This document discusses neck dissections and related anatomy. It covers the layers of fascia in the neck, important muscles and structures, lymph node levels, types of neck incisions and dissections, and complications. The key types of neck dissections are radical, modified radical, and selective neck dissections. Common neck incisions discussed include transverse, Criles, apron, and double Y incisions.
Zygoma: Strong buttress of lateral midface lying between zygomatic process of frontal bone and maxilla.
The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.
Zygoma: Strong buttress of lateral midface lying between zygomatic process of frontal bone and maxilla.
The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
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This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
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This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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2. Outline
1. ANATOMY OF NECK
2. LYMPH NODE LEVELS
3. STAGING OF CANCER
4. TYPES OF NECK INCISIONS
5. TYPES OF NECK DISSECTIONS
6. COMPLICATIONS
3. ANATOMY OF NECK
The LOWER BORDER
OF THE MANDIBLE&
The SUPRASTERNAL
NOTCH and the
UPPER BORDER OF
CLAVICLE.
4. FASCIAL LAYERS OF NECK
Superficial cervical fascia
- Platysma
• Deep cervical fascia
– Superficial layer
• SCM, strap muscles, trapezius
– Middle or Visceral Layer
• Thyroid
• Trachea
• esophagus
– Deep layer (also prevertebral fascia)
• Vertebral muscles
• Phrenic nerve
5.
6. Superficial Fascia- Platysma
• Origin – subcutaneous tissues of infra and
supraclavicular regions
• Insertion – 1) depression muscles of the
corner of the mouth, 2) base of the mandible
• Nerve: Cervical branches of fascial nerve
• Artery: Submental and suprascapular arteries
7. Function –
1) wrinkles the the neck
2) depresses the corner of the mouth
3) increases the diameter of the neck
4) assists in venous return
Surgical considerations
– Increases blood supply to skin flaps
– Absent in the midline of the neck
– Fibers run in an opposite direction to the SCM
10. DEEP CERVICAL FASCIA
• SCM:
Origin –
1) medial third of the clavicle (clavicular head)
2) manubrium (sternal head)
Insertion – mastoid process
Nerve supply – spinal accessory nerve (CN XI)
Blood supply –
1) occipital a. or direct from ECA
2) superior thyroid a.
3) transverse cervical a.
12. • OMOHYOID :
• Origin – upper border of the scapula
• Insertion –
1) via the intermediate tendon onto the clavicle and first rib
2) hyoid bone lateral to the sternohyoid muscle
• Blood supply – Inferior thyroid a.
• Function –
1) depress the hyoid
2) tense the deep cervical fascia
14. • Surgical considerations
– Absent in 10% of individuals
– Landmark demarcating level III from IV
Inferior belly lies superficial to
• The brachial plexus
• Phrenic nerve
• Transverse cervical vessels
Superior belly lies superficial to
• IJV
15. • TRAPEZIUS
• Origin –
1) medial 1/3 of the sup. Nuchal line
2) external occipital protuberance
3) ligamentum nuchae
4) spinous process of C7 and T1-T12
• Insertion –
1) lateral 1/3 of the clavicle
2) acromion process
3) spine of the scapula
• Function – elevate and rotate the scapula and
stabilize the shoulder
17. • DIGASTRIC MUSCLE
• Origin –
1. anterior belly :digastric fossa of the mandible (at the
symphyseal border) –(N:- mandibular br)
2. Posterior belly: mastoid process of temporal bone ( N :-
fascial N)
• Insertion –
hyoid bone via the intermediate tendon
• Function –
1) Opens the jaw when masseter and temporalis are relaxed
19. • Surgical consideration
Posterior belly is superficial to:
• ECA
• Hypoglossal nerve
• ICA
• IJV
Anterior belly
• Landmark for identification of mylohyoid for dissection of the
submandibular triangle
22. Suprahyoid triangle
Submental triangle
• Lies below the chin and is
bounded laterally by
anterior bellies of digastric,
and inferiorly by the body
of hyoid bone
• Covered by skin,
superficial fascia and
investing fascia
• Floor-mylohyoid muscles
• Contents-submental
lymph nodes
24. Submandibular triangle
• Bounded by anterior and posterior bellies of digastric and
lower border of the body of the mandible
• Floor- mylohyoid, hyoglossus and middle constrictor of
pharynx
• Contents-submandibular gland, facial a., v., hypoglossal n.
and v., lingual n., submandibular ganglion and submandibular
lymph nodes
25.
26. • Why we remove submandibular gland in neck
dissection?
27. • Level I of neck includes pre- glandular and post glandular
nodes and pre – post vascular LN
• Submandibular gland has no intraparenchymal LN
• Tumour involvement in the submandibular gland must be
through extension from locally involved LN or primary tumour.
• Cases has been reported for preservation of submandibular
gland in early stage lower lip carcinomas
28. Infrahyoid triangles
Carotid triangle
sternocleidomastoid,
superior belly of omohyoid
and posterior belly of
digastic muscles
• Floor-prevertebral fascia
and lateral wall of pharynx
• Contents-common carotid
a. and its branches, internal
jugular v. and its tributaries,
hypoglossal n. with its
descending branches, the
accessory and vagus nerves,
and part of the chain of
deep cervical lymph nodes
29. Muscular triangle
• Bounded by midline of the
neck, superior belly of the
omohyoid and anterior
border of the
sternocleidomastoid.
• Floor-prevertebral fascia
• Contents-sternohyoid,
sternothyroid, thyrohyoid,
thyroid gland, parathyroid
gland, cervical part of
trachea and esophagus
30. Lateral regions of neck
• Bounded by posterior
border of
sternocleidomastoid,
anterior border of trapezius
and middle third of clavicle
• Divided by inferior belly of
omohyoid into occipital and
supraclavicular triangles
31. contents
Arteries:
1. Subclavian (3rd part)
2. Superficial cervical &
suprascapular
(branches of
thyrocervical trunk, a
branch of 1st part of
subclavian artery
3. Occipital, a branch of
external carotid artery
32. Nerves:
Branches of cervical
plexus
Spinal part of accessory
nerve
Brachial plexus
33. Occipital triangle
• Bounded by posterior border of
sternocleidomastoid, anterior
border of trapezius and superior
border of inferior belly of
omohyoid
• Floor-prevertebral fascia and
scalenus anterior, scalenus
medius, scalenus posterior,
splenius capitis and levator
scapulae
• Contents
– Accessory n.emerges above the
middle of the posterior border of
sternocleidomastoid and crosses
the occipital triangle to trapezius
– Cervical and brachial PLEXUS
34. Supraclavicular triangle
• Bounded by posterior border of
sternocleidomastoid, inferior
belly of omohyoid and middle
third of clavicle
• Floor-prevertebral fascia and
inferior parts of scalenus
• Contents
– Subclavian v. and venous
angle
– Subclavian a.
– Brachial plexus
35. Marginal mandibular nerve
• Most commonly injured
dissection level Ib
• Landmarks:
– 1cm anterior and inferior to
angle of mandible
– Mandibular notch
• Subplatysmal
• Deep to fascia of the
submandibular gland
• Superficial to facial vein
• It lowers lip & corner of mouth
down and laterally
36. Hypoglossal nerve
• Motor nerve to the tongue
• • Cell bodies are in the
Hypoglossal nucleus of the
• Medulla oblongata
• • Exits the skull via the
hypoglossal canal
• • Lies deep to the IJV, ICA, CN
IX, X, and XI
• Iatrogenic injury
Most common site - floor of the
submandibular triangle, just deep
to the duct
37. Spinal accessory nerve
• Penetrates deep surface of
the SCM
• Exits posterior surface of
SCM deep to Erb’s point
• Traverses the posterior
triangle on the levator
scapulae
• Enters the trapezius about 5
cm above the clavicle
Hypoglossal N
Vagus N
Spinal Acc N
38. CN XI – Relationship with the IJV
Crosses the IJV
• Crosses lateral to the transverse process of
the atlas
• Occipital artery crosses the nerve
• Descends obliquely in level II (forms Level IIa and IIb
39. Phrenic nerve
• Sole nerve supply to
diaphragm
• Nerve roots C3-5
• Runs obliquely towards
midline on the anterior
surface of anterior scalane
• Covered by prevertebral
fascia
• Lies posterior and lateral to
carotid sheath
Phrenic ner
41. Thoracic duct
• Conveys lymph from entire body
back to blood
• Exception: right side of head &
neck, RUE, right lung & right side
of heart, and portion of liver
• Begins at cisterni chyli
• Enters post mediastinum
between azygous vein & thoracic
aorta
• Courses left into neck anterior to
vertebral vessels
• Enters junction of left subclavian
and IJV
42. Lymph nodes of neck
• Developed by Memorial Sloan-Kettering Cancer Center
• Ease and uniformity in describing regional nodal involvement
in cancer of the head and neck
43. Positions of neck nodes
1. Submental
2. Submandibular
3. Parotid / tonsilar
4. Preauricular
5. Postauricular
6. Occipital
7. Anterior cervical superficial
and deep
8. Supraclavicular
9. Posterior cervical
44. Level of LN
• Ia: submental triangle
• Ib: submandibular triangle
• II: Base of skull to bifurcation of
common carotid A
• III: Hyoid bone upto inferior
border of cricoid
• IV: inferior border of cricoid
cartilage to clavicle
• V: posterior traignle: below spinal
A N and transverse cervical
vessels
• VI: central compartment
• VII: mediastinal LN
45. The regional lymph node groups draining a specific
primary site as first echelon lymph nodes
47. Staging of neck
• Nx: regional lymph node cannot be assessed
• No: no regional lymph nodes
• N1: mets in single ipsilateral lymph node, 3 cm or smaller in
greatest dimension and ENE –
• N2:
1. N2a: metastasis in single ipsilateral node larger than 3 cm but
not larger than 6 cm In GD and ECE-
2. N2b: mets in multiple ipsilateral nodes, none larger than 6
cm in GD ENE –
3. N2c: mets in bil or contralateral LN, none larger than 6 cm in
GD
48. • N3:
1. N3a: mets in a lymph node larger than 6 cm in greatest
dimension and ENE –
2. N3b: mets in any nodes with clinically overt ENE +, ENCc
Midline nodes: ipsilateral nodes
ENCc: defined as invasion of skin, infiltration of musculature, dense tethering or
fixation to adjacent structures or cranial nerves, brachial plexus, sympathatic trunk,
phrenic nerve invasion with dysfunction
Designation of U & L category : positive nodes above the cricoid cartilage : U
positive nodes below the cricoid cartilage : L
49. Classifications of neck dissection
• Standardized until 1991
• Academy’s Committee for Head and Neck Surgery
and Oncology publicized standard classification
system
50. • Academy’s classification
Based on 4 concepts
1) RND is the standard basic procedure for cervical
lymphadenectomy against which all other modifications are
compared
2) Modifications of the RND which include preservation of any
non-lymphatic structures are referred to as modified radical
neck dissection (MRND)
51. • Academy’s classification
3) Any neck dissection that preserves one or more groups or
levels of lymph nodes is referred to as a selective neck
dissection (SND)
4) An extended neck dissection refers to the removal of
additional lymph node groups or non-lymphatic structures
relative to the RND
52. • Academy’s classification(1991)
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
3) Selective neck dissection (SND)
• Supra-omohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type
4) Extended radical neck dissection
53. • Medina classification (1989)
– Comprehensive neck dissection
• Radical neck dissection
• Modified radical neck dissection
– Type I (XI preserved)
– Type II (XI, IJV preserved)
– Type III (XI, IJV, and SCM preserved)
– Selective neck dissection
54. Spiro’s classification
– Radical (4 or 5 node levels resected)
• Conventional radical neck dissection
• Modified radical neck dissection
• Extended radical neck dissection
• Modified and extended radical neck dissection
– Selective (3 node levels resected)
• SOHND
• Jugular dissection (Levels II-IV)
• Any other 3 node levels resected
– Limited (no more than 2 node levels resected)
• Paratracheal node dissection
• Mediastinal node dissection
• Any other 1 or 2 node levels resected
55. • Indications:
1. Presence of clinically positive N1, N2a, N2b & N3 nodes
2. Extra nodal spread (including skin involvement)
3. Recurrence after RT treatment
4. Selective neck dissection in No neck where higher risk of
micrometastasis
56. • Contraindications:
1. Uncontrolled primary lesion
2. Involvement of internal / common carotid artery
3. Presence of distant metastasis.
4. Poor anaesthetic risk patient.
61. Basic needs of neck incisions
1.Good exposure of the neck and primary disease.
2. Ensure viability of the skin flaps. Avoid acute angles
3. Protect carotid artery even in the cases of wound infection.
4. Facilitate reconstruction Example, if pectoral muscle is used a
lower limb should be near the clavicle to enable flap
accommodation.
5. It should be cosmetically acceptable.
62. Criles incision
• ADVANTAGES:
• Easy to perform
• Maximum exposure to repair field
• DISADVANTAGES:
• Trifurcation point is prone for delayed healing
• Vertical limb of this incision overlies carotid
artery.compromised healing results in exposure of carotid
vessels
• Unsightly scar later forms contracture band
64. • Hyes Martin:
• Disadvantage:
• This flap most often gets
cyanosed.
• Flap necrosis and carotid
exposure is more in this
type of incision.
• Apron flaps:
• Advantages
– Carotid artery is well
protected
– Protects the descending
arterial recovery
• Disadvantages
– It will damage the ascending
arterial and venous recovery
– Venous congestion and
oedema might develop at the
bottom corner
66. Modified radical neck dissection
• Removes
– Nodal groups I-V
• Preserves
– SCM, IJV, XI (any combination)
– TYPE I MRND
• Indications
– Clinically obvious lymph node
metastases
– SAN not involved by tumor
–Intraoperative decision
–
Spinal acc N
67. Spinal ACC N
IJV
TYPE II MRND
Spinal Acc N
SCM
IJV
TYPE II MRND
Rarely planned
– Intraoperative tumor found adherent
to the SCM, but not IJV and SAN
Nodes not within muscular
aponeurosis or glandular capsule
(submandibular gland)
NO neck
( functional neck dissection)
68. Selective neck dissection
• Definition
– Cervical lymphadenectomy with preservation of one or more
lymph node groups
– Four common subtypes:
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection
69. • Also known as an elective neck dissection
• Rate of occult metastasis in clinically negative neck 20-30%
• Indication: primary lesion with 20% or greater risk of occult
metastasis
70. supraomohyoid
Most commonly performed SND
• Definition
– En bloc removal of cervical lymph node groups I-III
– Posterior limit is the cervical plexus and posterior border of the SCM
– Inferior limit is the omohyoid muscle overlying the IJV
• Oral cavity cancers with No
• T2-T3 No – if intraoperative suspicion of mets at level II – III then
level IV clearance: extended SOHND
71. B/L SOHND
• Anterior tongue
• Oral tongue and FOM that approach the midline
– SOHND + parotidectomy
• Cutaneous SCCA of the cheek
• Melanoma (Stage I – 1.5 to 4mm) of the cheek
72. SND lateral type
• Definition
– En bloc removal of the jugular lymph nodes including Levels II-
IV.
• Indications
N0 neck in carcinomas of the oropharynx, hypopharynx,
supraglottis, and larynx
73. SND posterolateral
Definition
– En bloc excision of lymph bearing tissues in Levels II-IV and
additional node groups – suboccipital and postauricular.
• Indications
– Cutaneous malignancies
• Melanoma
• Squamous cell carcinoma
• Merkel cell carcinoma
– Soft tissue sarcomas of the scalp and neck
74. SND anterior compartment
Definition
– En bloc removal of lymph structures in Level VI
• Perithyroidal nodes
• Pretracheal nodes
• Precricoid nodes (Delphian)
• Paratracheal nodes along recurrent nerves
– Limits of the dissection are the hyoid bone, suprasternal notch
and carotid sheaths
75. • Indications
– Selected cases of thyroid carcinoma
– Parathyroid carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma with subglottic extension
– CA of the cervical esophagus
76. Extended neck dissection
Definition
– Any previous dissection which includes removal of one or more
additional lymph node groups and/or non-lymphatic structures.
– Usually performed with N+ necks in MRND or RND when
metastases invade structures
77. • Indications
– Carotid artery invasion
– Other examples:
• Resection of the hypoglossal nerve resection or digastric muscle,
• dissection of mediastinal nodes and central compartment for
subglottic involvement, and
• removal of retropharyngeal lymph nodes for tumors originating in
the pharyngeal walls.
79. Intraoperative
• Inadvertent injury to local blood vessels and
nerves .
-marginal mandibular N.
- Spinal accessory N.
- Cervical plexus
- Brachial plexus
- Thoracic duct injury .
80. Immediate post op
• Haemorrhage: Needs evaluation of the extent of bleeding
and occasionally may need re-exploration.
• Lymph leak: When the drainage is of milky fluid and is
persistently high >100ml /day after 2days.A possibility of
lymph leak has to be considered.
81. • Carotid blow out: A dreaded complication that occurs
secondary to wound break down. If exposed the carotids have
to be covered using vascularised flaps.
• Facial oedema: A common occurrence usually settles down in
4-6 weeks.
82. Late complications
• Wound infection
• Fistulae
• Devitalisation of the reconstructed flap
DELAYED COMPLICATIONS
• Dysphagia ( CN V,IX, X, XI)
• Shoulder weakness
• Trismus