Plastic surgery options for Reconstruction for Oromaxillofacial Malignancies

1. — Dr Amey Pednekar
MCh Plastic Surgery
Reconstructive Surgery for Head
and Neck Malignancies

2. whe
n?
why? how?

3. • Coverage of vital structures (eye, nasal cavities,
sinuses, mandible etc) which are exposed after
malignancy resection
• Allow continuation of activities such as speech and
swallowing
• Restore aesthetics
• To preserve and restore the preoperative activity and quality of life
why?

4. Goals
• Restoration of Function
• Restoration of Form and Symmetry
• Creation of a barrier between cavities and spaces in head and
neck that do not communicate in normal anatomy
• Facial reanimation
• Dental rehabilitation

5. • Ideal: At the time of Tumour resection
• Immediate reconstruction
• Prevents retraction and fibrosis of the defect
• Allow administration of adjuvant therapy
• Minimizes the number of surgical procedures
• Favours psychological rehabilitation
• Some authors, in the past, advocated delayed recon, as identification
of the tumour recurrence under a flap was difficult to monitor
• With better diagnostic and imaging techniques (CECT, MRI, PET) the
above premise is no longer valid
whe
n?

6. • Surgical options for reconstruction have been described
as a ‘Reconstructive Ladder’
*Reconstructive Elevator
how?

7. Secondary Intention

8. Secondary Intention
• When the sides of the wound are not apposed. Healing occurs by
epithelial migration from the edges of the wound and from the base of the
wound (pilosebaceous)
• Area: Tip of the nose (< 5-7 mm), Forehead
• Advantage: No additional incisions
• Best for monitoring for recurrence
• Disadvantage: Long term dressing
• Chances of wound infection
• Cosmetically not the best
• Not suitable for large lesion or after exposure of vital structures

10. Primary Closure

11. Primary Closure
• Elastic skin in head, face, neck
with a strong dermal and
subdermal component of skin
circulation >> Allows extensive
undermining, esp in elderly with
lax skin
• Primary closure should be used
for the repair of eyelids and lips.
Defects of up to one third the
length of the lid and lip can be
closed primarily without any
functional issues

14. Skin
Graft
split
Full

15. Skin Grafts: FTSG & STSG
• Skin grafts are used for resurfacing well vascularised soft tissues,
periosteum and perichondrium
• Exposed bone, cartilage, irradiated tissues, unstable or
contaminated tissues will not hold a skin graft

16. Skin Grafts
Split Thickness Skin Graft Full Thickness Skin Graft
Used for large surface defects
Suitable for small defects due to
paucity of donor sites
Contract more upon healing Contract to a lesser extent
Lesser sensory recovery Better sensory recovery
Colour and texture mismatch
Superior colour and texture match than
SSG
Donor site: Thigh, back, scalp
Post auricular, Pre auricular, eyelid,
groin, medial arm, Supraclavicular
regains
Donor sites are left to heal by epithelial
migration from the edges and
pilosebacious elements
Donor sites are closed primarily

17. Flaps

18. Classification
• Flap is a full-thickness segment of tissue that has its own blood
supply
• Location: Local, Regional, Distant
• Type of tissue: Cutaneous, Fasciocutaneous, Muscle,
Musculocutaneous, Osseus, Oscteocutaneous
• Blood supply: Random ( local or subdermal blood supply 1:1),
• Axial (containing a vascular pedicle which is
attached to the parent pedicle)
• Free (containing a discrete vascular pedicle which
is detached and ananstomosed to recipient
vessels)

19. Local flaps

20. Local flaps
• Tissue obtained from the immediate surrounding of the defect but
retains connection to the surrounding to preserve the blood supply
to the flap
• Mostly cutaneous flaps for small to moderate size defects
• Local flaps may be Transposed, Rotated or Advanced and the
resultant donor site closed primarily
• Eg Limberg or Rhombiod (transposition), V-Y (advancement)

21. Local flaps
• Random Flap is a cutaneous flap (ie skin and subcutaneous
tissue) which receives its blood supply through the subdermal
capillary plexus.
• Transposition, Rotation, Advancement flaps
• Length to width ratio limits the size of the random flaps. This
should not exceeding 3 is to 1 (in face)
• Delay phenomenon: is the procedure to get a longer length of the
flap than possible in the single surgical setting, by partially dividing
the blood supply so that the supply from the other sources
becomes stronger
RANDOM FLAP

22. Transposition flap, V-Y advancement flap, Limberg flap

23. Local flap: Limberg flap

24. Z - plasty for excision defect closure

25. Local flaps
• These are flaps based on a single named vessel
• This allows further mobilisation of the cutaneous segment which
can be islanded on the vessel
• Length to width ratio is not a concern as there is an identifiable
source of blood supply.
• In head and neck reconstruction two commonly used axial flaps
are Paramedian forehead flap and Nasolabial flap
Axial flaps

26. Local flaps
Nasolabial flap
Infratrochlear artery
Angular artery

28. Local flaps
Paramedian forehead flap

30. Abbe Flap

31. Regional Flaps

32. Regional Flaps
• From the same or adjacent region as the defect
• Flap carries its blood supply from the donor site
• 3 - 4 weeks waiting period for the neovascularisation of the flap
from the recipient area
• Usually a delay followed by division is done to give time for the
‘choke vessels’ to open up.

33. Regional Flaps: Pectoralis Major
• PM originates from the first 5-6 ribs, clavicle, Xiphoid, Rectus
sheath. It inserts on the Humerus on the lateral lip of the inter-
tubercular sulcus
• Blood supply: IMA, Lateral thoracic artery (Type V Mathes &
Nahai)
• Skin paddle can be raised anywhere over the muscle.
• Cervial, intraoral, pharyngeal, tongue, cheek with floor of the
mouth, mandible defects.
• Donor site is closed primarily in most cases, may need a small
SSG

36. Regional Flaps: Deltopectoral flap
• Once a workhorse for intraoral, cheek and neck reconstruction
• Based on 1st, 2nd, 3rd perforators of IMA in the parasternal region
• Base of the flap is 2cm lateral to the sternal edge at which site the
perforators of IMA pierce through the muscle
• Used for defects of the neck, face and oral cavity
• Donor site requires SSG, resulting in a significant disfigurement

39. Regional flap: Trapezius flap

40. Regional flap: Trapezius flap

41. Regional flaps: Latissimus Dorsi

42. Distant flaps

43. Distant flaps: FRAF
• Radial artery: 18cm, 3mm
• 2 venae commitante, 1 Cephalic vein
• Skin, fascia +/- bone
• Donor defect to be skin grafted
• Microvascular anastomosis
necessary
• 8-0 to 10-0 ethylon
• Anastomosis of Ceph vein + at least
1 venae commitans
• Preferred when there is a need for a
pliable flap for small defects

46. Distant flap: ALT Flap
• Septocutaneous or
musculocutaneous vessels that
arise from the descending branch
of LCFA
• Venae comitantes of LCFA
• Skin, fat, fascia
• Primary closure of the donor/SSG
• Preferred where there is a need for
volume to be reconstructed is
more than FRAF

48. Distant flap: Free Fibula
• Nutrient artery from Peroneal artery
• Venae comitantes of Peroneal artery
• Best source for vascularised bone graft
• Mandible, maxilla, Tibia, forearm
• Osseus, Osteomuscular,
Osteocutaneous,
Osteomusculocutaneous
• CAD, CAM (Computer Aided Design ,
Computer Aided Manufacturing

49. Free Fibula: CAD CAM
• Planning of the resection of the Mandible

50. Free Fibula: CAD CAM
• 3D scanned Fibula is planned to reconstruct the Mandible

51. Free Fibula: CAD CAM
• 3D printed design to assist in the sectioning of the harvested Fibula

52. Free Fibula: CAD CAM
• Designed Mandible is 3D printed to mould the Reconstruction plate

53. Free Fibula: CAD CAM
• Mandibular excision guides are placed and diseased segment
resected

54. Free Fibula: CAD CAM
• 3D printed guide is placed along the harvested bone and bone is sectioned

55. Free Fibula: CAD CAM
• Premoulded Recon plate is fixed to the sectioned Fibula

56. Free Fibula: CAD CAM
• Fixing is done with screws while protecting the vascular pedicle

57. Free Fibula: CAD CAM
• Recon plate is fixed to the Mandibular remnant

58. Free Fibula: CAD CAM
• Vessel anastomosis is done

59. Free Fibula: CAD CAM
• At extubation

60. Reconstruction Aims At
• Flaps that cause least problems in other spheres of life
• MSAP
• ALT
• Free Fibula
• Free groin flap
• To restore the life of the patient to as close to his pre-cancer life,
so he can perform his basic duties, continue to earn his living (not
a dependent on his family) and be able to mix with his peers
without being discriminated.
• Aim: Restore the ‘Quality of Life’

61. Thank You