reconstructive microsurgery in head & neck defect based reconstruction.pptx

Reconstructive microsurgery in head & neck
Defect based reconstruction of mandible, oral cavity, pharynx and midface

1. Dr. Sudin Kayastha 2 nd Year Resident Bir Hospital, NAMS Reconstructive Microsurgery in Head and Neck Defect Based Reconstruction of Mandible, Oral Cavity, Pharynx & Mid face

2. Classification of Free flaps Cutaneous flaps : includes fascia, subcutaneous fat, and skin Myocutaneous flaps: muscle with cutaneous elements Osseocutaneous flaps: bone and cutaneous elements Myo -osseous flaps: combining muscle and bone

3. Perforator flap Consists of skin and/or subcutaneous tissue supplied by a perforating vessel that passes through or between the deep tissues, usually muscle Muscle perforator Septal perforator Muscle perforator flap Septal perforator flap

4. Perforator flap

5. Free Flaps in Head and Neck Reconstruction

6. Forearm Flaps Yang in 1983 to reconstruct neck defect due to burn scar Soutar et al in 1983 used for oral and mandibular reconstruction

7. Anatomy Based on Radial artery Venae comitantes / branches extending from skin to cephalic vein Consistent anatomy Proximal arm: deep to brachioradialis Distal arm: Between brachioradialis and flexor carpi radialis Vascular supply to skin by perforating vessels Forearm Flaps

8. Forearm Flaps

9. Osseocutaneous version of flap : with perforating vessels supply periosteum of distal radius Incorporate a sensory nerve- lateral ante branchial cutaneous nerve  sensate flap for oral reconstruction Skin island available: as large as entire volar surface of forearm Bone available: from pronator teres insertion to distal radius  10-12 cm max length Forearm Flaps

10. Advantages: Consistent anatomy Easy to learn and harvest reliably Thin skin  reconstruction of tongue and floor of mouth Sensate flap Simultaneous surgery Forearm Flaps Disadvantages: Volume of tissue Skin colour match Donor site need skin graft scar Wrist stiffness, cold sensitivity

11. Flap harvest in torniquet control Check for patent Ulnar artery Allen’s test Avoid injury to cutaneous branch of radial nerve Donor site: full/split skin thickness graft Risk of Radius #  no more than 1/3 rd of width of radius  curving osteotomy , avoid perpendicular cuts  prophylactic plating  avoid in elderly osteoporotic females Forearm Flaps

12. Applications: Oral cavity and oropharynx Thin subcutaneous layer, pliability, potential sensation  for oral reconstruction Mandibular reconstruction Osseocutaneous forearm flap: segmental mandibular defect Radius less than ideal  short vertical height  secondary prosthetic dental arch reconstruction difficult Secondary option if other bone flaps not available Forearm Flaps

13. Forearm Flaps

14. Buccal Mucosal Reconstruction Only cutaneous flap with appropriate thickness for buccal defects Palate Reconstruction For small defects of central palate and alveolus and mid face reconstruction Thinness of flap and long vascular pedicle  reach recipient neck vessels Oropharynx reconstruction Tonsil-Tongue base soft palate defects Flexibility of flap  Can contour 3D defects Forearm Flaps

15. Forearm Flaps External skin For small cutaneous defects of head and neck Limited amount of skin available Poor colour match to facial skin Lip Reconstruction Ability to replace entire aesthetic unit of upper and lower lip along with tendon sling (with PL or FCRL) Nasal Reconstruction Create lining and infrastructure of nose

16. Lateral Arm Flap Song et al in 1982 Anatomy Based on Radial collateral artery of arm Arise from deep brachial artery Runs with radial nerve in lateral aspect of upper arm Anterior and Posterior Branch Skin supplied by fasciocutaneous perforators from posterior branch

17. Divides into anterior and posterior branch Anterior branch continue inferiorly with radial nerve between brachialis and brachioradialis Posterior branch enter lateral intermuscular septum between brachialis and triceps and towards lateral epicondyle

18. Lateral Arm Flap Advantage Location Donor site: inconspicuous and can be closed primarily in most patients Good colour match Can be harvested as sensate flap Disadvantages: Wide flaps require skin graft for closure Fat  too much volume Pedicle  small calibre (1.5mm diameter, 4-8 cm in length

19. Lateral Arm Flap

20. Lateral Arm Flap Clinical Applications: Reconstruction of floor of mouth and lateral tongue Good colour match  recontouring radical parotidectomy defects or narrow defects of lateral face or neck

21. Scapular/ Parascapular Flaps Swartz et al and dos Santos Unique as no other single area provides such a variety of options for reconstruction Can provide skin, muscle and bone with 2-3 muscle flaps

22. Scapular/ Parascapular Flaps Anatomy Axillary artery  subscapular artery  Circumflex scapular (CSA)  Thoracodorsal (TDA) CSA Nutrient and periosteal supply to lateral border of scapula  2 perforating branches  skin over scapula  lies in space bounded by Teres major, Teres minor and triceps  parascapular perfortors and transverse scapular perforators TDA branch to serratus anterior & lattisimus dorsi  Angular artery distal 1/3 rd of scapula and overlying muscle Paired vene comitantes  join axillary vein

23. Scapular/ Parascapular Flaps Flaps available Cutaneous flaps  transverse scapular, parascapular , thoracodorsal artery perforator flap Myocutaneous flaps  Lattisimus dorsi flap, myogenous flap with serratus anterior, lattisimus dorsi and teres major muscles Osseous flap  scapular bone flap based on nutrient vessels from circumflex scapular artery, or scapular tip via angular artery

24. Scapular/ Parascapular Flaps

25. Scapular/ Parascapular Flaps Advantages : Available skin : 18 x 10-12 cm with primary closure of donor site Flexibility in positioning of skin island relative to bone segmen t Vascular anatomy consistent Good colour match with head and neck Vessels in scapular system spared in peripheral vascular disease  well tolerated in elderly Donor site  less morbidity

26. Scapular/ Parascapular Flaps Disadvantages: Patient positioning Bone of scapula difficult to harvest If teres major and subscapularis not repaired properly  problems with shoulder strength and range of motion post-operatively Pedicle  short (especially nutrient artery based osseous flap) Short Available bone  10-12 cm (not ideal for mandibular reconstruction) Skin  thick dermis and dense subcutaneous fat  inflexible (not good for floor of mouth, tongue and palate reconstruction)

27. Scapular/ Parascapular Flaps Clinical Applications: Cutaneous Flaps Defects of lateral face, neck, tempcoral region Facial recontouring in Romberg’s disease Defects in lateral neck Scalp reconstruction Osseocutaneous Flaps Mandibular defects  easy to osteotomize Midface and maxillary defects

28. FLAPS from Abdominal Wall and Pelvis

29. Rectus Abdominis & Deep inferior epigastric artery perforator flaps Can be harvested as a myocutaneous or perforator based flap Anatomy Based on deep inferior epigastric artery and its veins Arises from external iliac artery immediately below inguinal ligament Below umbilicus gives perforating to rectus abdominis and overlying skin Pedicle length : 8-14cm , Vessel calibre : 2-3mm Sensation from lower six to seven spinal thoracic nerves

30. Rectus Abdominis & Deep inferior epigastric artery perforator flaps Advantages: Consistent anatomy Versatility transfer skin/muscle flap, perforator based skin flap, myogenous flap Large areas of skin available  amenable to primary closure Aesthetic benefit of abdominal lipectomy Two-team procedure Disadvantages: Central Abdominal hernia Poor colour match In obese pts, volume of subcutaneous fat may be inappropriate

31. Rectus Abdominis & Deep inferior epigastric artery perforator flaps Clinical Applications Large volume reconstructions of oral cavity, oropharynx , or lateral skull base Total glossectomy defects Extensive facial and neck defects or lateral defects

32. Rectus Abdominis & Deep inferior epigastric artery perforator flaps

33. Deep Circumflex Iliac Artery flaps Taylor 1982 Osseomyocutaneous , myo -osseous or osseous flap Commonly harvested version of flap incorporates internal oblique Anatomy: Based on deep circumflex iliac artery and its venae comitantes Arises from external iliac artery just above inguinal ligament Bone harvested 12-14 cm vascular pedicle 6-8 cm in greatest length Calibre of artery and vein 2-3 mm

34. Deep Circumflex Iliac Artery flaps

35. Deep Circumflex Iliac Artery flaps Advantages: Ideal for reconstruction of mandible Can be shaped to recreate both mandibular body and vertical ramus Bone stock excellent  corticocancellous proportion and vertical height and breadth Suitable for primary or secondary osseointegration

36. Disadvantages: Unreliable skin island as perforator pass thru 3 layers of muscles Hernia formation or chronic laxity of lower abdominal wall Numbness of lateral thigh if lateral cutaneous nerve of thigh is injured Donor site is painful if entire iliac crest is harvested Pedicle length unsuitable for maxillary reconstruction Difficult to harvest; difficult positioning during surgery Deep Circumflex Iliac Artery flaps

37. Clinical Applications: Defects of mandible and maxilla Myo osseous flap with internal oblique  oral cavity defect Hard palate reconstruction Deep Circumflex Iliac Artery flaps

38. Anterolateral thigh flaps Song et al 1984 Koshima et al 1989 Is a fasciocutaneous flap based on musculocutaneous and septocutaneous perforators of descending branch of lateral circumflex femoral artery and its veins Popular in oral cavity reconstruction in asian population Length of pedicle : 8cm to 16 cm

39. Anterolateral thigh flaps Advantages: Two team harvest Limited donor site morbidity, can be closed primarily Large skin islands 15-20cm x 10 cm can be harvested May be harvested as perforator flap with or without fascia or incorporate vastus lateralis if required In pt with appropriate body habitus , flap is thin and pliable  oral tongue and floor of mouth reconstruction

40. Anterolateral thigh flaps Disadvantages: Poor skin colour match to face and neck Anatomy is variable Small calibre of vessel  Proximal venous occlusion  difficult to salvage Small size of perforating vessels  poor choice for tunnelling of pedicle Thick fat volume and bulk of flap  poor functional outcome

41. Anterolateral thigh flaps Clinical Applications: Variety of defects in head and neck as radial forearm flap Can be tubed to reconstruct total pharyngectomy defect

42. Free Osseocutaneous fibular flaps Taylor for tibial pseudoarthrosis Hidalgo and Rekow for mandibular reconstruction Anatomy Based on peroneal artery and vein Branch of tibioperoneal trunk Lies on medial aspect of fibula between tibialis posterior and flexor hallucis longus Gives perforating branches to surrounding muscle and nutrient and periosteal supply to fibula

43. Free Osseocutaneous fibular flaps

44. Free Osseocutaneous fibular flaps

45. Free Osseocutaneous fibular flaps Skin available : surface of lateral aspect of lower leg 12-16cm x 8-10 cm available Length of bone available: 18-24 cm Pedicle length depends on amount of bone required (longer bone length= shorter pedicle) Vessel diameter 3-4 mm for artery and 4-5 mm for vein

46. Free Osseocutaneous fibular flaps Advantages: Ideal transfer for majority of defects of oral cavity and mandible Bone length available can reconstruct entire mandible Skin island  appropriate thickness for most oral cavity and oropharyngeal reconstructions Disadvantages: Not good option in established peripheral vascular disease Delayed healing of skin graft site in venous insuffiency cases Ankle and leg stiffness Flexion deformity of great toe if large cuff of flexor hallucis harvested

47. Free Osseocutaneous fibular flaps Clinical Applications Oromandibular reconstruction  bone flap short in vertical height  double barrelling can be done Maxillary reconstruction reconstructing central maxilary defects

48. Free Osseocutaneous fibular flaps

49. Enteric Reconstructions

50. Free Jejunal Transfer Seidenberg and Hurwitt in 1958 Used for conduit reconstruction of pharynx Anatomy 2/5 th of 7 meter long small bowel Blood supply from 5 branches from superior mesenteeric artery Vessels run parallel to each other between mesenteric layers Each vessel branches into two to form arcade 10-20 cm of jejunum can be harvested Pedicle length of 8-10 cm Artery 1.5-2.5 mm in diameter Vein extremely thin

51. Free Jejunal Transfer Flap harvested with a mini laparotomy or endoscopically Harvest more length than needed Segment of mesentery is available to place through the skin incision as an external monitor Must be placed in isoperistaltic position Must be stretched to fit the defect  once revascularized length increases

52. Free Jejunal Transfer Advantages: Mucosal lined conduit  ideal for total pharyngectomy defect Adequate length Has peristaltic wave, unidirectional- assist in swallowing Disadvantages: Flap dosesnot tolerate long periods of ischemia Must be oriented in appropriate direction May go into spasm with hot and cold liquids  swallowing adequate but slow Secondary tracheo-oesophageal speech is patulous and wet

53. Free Jejunal Transfer Clinical Applications Total pharyngectomy defects Oropharyngeal reconstruction especially in radiation failure patients with xerostomia (secretions are tenacious and foul smelling )

54. Free Gastro- omental flap Baudet et al in 1978 Used for oral cavity and conduit reconstruction of total laryngopharyngectomy defects Anatomy: Greater curvature of stomach and omentum supplied by right and left gastroepiploic artery ; terminal branches of gastroduodenal and splenic artery Form gastroepiploic arterial acrh Right gastroepiploic artery is the dominant supply

55. Free Gastro- omental flap

56. Free Gastro- omental flap Flap harvested by a mini laparotomy incision A large segment of greater omentum is harvested  can be reduced in volume after insetting Stomach tube is created by placing gastrotomy at least 2-3 cm proximal to pylorus

57. Free Gastro- omental flap

58. Free Gastro- omental flap Clinical Applications Conduit reconstruction following laryngopharyngectomy Large segment of greater omentum  reduce risk of perioperative complications in chemoradiation failure patients

59. Defect Based Reconstruction

60. Defect Based Reconstruction of Mandible & Oral Cavity Important functionally and cosmetically Facial appearance Mastication Speech Swallowing Support to tongue Maintenance of airway

61. Defect Based Reconstruction of Mandible & Oral Cavity Mandibular resections : Segmental Whole height of mandible Mandibular discontinuity Lateral : posterior to mental foramen  deviation of mandible to resected side Anterior : anterior to mental foramen  functional problem and Andy Gump deformity Marginal Only alveolar bone resected Need dental rehabilitation  dental implants

62. ANDY GUMP DEFORMITY

63. Defect Based Reconstruction of Mandible & Oral Cavity Classification of mandibular defects : Urken Classification H – lateral defect of any length including condyle L – as above but condyle not included C – entire central segment from canine to canine Eg : defect from angle of mandible to angle of mandible  LCL Boyd’s Classification Soft tissue defect: o  neither skin, or mucosa affected s  skin affected m mucosa affected Eg : all through and through defect  sm

64. Defect Based Reconstruction of Mandible & Oral Cavity Cosmetic deformity and functional loss after resection depends on size and location of segmental defects More anterior the defect greater the deformity and loss of functions Posterior defect better tolerated but malocclusion in dentate patients

65. Defect Based Reconstruction of Mandible & Oral Cavity

66. Defect Based Reconstruction of Mandible & Oral Cavity Alloplastic materials used: Mandibular plate must be biocompatible and able to withstand forces sustained by mandible in mastication Medical polymers Ceramics Metal alloys : vitallium , stainless steel THORP (titanium hollow osseointegrated reconstruction plate): able to withstand masticatory force and rare plate #

67. Defect Based Reconstruction of Mandible & Oral Cavity

68. Defect Based Reconstruction of Mandible & Oral Cavity Comparisons of bony flaps

69. Defect Based Reconstruction of Mandible & Oral Cavity Absolute indications for free vascularized bone transfer: (Chen et al. ) Osteoradionecrosis of mandible or an irradiated tissue bed Hemimandibular reconstruction with free end in glenoid fossa Long segmental defects Inadequate skin or mucosa to reconstruct soft tissue defects Failure of reconstruction by other modes Near total mandibular reconstruction

70. Defect Based Reconstruction of Mandible & Oral Cavity Distraction Osteogenesis : Growing new bone by distraction (stretching) of preexisting bone Used by Ilizarov for patients with limb defects Distraction devices can be extra oral or intra oral Advantages: better for dental prosthesis and implants -  better bone quality, quantity and ability to produce normal mucosa Disadvantages : time consuming, occlusal disturbance

71. Defect Based Reconstruction of Mandible & Oral Cavity

72. Defect Based Reconstruction of Mandible & Oral Cavity 4 main stages: Osteotomy Latency  primitive callus formation Distraction  callus stretched at arate of 1 mm per day (0.25mm of 4 movements per day) Consolidation: new bone stabilized for up to 4 weeks

73. Defect Based Reconstruction of Mandible & Oral Cavity Dental Implants: Complete rehabilitation after mandibular resection  mandibular continuity with dentoalveolar structures recontructed Osseointegration is incorporation of metal into living bone Bone able to remodel under loading of implant Implants coated with titanium oxide

74. Defect Based Reconstruction of Midface Resecting the maxilla result in loss of support for orbit, facial skin, dentition Adequate obturation or reconstruction essential to avoid facial collapse, ectropion , enopthalmos , loss of dentition and nasal collapse

75. Defect Based Reconstruction of Midface Classification of Maxillectomy defect:

76. Defect Based Reconstruction of Midface Classification of Maxillectomy defect: 2 3 4

77. Defect Based Reconstruction of Midface Reconstruction techniques: Local flaps: palatal or buccal fat pad Pedicled flaps: facial artery myomucosal submental island temporalis temporoparietal greater palatine island 3. Free tissue transfer

78. Defect Based Reconstruction of Midface

79. Defect Based Reconstruction of Midface

80. Defect Based Reconstruction: Pharynx Goal of reconstruction: to restore a patent pharyngeal conduit that permits speech and swallowing 2ndry goals: prevent complications like Pharyngocutaneous fistula, Pharyngeal stricture, minimize systemic and donor morbidity

81. Defect Based Reconstruction: Pharynx

82. Defect Based Reconstruction: Pharynx Techniques of reconstruction of pharynx: Cervical skin flaps for staged reconstruction with Tracheostome , pharyngostome , and oesophagostome Transposed viscera for pharyngo-oesophageal reconstruction  pedicled jejunum, colonic transfer, gastric tube, reverse gastric tube Gastric transposition  gastric pull up Pedicle and axial flap reconstruction  deltopectoral flap, Internal mammary artery perforator flap, pectoralis major flap, tubing of the flap Enteric free flap reconstruction jejunal free flap, gastro- omental free flap Fasciocutaneous free flaps: Tubed Radial forearm free flap, Anterolateral thigh free flap

83. Defect Based Reconstruction: Pharynx Cervical skin flaps for staged reconstruction with Tracheostome , pharyngostome , and oesophagostome

84. Defect Based Reconstruction: Pharynx Gastric transposition  gastric pull up

85. Defect Based Reconstruction: Pharynx Pedicle and axial flap reconstruction  deltopectoral flap, Internal mammary artery perforator flap, pectoralis major flap, tubing of the flap

86. Defect Based Reconstruction: Pharynx Enteric free flap reconstruction jejunal free flap, gastro- omental free flap

87. Defect Based Reconstruction: Pharynx Fasciocutaneous free flaps: Tubed Radial forearm free flap, Anterolateral thigh free flap

88. Defect Based Reconstruction: Pharynx

89. Defect Based Reconstruction: Pharynx

90. References Scott-Brown’s Otorhinolaryngology Head and Neck Surgery, 8 th edition Stell & Maran’s Textbook of Head and Neck Surgery and Oncology, 5 th Edition Sataloff’s Comprehensive Textbook of Otolaryngology Head and Neck Surgery, 2016

91. THANK YOU