2. Problem
In india->30% of all cancers are head neck ca.
In head neck ca. upper aerodigestive tract is most
common site- with oral cavity being most common
site followed by oropharynx followed by larynx
90% of all upper aerodigestive tract ca. is SCC.
3. Relevant anatomy
Upper aerodigestive tract constists of
-oral cavity
-oropharynx
-hypopharynx
-larynx
-nasopharynx and paranasal sinuses
4. Oral cavity
Function
Mastication/
Bolus/deglutition
Speech
Sphinchter/seal
Direction of saliva
10. Things to consider for best
functional and aesthetic result
Skin quality-color, texture, hair bearing etc.
Middle lamella-muscles of facial expression,
muscles of mastication
Deeper tissue-bone (contour) and soft tissue
Mucosal lining
12. Why Integrity is must?
continence (feeding)
Protect vital structures from Blow Outs
Separation from intracranial structures in skull base
(to prevent infection in/leak out)
Prevent aspiration
So must for survival
13. Function (Minimal goal if patient fit)
E.g.
Restoration of tongue bulk
Restoration of floor
Restoration of mandible
So better Quality of life
14. Form-aesthetics
E.g.
Maxillary defect- obturator vs free fibula (projection
and implant)
Aesthetic subunits
Secondary surgeries
Free flaps instead of pedicle
15.
If possible reconstruction should be done primary
-as post operative and post radiotherapy scarred
tissue hampers recipient vessel dissection.
-vein grafts to opposite side has more chances of
thrombosis
18. Donor site
Availability ( previous operations / trauma /vessel)
Donor site (so that 2 team approach)
Tissue quality (according to plan)
-to restore coverage (skin , mucosa, muscle to
mucolise)
-bulk ,support (flap thickness, muscle, fat, bone
,cartilage)
-if possible function
For free flaps- also Pedicle (length/caliber/no. of
veins/nerve/direction)
Residual donor defect
19. Patient
Fitness/age
Preference (expectation/stages)
compliance
Post op radiotherapy
21. Reconstructive options
(Even though actual defect only known intra-operatively
reconstruction must be planned )
Primary closure/secondary healing
Grafts-skin/bone..
Local flap/Regional flap
Free flap---single/chimeric/compound/flow through
22. Why Reverse ladder ?
Robust new tissue with own blood supply
Enough volume
Variety of Aesthetically pleasing combinations
More radioresistant
Osteo-integrated implants
Cost??
23. History
1951-Edgerton-concept of immediate reconstruction
1959-1st free jejunum for esophagus
1963-McGregor-laterally based forehead flap
1965-Bakamijan-deltopectoral flap
1976-Panje and Harashina described free flap for oral
defects
1979-Ariyan-PMMC flap
1980s and early 1990-osteocutaneous free flaps for
mandibular defects.
24.
1979 – Taylor et al. – iliac crest composite flap
1980 – dos Santos et al. – scapular cutaneous flap
1981 – Yang et al. – radial forearm free flap
1982 – Nassif et al. – parascapular cutaneous flap
1982 – Song et al. – lateral arm fasciocutaneous flap
1984 –Song et al. – Antero lateral thigh flap
1983 – Baek et al. – lateral cutaneous thigh flap
1985 – Drever et al. – rectus Abdominis myocutaneous flap
1986 – scapular osseocutaneous flap
25. Primary closure & secondary
healing
Primary closure – for small defects of lateral tongue
/ buccal mucosa.
Small defects of buccal mucosa, sulcus, floor of
mouth, hard palate left open or packed with
xeroform to allow healing by secondary intention
26. Skin grafts
STSG – used to close superficial defects of alveolus,
palate, dorsum or lateral edge of tongue.
Contraction of graft unlikely to cause a functional
problem in these areas.
Disadvantages –
Tendency to contract in extensile areas like floor of
mouth / buccal surface makes them less useful.
Increased risk of partial / total graft loss due to
scarring & radiation.
Immobilization of intraoral grafts -challenging
27. Local & regional flaps
Tongue flaps- used to close small oral defects in past,
fallen into disfavor because of tethering & resulting
functional disturbances.
Forehead, temporalis muscle flaps rarely used now
because of free tissue transfer.
Facial artery musculomucosal flap for small defects of
hard palate, alveolus, tonsillar fossa & floor of mouth, but
limited application.
Deltopectoral flap- an axial –pattern cutaneous flap based
on 2-4 the branch of internal mammary artery
Revolutionalized head & neck reconstruction, but fallen
into disfavor- questionable reliability without delay.
29. Based on submental artery
Elevation started from inferior border of mandible
between 2 angles
Plane is under plastysma
Anterior belly of digastric incuded to ensure
inclusion of perforator
31. Nasolabial flap
Based on angular artery
2x5 cm
Superiorly or inferiorly
based
Temporary
orocutaneous fistula
Best for old age with lax
skin
It requires bite block for
14 days
36. Musculocutaneous flaps
Superiorly based sternocleidomastoid flap- useful to
augment mandibular coverage, but unreliable & rarely
used.
Lateral & inferior trapezius flap used for intraoral
defects; lateral- poor flap reliability, inferior – reliable
(intraoperative positioning difficulties).
Latissimus dorsi- safe & reliable , but patient must be
repositioned for access to donor site, extensive
dissection required, used in salvage situations.
Pectoralis major still widely used
platysma limited role
42. Free flaps
Microvascular surgery revolutionalized management of
carcinoma of head & neck.
Reliable immediate single- stage reconstruction yields
superior functional & aesthetic results,reduces mortality
& maximizes quality of life in patients with reduced life
expectancy.
Introduction of well vascularized bed increases chances of
primary wound healing.
Free flaps demand microsurgical expertise, patient
management skills,proper anesthesia, appropriate
instrumentation,well equipped postoperative care unit
Favorite flaps –ALT,radial forearm & rectus abdominis,
second line flaps- lateral thigh, parascapular, LD
50. Latissimus Dorsi Free Flap
Arterial supply based
on thoracodorsal
artery
Venous drainage from
thoracodorsal vein
Motor nerve
innervation potential
with thoracodorsal
nerve
51. Latissimus Dorsi Free Flap
Advantages
Large flap with long pedicle
( artery 2-3 mm, vein 3-5
mm, length: 7-10 cm)
2nd largest skin paddle
Possibility for “axillary
megaflap”
Multiple skin paddles
Low donor site morbidity
Possibility of muscle
reinnervation via
thoracodorsal nerve
Disadvantages Difficult
positioning and two team
harvest
30-45% LD Postoperative
seroma formation
Bulky flap
Unable to tube
52.
53. Jejunum Free Flap
Seidenberg (1959) - First case report in a
human
Roberts and Douglas (1961) – first patient
to survive
Primarily use for reconstruction of
pharyngoesophageal defects
54. Jejunum Free Flap
Arterial supply from
portion of superior
mesenteric arterial
arcade (2nd or 3rd
arcade)
Venous supply from
venous branches along
arcade
56. Jejunum Free Flap
Advantages
Tubular
Mucosal surface may
help with lubrication
Minimal donor defect
Disadvantages
Bowel or pharynx fistulas
Need for laparotomy
• Gen. Surg. team
No neovascularization
Reverse peristalsis
Poor TE speech
Short pedicle
Difficult in obese persons
57. Jejunum Free Flap
Contraindications
Ascites
History of extensive abdominal surgery
Involvement of the thoracic esophagus
H/o of intestinal disease (Crohn's)
70. Recipient vessels
Look for atherosclerosis, previous surgery, radiotherapy
Some may prefer to dissect it prior to flap dissection
Best if more than one recipient artery is available to
choose best if location permits.
At least 2 veins anastomosis should be goal
2 major sources for recipient arteries-ext.carotid system
and thyrocervical system
71. artery
Superior thyroid is most suitable
when anastomosis with ext.carotid- 2-3 cm after
bifurcation.
When prior radiation, surgery, age limit use of ext.
carotid –thyrocervical system
Benefit of transverse cervical artery-less
atherosclerosis and as it riches mid neck greter
caliber donor artery can be used as no trimming is
required as in ext.carotid.
72. Veins
Extternal jugular, transeverse cervical best(if not
ligated during dissection)
Anterior jugular if not demaged while tracheostomy
Cephalic vein-mosrtly pos irradited areas.
73. Principles of microvascular
surgery
Delay flap mobilization till creation of defect
Preserve recipient vessels (atleast 1 cm)
Select vessel with similar lumen size
Pedicle lengh carefully measured
Better to give inset 1st-to avoid maneuvering of
completed anastomosis/suturing of bleeding flap
and misjudgment of pedicle length
Tissues sculpted once vascularization completed
75. Buccal mucosa
Size of the defect is measured with mouth fully open
Soft, pliable, sizable flap is best
Defect if-
Thin defect -radial/ulnar forearm fasciocutaneous
Thicker defect-thin ALT
Full thickness defect-thick fasciocutaneous or
musculocutaneous
Marginal mandibulectomy-ALT myocutaneous
Reconstruction goal-Avoid trismus
78. Buccal sulcus
Small superficial defects- closed primarily or allowed to
heal by secondary intention.(this may make sulcus
shallow)
Large defects- skin / mucosal grafts / mucosal rotation
flaps- limited by loss of excursion ,
so thin , pliable flaps( platysma, radial forearm free flap)
Marginal mandibulectomy-ALT myocutaneous
Excess bulk avoided- patient tends to bite the flap..
Reconstruction goal- to maintain the sulcus
79. Trigone
Defect here may expose mandible
Direct closure may distort tongue and pillar
80. Tongue
Reconstruction goal- tongue mobility and restore
bulk
Less than 1/3-1/2– primary closure vs. STSG
81.
82.
83.
84.
85. Floor of mouth
Soft, sensate, mobile with Preservation of tongue
mobility.
Small defects-heal secondarily / skin grafting.
Flap- thin & supple ( free radial forearm ); reliable
Anterior segmental mandibulectomy- osteocutaneous
flap (free fibula).
Reconstruction goal- to maintain lingual vestibule,
sufficient height to floor of mouth avoiding pooling of
saliva & food particles
86. Lower and upper
alveolar ridge
Tumors of lower gingiva - involve bone requiring partial
mandibular resection.
For small cancers- adequate remaining mucosa- direct
closure over bone, if not- raw surface accepts a skin graft.
After extensive marginal- reinforcement with a low-profile
reconstruction plate, when postoperative
radiotherapy planned covering it with well vascularised
soft tissue, preserving sulcus ( e.g.. radial forearm free
flap)
If segmental mandibulectomy- osteocutaneous
Maxillary- small superficial cancers- excised, left to heal
by secondarily, large- alveolectomy/ maxillectomy
87. Hard Palate
Hard palate- minor salivary gland tumors predominate.
Small defects- skin grafting/ heal secondarily.
Bone involvement- alveolectomy / partial / total
maxillectomy- palatal obturator, Osseo integrated
implants, osteocutaneous flap.
88. Soft palate
Soft palate- large defects, best prosthetically as flaps
sag & ineffective in this highly dynamic region.
A delayed surgical prosthesis followed by a
definitive obturator , interacts with the normally
functioning velopharyngeal complex on the opposite
side to help restore speech & swallowing.
if flaps used till radition completed and dentures
fitted—they must be tight enough to prevent
respiratory obstrction
106. Algorithm for surgical
treatment
Position- supine with shoulder roll to extend neck.
Prepare potential flap donor sites /skin / vein graft
donor sites.
Through out the operation strict sterile precations
are important
Ther has to be different trolley for oncosurgery and
reconstruction.
Adequate exposure for resection & reconstruction.
110. Tumor removed with frozen section control of margins.
Once nature of defect known- reconstruction team
begins to harvest flap.
If free flap- best to evaluate recipient vessels before
raising the flap.
Recipient vessels prepared.
An A-V loop created before flap harvest to minimize
ischemia time.
Defect measured , tissue needs (bulk, lining ) identified
111. Flap designed & elevated.
Flap rotated into position / harvested & brought to
recipient site.
For free flap orientation of flap is very important to
ensure most vascularized portion for water tight seal of
gullet.
In free flap, some insetting done before anastomosis to
allow accurate placement of sutures.
Insetting done with vertical or horizontal mattress or
tightly spaced interrupted sutures of 3-0 vicryl
attempting to secure a water- tight closure.
Simultaneously closure of donor site/STG done
112. Before starting anastomosis remove sand bag.
Microvascular anastomosis performed to large high- flow
vessels.
End to side to external carotid artery / internal jugular vein
preferred.
If atherosclerosis suspected, branch of external carotid to
minimize risk of embolic stroke.
It’s most important to prevent infection in this region and
protect it from any leakage with adequate tissue.
Drains are placed as indicated.
A site for external doppler monitoring marked with a suture
on flap skin.
Neck incision closed in layers.
Donor site closed over drains / grafted,dressed & splinted as
needed
113. Postoperative Management
Skilled nursing important
No pressure on pedicle (no ties on neck)
Eliminate cooling of flap
Keep head in neutral position
No pressors– keep BP stable
Hematocrit important
Frequent inspections and doppler pedicle