Reconstruction of head and neck defects –options portblair.pptx

This ppt is about reconstruction of head and neck cancers in the field of ENT.
This protocol is used along Whole south India.
Welcome you all the see this ppt

1. Reconstruction of head and neck defects –options and challenges Naveen hedne Chandrasekhar Ms , MCh Senior consultant and lead head and neck surgery Apollo cancer center chennai

2. Limitations –reconstructive surgeon

3. Break up History Application of reconstruction----oncological /non oncological Reconstruction options Available options Planning -Choosing the options Problems and challenges Way ahead

4. History The first pedicled flap-- Susruta in 800 BC -- forehead flap McGregor in 1963 popularized -turning point in reconstructive surgery---first ever reliable transposition flap 1979-Ariyan –pectoralis major myocutaneous flap ---- pectoral branch –thoraco acromial artery --- work horse Microvascular surgery - 1970s Daniel and Taylor-first cutaneous free flap in 1973 Free flap - reconstruction = gained popularity = standard of care for large head & neck defects

5. Need for reconstruction Ablative oncological surgery Benign tumors Traumatic defects Corrosive strictures Infections – co vid pandemic –fungal infections/ necrotizing fasciitis Non vital organ transplants -larynx, face, parathyroid

6. principles Provide lining Restore bone continuity Continuity of alimentary tract Prevent salivary leak Cover major blood vessels cosmesis

7. Sites Oral cavity Paranasal sinuses /orbit, and anterior skull base Laryngopharynx Trachea Scalp/ facial/Cutaneous defects Ear and lateral skull base Maxillo facial prosthetic and dental rehabilitation

8. Reconstruction ladder to ELEVATOR Reconstructive ladder – reconstruction elevator Primary closure - skin grafting -- local flaps regional/ free flaps

9. Principles Upper aero digestive tract ,head and neck - complex anatomy--critical structure--special senses Reconstruction involves restoration of both form and function Requires replacement of composite tissue like skin, bone and mucosa Reconstruction must aim at early healing for commencement of adjuvant therapy Minimize donor site morbidity Replace Like with like

10. Principles What is excisable is re constructible Replace like with like Patient consideration- age , comorbidities , prior treatment Defect and disease considerations Donor site Availability of recipient vessels Resource and surgeon consideration

11. algorithm

12. Free flaps vs regional flaps/local flaps Free flaps –versatility, robustness expertise / longer operative time Flap selection –complex-pros /cons

13. Options available Primary closure Skin graft- Split thickness skin graft/ full thickness skin graft Local flaps Regional flaps Free flaps-micro vascular tissue transfer Osseo integrated implant –prosthetic rehabilitation Tissue culture Non vital organ transplant

14. Classification of flaps Vascularity--- random /pedicled Composition--- cutaneous /myocutaneous/ osteo cutaneous Type of transfer-rotation / transposition / advancement / inter polated, free tissue transfer

15. Local flaps Flap harvested from adjacent area Reliable –extensive vascularity in head and neck Safe and predictable Simple and easy to harvest by primary surgeon Lesser operative time Tissue match- color and texture

16. Problems Limited availability – size –smaller Defects Oncological safety Neck status and surgery Facial scar

17. Local flaps in head and neck Rhomboid flap Bilobed flap Buccal fat pad Fore head flap Paramedian fore head flap Naso labial –islanded vs conventional FAMMF Buccal fat pad Palatal rotation Submental flap Platysmal flap INRAHYOID FLAP

18. Buccal fat pad

19. BCC excision and V Y Advancement flap

20. Famm flap

21. FAMM flap

22. Famm flap Mucosal lining Limited tissue IFAMM

23. Islanded Nasolabial flap for tongue reconstruction Good pliable tissue Reliable Can be tunneled under mandible Ontologically safe Easy to harvest Donor site –minimal morbidity FACIAL SCAR

24. OSMF Release + Bilateral islanded nasolabial flap

25. Islanded Nasolabial flap for lip reconstruction

26. post co vid fungal defect

27. Good pliable skin Limited amount of tissue Reach Good for pharyngeal defects Unreliable if prior neck dissection

28. Submental flap Oncological concerns Male –beard Reliable

29. Submental flap

30. Pre-op Post-op

31. Left extended maxillectomy + Reconstruction with prolene mesh + Temporalis flap + submental flap + Zygomatic basal implants + selective neck dissection ( I, II) + PEG tube insertion Post excision defect Dental impression for prosthesis

32. Infrahyoid flap

33. Infrahyoid flap + nasolabial flap Limited tissue Reach Bad scar

34. Temporalis flap

35. Forehead flap

36. Paramedian forehead + temporoparietal flap

37. Regional flaps Harvested from area near the defect site – islanded - intact blood supply- rotated into defect Good amount of skin and soft tissue Reasonably -reliable Reach is limited Lack of bone 1Pectoralis major myocutaneous flap 2Latissimus dorsi flap 3Trapezius flap 4Deltopectoral flap

38. PMMC Work horse in head and reconstruction Paradigm shift in H & N oncological surgery Reliable Easy to harvest Limitation- limited reach , bulky in women, Distortion of breast

39. pmmc

40. Follicular ca thyroid Sternectomy –mesh +bone cement+PMMF

41. TOTAL LARYNGECTOMY +PP+SLIVARY BYPASS TUBE+PATCH PHARYNGOPLASTY

42. Intra-op

43. post-op

44. Scalp reconstruction

45. Commonly used free flaps Radial artery free flap Lateral arm flap Anterolateral thigh flap Rectus abdomens flap Parascapular flap Free fibula flap DCIA flap Scapular flap

46. RAFF Thin pliable skin, good for lining defects Long pedicle Limited soft tissue and thin bone Donor site -graft

47. RAFF

48. Floor of mouth – Post op Free Radial forearm flap + implant supported over denture

49. Lateral arm flap Relatively thick skin Primary closure-hidden scar Short pedicle length

50. Medial Sural artery flap

51. Peroneal artery perforator flap

52. Secretory surface

53. ALT LARGE amount of skin and soft tissue-composite defects Good pedicle length Primary closure Hidden scar Lack of bone Variable anatomy

54. ALT

55. Laryngeal suspension for total glossectomy

56. CHIMERIC ALT+ RECON plate ?double flAP

57. Buccal cancer-compartmental resection Disease extent Terminal branches of ECA Facial nerve

58. Compartmental resection specimen

59. Reconstruction ALT free flap

60. Double flaps

61. Free fibula Upto 22 cms thick cortical bone Can be ostetomised –periosteal blood supply Good Skin paddle Good for dental implant skin paddle limited mobility Donor site

62. OPG

63. Dental rehabilitation

64. dental rehabilitation

65. DCIA Flap Thick Cancellous bone- healing better Osteotomies easier/less needed Short pedicle Donor site morbidity

66. Circumferential Pharyngeal reconstruction Jejunal flap Tubed ALT

67. ACC INFRATEMPORAL FOSSA ICA –MCA BYPASS after tumor resection

68. POST TRACHEAL RESECTION AND ANASTAMOSIS Tracheal Anastamosis Post Tracheal resection

69. Flap failure

70. Force