Reconstruction dr.shaji HEAD AND NECK RECONSTRUCTIONS

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

Life beyond cancer
Impact of major head and neck
surgery
Devastating morbidities
Cosmetic
Functional
Physical
Psychological
Nutritional
Quality of life

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Reconstructive surgeries
Aim : Restoration of form and function
Form: Esthetic
Restoration of contour
Expression of face
Oral competence
Functions:
Speech
Mastication
Deglutition

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Reconstructive ladder
Primary closure
Skin grafting
Local flaps
Regional flaps
Distant flaps
Free flaps

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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

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Primary Closure
Small and moderate defects of
– Skin
– Soft tissues
– Mucosa
Should not cause
– Restriction of movements
– Tension
– Cosmetic disfigurement

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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

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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.

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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.

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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

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Local Flaps
Advancement Flaps
Rotation Flaps
Transposition Flaps
Rhomboid flaps
Bilobed flaps

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Local flaps
Random –(skin or mucosal)
Rotation,Advancement,Transposition, Interposition & Interpolation
Axial pattern-
A distinct blood vessel is identifiable in the pedicle
Nasolabial,Forehead

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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.

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Regional Flaps
Flaps from adjoining areas
Nasolabial flaps
Forehead flaps
Cervical flaps
Submental flaps

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Nasolabial Flaps
Superiorly based
Alar defects of nose
Eye lid
Cheek
Inferiorly based
Lower lip
Oral commissure
Tongue
Floor of mouth
Other intraoral defects

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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

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.

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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.

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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

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Myocutaneous Flaps
• Commonest reconstructive option for major head and neck
defects
 Pect.major flaps
 Sternomastoid flaps
 Trapezius myocutaneous flaps
 Lat.dorsi flaps

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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.

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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.

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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.

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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

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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.

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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

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Free Flaps
Radial Forearm flap
Antero lateral Thigh flap
Free Fibula flap
Latissimus Dorsi flap
DCIA flap
TRAM flap
Others

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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

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Free fibula flap

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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

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

Reconstruction dr.shaji HEAD AND NECK RECONSTRUCTIONS

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