>Liu R, Gullane P, Brown D, Irish J. Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol. 2001 Feb; 30(1): 34-40 </li></ul><ul><li>  </li></ul><ul><li>Abemayor E, Blackwell KE. Reconstruction of soft tissue defects in the oral cavity and oropharynx. Arch Otolaryngol Head Neck Surg. 2000 Jul; 126(7): 909-12 </li></ul><ul><li>  </li></ul><ul><li>Berenholz L, Kessler A, Segal S. Platysma myocutaneous flap for intraoral reconstruction: an option in the compromised patient. Int J Oral Maxillofac Surg. 1999 Aug; 28(4): 285-7 </li></ul><ul><li>  </li></ul><ul><li>Burkey BB, Coleman JR Jr. Current concepts in oromandibular reconstruction. Otolaryngol Clin North Am. 1997 Aug; 30(4): 607-30 </li></ul><ul><li>  </li></ul><ul><li>Wells MD, Edwards AL, Luce EA. Intraoral reconstructive techniques. Clin Plast Surg. 1995 Jan; 22(1): 91-108 </li></ul><ul><li>  </li></ul><ul><li>Hausamen JE, Neukam FW. Resection of tumors in tongue, floor of the mouth, and mandible: possibilities of primary reconstruction. Recent Results Cancer Res. 1994; 134:25-35 </li></ul><ul><li>  </li></ul><ul><li>Boyd JB. Use of reconstruction plates in conjunction with soft-tissue free flaps for oromandibular reconstruction. Clin Plast Surg. 1994 Jan; 21(1): 69-77 </li></ul><ul><li>  </li></ul><ul><li>Yousif NJ, Matloub HS, Sanger JR, Campbell B. Soft-tissue reconstruction of the oral cavity. Clin Plast Surg. 1994 Jan; 21(1): 15-23 </li></ul>