REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Reconstructive options after
Head and Neck Cancer resections
DR.SHAJ...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Impact of major head and neck
surgery
Devastating morbidities
Cosmet...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Reconstructive surgeries
Aim : Restoration of form and function
Form...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Reconstructive ladder
Primary closure
Skin grafting
Local flaps
Regi...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
How to select
• Select the most appropriate option for the particula...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Primary Closure
Small and moderate defects of
– Skin
– Soft tissues
...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Skin Grafts
For small and superficial defects of skin and mucosa
Spl...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Full thickness skin Grafts
Ideal for covering small defects after re...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Locoregional Flaps
A local flap implies that the tissue is adjacent ...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Local Flaps in Head and Neck
Rich Vascularity
Lot of local flaps ava...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Local Flaps
Advancement Flaps
Rotation Flaps
Transposition Flaps
Rho...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Local flaps
Random –(skin or mucosal)
Rotation,Advancement,Transposi...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
The choice between use of a transposition flap or a rotation flap is...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Regional Flaps
Flaps from adjoining areas
Nasolabial flaps
Forehead ...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Nasolabial Flaps
Superiorly based
Alar defects of nose
Eye lid
Cheek...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Forehead Flaps
Median-both supratrochlear vessels
Paramedian
Sup.tem...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Submental artery Island Flap
This is an axial pattern flap based on ...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Flap planning
Upper limit within mandibular
margin.
Size of flap dep...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
DELTOPECTORAL FLAP
It served as the premier flap for reconstructing ...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Myocutaneous Flaps
• Commonest reconstructive option for major head ...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Pectoralis major myocutaneous flap
This is the most frequently used ...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Main uses of Pectoralis major Myocutaneous flap in head and neck:
Fo...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Platysma flap
An island myocutaneous flap based on the platysma musc...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Sternomastoid flap
Advantages
The skin paddle of superiorly based st...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Trapezius Myocutaneous Flap
The trapezius myocutaneous flap can be u...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Free flaps
Microvascular free tissue transfer
Not constrained by siz...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Free Flaps
Radial Forearm flap
Antero lateral Thigh flap
Free Fibula...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Bony Defects
• Mandibular Reconstruction
• Is it a must to reconstru...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Free fibula flap
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Conclusion
Reconstructive surgery is an essential part of head and n...
REGIONAL CANCER CENTRE, TRIVANDRUM
Life beyond cancer
Conclusion
Most of these reconstrucive procedures can be performed i...
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Reconstruction dr.shaji HEAD AND NECK RECONSTRUCTIONS

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RECONSTRUCTIVE OPTIONS AFTER MAJOR HEAD AND NECK RESECTIONS

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Reconstruction dr.shaji HEAD AND NECK RECONSTRUCTIONS

  1. 1. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Reconstructive options after Head and Neck Cancer resections DR.SHAJI THOMAS MS,MCh Additional Professor Division of Surgical Oncology Regional Cancer Centre Trivandrum
  2. 2. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Impact of major head and neck surgery Devastating morbidities Cosmetic Functional Physical Psychological Nutritional Quality of life
  3. 3. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Reconstructive surgeries Aim : Restoration of form and function Form: Esthetic Restoration of contour Expression of face Oral competence Functions: Speech Mastication Deglutition
  4. 4. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Reconstructive ladder Primary closure Skin grafting Local flaps Regional flaps Distant flaps Free flaps
  5. 5. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer How to select • Select the most appropriate option for the particular defect • Patient factors-Age,perfomance status,comorbidities • Patient choice and expectations • Tissues to be replaced • Occupation • Patient counselling
  6. 6. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Primary Closure Small and moderate defects of – Skin – Soft tissues – Mucosa Should not cause – Restriction of movements – Tension – Cosmetic disfigurement
  7. 7. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Skin Grafts For small and superficial defects of skin and mucosa Split thickness skin graft Full thickness skin grafts Graft Contracture Restriction of movements Trismus
  8. 8. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Full thickness skin Grafts Ideal for covering small defects after removal of tumours in areas like 1. Tip of nose 2. Parts of the pinna 3. Lower eye lid.
  9. 9. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Locoregional Flaps A local flap implies that the tissue is adjacent to the open wound in need of coverage. Although Free flaps have taken over, the local flaps still the method of choice for repair of most facial defects which cannot be closed primarily.
  10. 10. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Local Flaps in Head and Neck Rich Vascularity Lot of local flaps available Long and thin local flaps can be planned Good colour and texture match Good healing of donor site Less morbidity Same incision & field Little expertise Time saving
  11. 11. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Local Flaps Advancement Flaps Rotation Flaps Transposition Flaps Rhomboid flaps Bilobed flaps
  12. 12. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Local flaps Random –(skin or mucosal) Rotation,Advancement,Transposition, Interposition & Interpolation Axial pattern- A distinct blood vessel is identifiable in the pedicle Nasolabial,Forehead
  13. 13. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer The choice between use of a transposition flap or a rotation flap is often influenced by the nature and size of the defect. When the defect to be reconstructed is large, a transposition flap is safer and ideal. Local flaps are usually preferred in scalp defect reconstruction because it is hair bearing.
  14. 14. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Regional Flaps Flaps from adjoining areas Nasolabial flaps Forehead flaps Cervical flaps Submental flaps
  15. 15. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Nasolabial Flaps Superiorly based Alar defects of nose Eye lid Cheek Inferiorly based Lower lip Oral commissure Tongue Floor of mouth Other intraoral defects
  16. 16. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Forehead Flaps Median-both supratrochlear vessels Paramedian Sup.temp Artery based-Transverse forehead flaps Used for-Nasal Med.canthal and eyelid defects Intra oral-transverse flap
  17. 17. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Submental artery Island Flap This is an axial pattern flap based on the submental branch of the facial artery Advantages: Donor defect can be closed primarily on the donor site scar is hidden under the mandible. Flap has a large and reliable vascular pedicle with excellent reach to most of the oral cavity sites. Ideal thickness for reconstructing buccal mucosa and tongue defects. Less bulk and less time consuming when compared with free flaps. Disadvantages: Submental flap harvested with a thick surrounding fibrofatty tissue and tissues around the facial vessels can compromise the lymphatic clearance. So it is better to avoid this flap in patients with clinically significant node in level IA and IB.
  18. 18. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Flap planning Upper limit within mandibular margin. Size of flap depends on the defect and which allows primary closure. Donor defect should be hidden under mandible.
  19. 19. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  20. 20. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  21. 21. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  22. 22. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  23. 23. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  24. 24. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer DELTOPECTORAL FLAP It served as the premier flap for reconstructing complex head and neck defects until the late 1970s Advantages Technical simplicity Predictable vascular supply Reconstruction in select cases in which vascularized skin coverage of the neck is needed The DP flap also provides a valuable salvage option
  25. 25. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Myocutaneous Flaps • Commonest reconstructive option for major head and neck defects  Pect.major flaps  Sternomastoid flaps  Trapezius myocutaneous flaps  Lat.dorsi flaps
  26. 26. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Pectoralis major myocutaneous flap This is the most frequently used myocutaneous flap for head and neck reconstructions The workhorse of the head and neck surgeon The blood supply to pectoralis major flap is consistent and so very reliable. The donor defect can be closed primarily in majority of cases.
  27. 27. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  28. 28. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Main uses of Pectoralis major Myocutaneous flap in head and neck: For reconstruction of major intra oral lining defects For reconstructing outside skin defects of cheek or full thickness defects of oral cavity. For covering major neck skin defects following extended radical neck dissection and in post irradiated patients. For protecting the exposed carotid vessels following neck dissection to prevent carotid blow out. For augmenting the pharyngeal closure following laryngopharyngectomy when there is tension in pharyngeal closure especially in salvage set up. For reconstructing circumferential pharyngeal and cervical oesophageal defects.
  29. 29. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Platysma flap An island myocutaneous flap based on the platysma muscle is ideal for reconstructing the superficial lining defects of oral cavity Disadvantages of platysma flap: Blood supply can be unreliable. Prior neck dissection or any neck surgeries precludes the use of this flap A proper neck dissection may damage the blood supply to the flap Removal of the platysma interferes with the blood supply to the overlying skin and can lead to necrosis of skin. Platysma flap is not advisable in patients with prior irradiation to neck.
  30. 30. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Sternomastoid flap Advantages The skin paddle of superiorly based sternomastoid flap is hairless and thin and is an ideal reconstructive option for medium sized cheek defects. It does not produce excessive bulk in the face or mouth Disadvantages A proper neck dissection is likely to cause damage to the vascular pedicle. Hence a previous neck surgery or concurrent lymphadenectomy preclude the use of this flap
  31. 31. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  32. 32. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  33. 33. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  34. 34. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Trapezius Myocutaneous Flap The trapezius myocutaneous flap can be used for reconstructing defects of head and neck region and upper back. Its location makes it the flap of choice for defects of the occipital, parotid and cervical spine regions.
  35. 35. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer
  36. 36. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Free flaps Microvascular free tissue transfer Not constrained by size and reach All types of defects can be reconstructed Skin, soft tissue, bone defects all can be reconstructed
  37. 37. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Free Flaps Radial Forearm flap Antero lateral Thigh flap Free Fibula flap Latissimus Dorsi flap DCIA flap TRAM flap Others
  38. 38. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Bony Defects • Mandibular Reconstruction • Is it a must to reconstruct all mandibular defects? • Yes in all young patients and cenral mandibular defects • Better cosmesis,prevents mandibular deviation,teeth can be implanted • Maxillectomy Defects • Prosthesis vs reconstruction
  39. 39. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Free fibula flap
  40. 40. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Conclusion Reconstructive surgery is an essential part of head and neck cancer surgery This improves the form and function of survivors and the quality of life. Various options are available for head and neck reconstructions and has to select the appropriate one
  41. 41. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer Conclusion Most of these reconstrucive procedures can be performed in medium level hospitals. Since head and neck cancer is a common problem in our population all general surgeons need a good exposure to head and neck resections and reconstructions
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