head and neck reconstruction surgery

The ulnar forearm flap drains via a deep or superficial venous system. Reconstructing the injury acutely minimizes the cascade of scar formation associated with the initial injury and confines the deleterious effects to a single period of postoperative wound contracture. The boundaries of the defect will often spare adjacent structures and preserved tissue of the tongue will retain partial function, at which point a thin and smaller flap is optimal because it is less likely to impede an already functioning tongue. The disadvantage of non-vascularized bone grafts includes unpredictable resorption rates and the inability to replace large structural defects. Tap for more info…. The anterior branch follows the course of the basilic vein distal to the elbow and innervates the medial half of the anterior forearm. SURGERY RESULTING FROM CANCER TREATMENT IS KNOWN AS HEAD AND NECK CANCER RECONSTRUCTION. The flap is designed with its central axis along the course of the ulnar artery in the mid- and distal forearm. 2018 Dec;34(6):597-604. doi: 10.1055/s-0038-1676076. Microvascular head and neck reconstruction is used to treat head and neck cancers, including those of the larynx and pharynx, oral cavity, salivary glands, jaws, calvarium, sinuses, tongue and skin. When facing a large composite facial defect in which both bone and soft tissue are missing, selecting a flap consisting of abundant soft tissue rather than both bone and soft tissue is not recommended. The forehead can be further divided into aesthetic subunits: central, paramedian, and lateral. Determining time to intervention is on an individualized basis because of multiple factors and comorbidity issues to contemplate. Also, harvesting fascia or chimeric flaps incorporating fascia or excess soft tissue can aid in protecting adjacent defects from fistula formation or excess. https://www.headandnecksurgery.london/patient-information/reconstruction The inset of the flap may require increasing the anterior mediastinal space that can be accomplished with partial manubrial excision, extending the diaphragmatic esophageal hiatus, and tunneling a pliable, soft dilating catheter from the stomach to the mediastinum. The concept of considering the tissue types and establishing their continuity or obliterating an apparent discontinuity is particularly important when some form of “lining” tissue (e.g., conjunctiva, nasal mucosa, sinus mucosa, or oral mucosa) is deficient. As with all types of reconstructive surgery, the goal of head and neck reconstruction is to restore and/or maximize patients’ function and appearance. The need for dental rehabilitation as well as the high complication rate associated with long-term use of hardware has made vascularized bone an ideal choice for mandibular reconstruction. With a professional background in both Head and Neck Oncology and Microvascular Reconstructive Surgery and Oral & Maxillofacial Surgery, Dr. Eftekhari is uniquely trained and is an expert in treating disorders and cancers of the head and neck region. The central subunit is bordered by the medial eyebrows and extends vertically from the glabella to the frontal hairline. The deep system is comprised of two venae comitantes accompanying the ulnar artery along its course through the intermuscular septum and drain into the median cubital vein at the level of the elbow. Reluctance to utilize the ulnar forearm flap, out of concern for compromising hand perfusion, still pervades the microsurgical community. The ulnar artery runs adjacent to the ulnar nerve and often courses deep to the nerve. Big improvements in head and neck cancer surgery have been made since the development and evolution of Microvascular reconstructive surgery. Microvascular Reconstruction Surgery. The perception of facial aesthetic subunit is actually dependent on multiple elements, representing an amalgam of interactions between composite soft and hard tissue. The fibula free flap is an excellent choice with adequate length and thickness. There is often an impetus to minimize the number of reconstructive procedures a patient requires. The field of head and neck surgery has gone through numerous changes in the past two decades. Head and neck reconstruction cannot be described in the 21st century without including free tissue transfer as an integral component in the current standard of care for various traumatic, oncologic, and congenital defects of the head and neck region. The fellow will be exposed to surgical pathology, maxillofacial prosthetics, and speech rehabilitation. Furthermore, a subset of patients may require a second reconstruction due to complications of the initial reconstruction requiring microsurgical free tissue transfer. Therefore, a “defect-oriented approach,” in which a soft tissue-only flap is used to solve the immediate goal of wound closure will often result in suboptimal cosmesis. The deformities of the head or neck are often the result of trauma, oncologic resection, infection, osteoradionecrosis, and congenital or developmental pathology. The periorbital region is composed of the superior, lateral, and inferior orbit and anteromedial portion of the temporal region. The ulnar forearm flap can be utilized in small, soft tissue midface defects, periorbital contracture or missing tissue ( Fig. Flaps with excess bulk and length facilitate contact between the palate and tongue owing to improved long-term outcomes in deglutition and speech. Current recommendations suggest free flap coverage is indicated for forehead defects >50 cm 2 . (A) Wound covered with silver-coated dressing with preoperative markings showing extension of the wound boundary. We are proud to offer a comprehensive and multi-disciplinary program in Head & Neck Surgery — Reconstruction Surgery. As with the radial forearm flap, the ulnar flap provides a thin, pliable skin paddle with lengthy vascular pedicle of relatively large caliber. The ulnar artery courses ulnar and deep to the pronator teres, flexor carpi radialis, and flexor digitorum superficialis running along the flexor digitorum profundus. The basilic vein is traced using the Doppler probe as well. Vascularized bone is the preferred choice when defects of the midface require free tissue transfer (such as a free fibula flap). If postoperative radiation therapy is anticipated, the excess volume should be further increased, since significant soft tissue contraction can result from radiation exposure. This can be as simple as closing a cut on the head to a major surgery after a car accident. The medial antebrachial cutaneous nerve travels with the basilic vein in the upper arm, exits the deep fascia above the elbow, and divides into anterior and posterior branches. The ulnar forearm flap surpasses the radial flap both in cosmetic outcomes of the donor and recipient sites. As a result, microsurgeons attempt single-stage procedures aimed at definitive reconstruction. The goals of midface reconstruction are to preserve projection of the midface and to restore the skeletal buttresses. The head and neck reconstruction is the procedure for cases of head and neck tumor, a task that involves many disciplines and where Reconstructive Surgery plays a crucial role in the restoration of appearance and functionality. 7 patients underwent TMJ reconstruction with custom made prosthesis and received either pre or post operative radiotherapy. The donor site is also better concealed along the ulnar aspect of the forearm, especially in repose as it sits along the body and out of sight during face-to-face interaction. However, anatomic variations in the origin of the ulnar artery do exist. Free jejunum and ileocolon flaps ( Figs 14.2 , 14.3 ) are able to restore voice with excellent long-term patency while simultaneously serving as conduits in esophageal reconstruction. Patient-specific needs must be considered in the risk–benefit analysis of selecting a flap, especially in the elderly, with respect to donor site morbidity, those with physical disabilities, and in the actively growing young person. The superficial temporal artery is commonly used for anastomosis due to its predictable location, ease of access, and adequate diameter and length, but other vessels can be used. Adequate soft tissue and bone can often be incorporated in the same free flap; however, multiple flaps may sometimes be required to provide sufficient quantities of both types of tissue. However, the advantages of the ulnar flap are its similar skin composition of facial components and relative soft tissue paucity that can act as a “double-edged sword,” in scenarios where more soft tissue is necessary. The technique of puncture and valve placement can be employed in the native esophagus or the neoesophagus. Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. Various options are available for head and neck reconstructions and has to select the appropriate one … Management of head and neck cancer has undergone many significant changes during the past two decades. Patel, Hackman, and Blumberg, provide state of the art reconstruction for traumatic and oncologic defects from … Continued The advantages of the jejunal free flap include its durability, sufficient quantity, and limited effect on physiologic effect of gastrointestinal function. Alter­natively, if bulk and a short pedicle are needed, the groin flap may be used. Head and Neck Reconstruction SURGERY RESULTING FROM CANCER TREATMENT IS KNOWN AS HEAD AND NECK CANCER RECONSTRUCTION. Our program brings together experts in reconstructive surgery, speech and swallowing therapy, nutrition, oral surgery, and prosthodontics, to help maximize your quality of life before, during, and after treatment. Defects >5 cm are best reconstructed with free tissue, whereas smaller defects may be reconstructed with bone grafts or hardware in select cases. These concepts are: Establishment of a skeletal buttress framework, Local revisions through multi-stage planning. In the midface, is it critical to assess which tissue types are missing and to reconstruct them accordingly. Ultimately, the specific defect and its components must guide reconstruction. This may be due to small anatomy and local ischemic effects or a discrepancy in the rate of anatomic growth in the growing infant/child, but to date, there is a lack of consensus regarding optimal conduit selection in all ages. PEDICLED FLAPS IN HEAD AND NECK SURGERY Dr . For example, consider a cheek defect comprising 40% of the aesthetic unit being reconstructed with a free ALT flap. Multiple tissue types that compose the craniofacial region including bone, cartilage, nerve, fat, muscle, mucosa, and varying dermal and epidermal thickness, as well the inherently intricate contours of the craniofacial skeleton can complicate reconstruction. Second, the dogmatic principles of aesthetic subunit reconstruction dictate that certain defects can be made larger in order to resurface the entire unit. Postburn Head and Neck Reconstruction: An Algorithmic Approach. However, strict adherence to several critical principles specific to the demands of craniofacial surgery is paramount to addressing complex injury or deformity of the head and neck. However, multiple studies have failed to demonstrate any significant long-term motor, sensory, or vascular impairments following ulnar forearm flap harvest. Ambitious single-stage procedures do not capture all of the tools in the plastic surgeon’s armamentarium in solving large craniofacial defects. The tissue that is most common moved during this procedure is from the arms, legs, back, and can come from the skin, bone, fat, and or muscle. Coronavirus update: we are still able to provide private curative treatment. This iatrogenic fistula is subject to reflux of esophageal content, secretions, and subject to aspiration and stricture. This article gives an overview of the major areas in the head and neck, highlighting current practice and more recent trends in reconstruction choices. Understanding the Surgery Because the lips, mouth, tongue, throat, and voice box are so vital for normal everyday function and appearance, proper reconstruction is critical. In order to reconstruct this complex defects great skill is required as well as … The subtleties of facial anatomy contribute to individual identity, and although phenotypic differences are recognized among ethnicity, sex, and various individuals, there is an overarching commonality of features that permeates a sense of normal . We are proud to offer a comprehensive and multi-disciplinary program in Head & Neck Surgery — Reconstruction Surgery. Small defects involve less than one-quarter of tongue segment, which are amenable to secondary intention healing, primary closure, skin grafts, or local flaps. Integration of the aforementioned concepts is crucial in replacing missing tissue, maximizing craniofacial function, and optimizing aesthetic results. In pediatric esophageal replacement, a meta-analysis found that stricture rates were higher in jejunal free flaps compared with colonic and gastric conduits. Apply. Vascularized fat can be used to provide soft tissue bulk and minimize atrophy. The maximum skin paddle size measures approximately 15 × 10 cm, similar to the area of the radial forearm skin paddle. Charge: The fundamental purpose of the AHNS Reconstructive Head and Neck Surgery Section is to improve and enhance care for patients in the field of head and neck reconstructive surgery through the pillars of education, research and mentorship while focusing on both quality and value of patient care. Understanding the Surgery Because the lips, mouth, tongue, throat, and voice box are so vital for normal everyday function and appearance, proper reconstruction is critical. Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. Latissimus dorsi flap 3. Rama raju 2. 2018 Dec;34(6):597-604. doi: 10.1055/s-0038-1676076. Prior to the adoption of clinical microsurgery, the traditional tongue reconstruction following total or subtotal glossectomy was pectoralis or trapezius pedicled flaps, primarily to achieve wound closure. Vascularized bone obviates many of the unforeseen complications that are associated with non-vascularized bone grafts and alloplastic materials, and therefore should be used for hard tissue reconstruction whenever possible. However, indications for free tissue transfer to the craniofacial region must broadly be considered from an anatomic, functional, and aesthetic perspective, all while considering alternative options. Aesthetic outcomes are largely dependent on the underlying skeletal structure of the region. For example, re-creation of the vermillion lip is challenging, since no autologous free flap options exist to re-create a satisfactory semblance of the subunit. Surgery endeavours to mitigate problems related to cancer resection. The ulnar forearm skin is usually less hirsute than the radial skin, allowing the surgeon to circumvent transfer of dense hair-bearing tissue to reconstruct a defect in a non–hair-bearing region. Options for reconstructive approaches may seem vast at times, but a means of providing an optimal relationship of hard and soft tissue, similar to the premorbid state, should drive the decision-making process. However, a split-thickness skin graft may be used. The Head and Neck-Reconstructive Surgery NSQIP provides a robust, specialty specific platform for data collection in patients undergoing head and neck surgery with flap reconstruction. This allows wounds to heal and reduces the impact on appearance, speech, eating and swallowing. Over time, advancements in technique and instrumentation have precluded the surgeon from simply trying to reconstruct a defect by “filling a hole,” and have permitted restoration of entire aesthetic subunits, even when removing healthy tissue may be required. COVID‐19 pandemic: Effects and evidence‐based recommendations for otolaryngology and head and neck surgery practice. However, this is often difficult to achieve because the face can be divided into discrete aesthetic subunits based on variations in skin texture, color, thickness, and histology. Once identified, vessel replantation may require supermicrosurgery. Any time the skin, muscle, bone or organs of the head and neck need to be repaired this is called “head and neck reconstruction”. This can be as simple as closing a cut on the head to a major surgery after a car accident. Author information: (1)Department of Plastic Surgery, University of Nebraska Medical Center, … Ileal-ileocecal valve for voice reconstruction. Historically, replantation of composite nasal tissue defects following traumatic amputation (often a dog bite or a form punishment) have resulted in a high failure rate or led to deforming contracture and nasal passage stenosis. As with all reconstructive procedures, meticulous assessment of wounds and careful reconstructive planning are essential to achieving successful outcomes. In addition, bone (preferably vascularized) is necessary for bone-anchored prosthetic rehabilitation either immediately or in a delayed fashion. These intricate surgeries enable both cosmetic repair and enable restoration of speech, swallowing and other important functioning. One of our practice team will be in touch with you as soon as possible. Ensuring ample tissue may be a challenge in the pediatric patient, especially when considering free tissue transfer to the pediatric craniofacial region. Tailoring the ear flap to a specific aesthetic subunit is ideal, but some defects may be too large, requiring a larger volume of tissue such as the radial forearm flap; prelaminated radial forearm flap; dorsalis pedis flap; composite rib; serratus, latissimus, and skin island flap; and others. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. Furthermore, reconstructions should be predicated on re-creation of the defect, especially in cases of delayed reconstruction where scarring and contracture may have obscured the initial defect, making it more difficult to appreciate a lining deficiency. The weaker, horizontal buttresses are comprised of the superior and inferior orbital rims and the alveolar ridge. Moreover, interpersonal communication and recognition of social cues are all delivered and interpreted via facial contour and movement. Cleveland Clinic's craniofacial surgery for adults includes restoration or reconstruction of the head and neck area. The most commonly used replacement organ for the esophagus is the stomach, either completely intact or tabularized, depending on the extent of esophageal excision and gastric involvement. With the understanding that secondary revisions are often inevitable in optimizing complex defects, the initial reconstructive procedure no longer assumes the burden of complete reconstruction but is the first of multiple approaches. Illustration of a raised ulnar flap with anatomy depicted, and depicting a proximally based flap. Including excess soft tissue affords the surgeon insurance of coverage in the event of excessive contracture or atrophy. He also treats cancer of the face and neck. This allows for incisions to be hidden in skin creases and behind or within specific structures. Despite optimal flap selection, the function and mobility of the tongue are dependent on re-creating the form of the tongue. Blood supply is based on the ulnar artery and its venae comitantes, but the basilic vein can be utilized for venous outflow. At this juncture, skin excision from the free flap with full-thickness skin grafting from a donor site similar in color and texture to the facial subunit, remains an option. Pioneered by Mario González-Ulloa, these concepts permeate throughout multiple facets of plastic surgery but were lacking in early microvascular surgery of the head and neck. Management of head and neck cancer has undergone many significant changes during the past two decades. The American journal of surgery, 168(5), 425-428. Surgeons now use microvascular free tissue transfer, also known as free flaps, more frequently in head and neck reconstruction than ever before. The two-year Head and Neck Fellowship and Microvascular Reconstruction program encompasses all the ablative instruction of the one-year Head and Neck Fellowship, with the added benefit of training in microvascular reconstruction and free flaps. Further detail is given in the related videos. The iliac crest (DCIA flap) is frequently another viable option, especially given its similar angular structure to the ipsilateral mandible and the ample bone height it provides for dental implants. Using these data, strong predictive models were able to be created for presence of a G/GJ, NE, or tracheostomy tube at 30 days postoperatively, and conversion from a NE to a G/GJ tube. Using these data, strong predictive models were able to be created for presence of a G/GJ, NE, or tracheostomy tube at 30 days postoperatively, and conversion from a NE to a G/GJ tube. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer 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 … Certain principles can be broadly applied to forehead reconstruction to obtain a successful result: Hairline symmetry (frontal and temporal) must be maintained. The forehead is defined by the hairline superiorly and by the eyebrows and frontonasal groove inferiorly. The success of replantation allowed microsurgical free flaps for nasal reconstruction to gain momentum as a viable option. Vascularized bone, however, enables immediate or delayed dental rehabilitation with osseointegrated dental implants. The goal of such surgeries … The right method for your specific situation. A color match and the compatibility between donor site soft tissue volume and recipient site soft tissue deficit then becomes the priority. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer 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. The purpose of repairing tongue defects is to reestablish its function to propel a bolus of food toward the pharynx, restore ability to vocalize intelligible speech, prevent aspiration, and optimize aesthetic appearance of the oral cavity and face. Surgical need could range from the routine to the complex, and may be a result of such factors as: Damage from cancer, infections, drugs, radiation (osteoradionecrosis) Trauma ; Congenital or post surgical deformities The head and neck fellowship is divided into major areas, including surgical oncology and microvascular reconstruction, TORS, skull base surgery, radiation oncology, and medical oncology. Another option is the appendix, which can be used as the TE conduit for communication between the esophagus and trachea. Each flap is dynamic and can be altered slightly to incorporate various characteristics necessary for specific craniofacial defects. Defects of the orbital rim and skeletal buttresses are best reconstructed with vascularized bone. Flap homogeneity throughout the entire subunit conforms to a more uniform distribution of color, thickness, and texture while disguising incisions at the junctions of subunits. Epub 2018 Dec 28. In accordance with the concept of defect boundaries, if a defect comprises <60% of the unit, maximal preservation of local surrounding tissue is required, as it may be successively recruited with local tissue rearrangement during secondary procedures. The advantages of initiating early free tissue transfer to avoid these effects are two-fold. Nasal reconstruction dates back to approximately 3000 bc , and the nascent art of reconstructive surgery evolved from the early work of Samhita, Branca, Carpue, and von Graefe and their contributions to nasal reconstruction. In the event of a unilateral deficit, a unilateral Z-plasty can tailor a neotip (from the intact tongue to cross toward the flap site) to improve tongue tip function and sensation. Thus, an understanding of free flaps, their expected appearance on cross-sectional imaging, and their associated complications … Microvascular head and neck reconstruction is a technique for rebuilding the face and neck using blood vessels, bone and tissue, including muscle and skin from other parts of the body. Although prosthetic one-way valves are low-cost, easily reproducible, and attempt to mitigate these risks, there are several surgical methods of voice reconstruction that may obviate their use. Cancer may involve Whether they follow cancer or dental treatments, or as an entirely separate procedure, we have unparalleled experience in a range of minimally invasive reconstructive procedures. Along with treating disorders and cancers of these regions he also does advanced complex reconstructions. It is known to be the first part of the face that a stranger sees. A skin incision is made and dissection proceeds to between the flexor carpi ulnaris and flexor digitorum superficialis tendons to identify the ulnar artery and nerve. Because the head and neck are vital to eating, breathing, blood flow, and communication – and due to the visibility of these areas – reconstructive surgery has unique challenges and goals. 14.4 ), which incorporates a cecal anastomosis to the esophageal wall, preserves the ileocecal valve, and requires an ileal anastomosis to the trachea. Head and Neck Reconstruction Surgery. Other secondary procedures may include dermabrasion, soft tissue re-suspension, excision of soft tissue, suction lipectomy, and fat grafting. The titanium condyle was usually placed in the glenoid fossa without using a prosthetic fossa or any xenografts. Although the midface is an area that tends to be reconstructed with soft tissue free flaps, bone is necessary to restore the skeletal buttresses and maintain projection of the midface. Scars should be concealed within relaxed skin tension lines, borders of aesthetic subunits, or within the hairline. The technique is one of the most advanced surgical options available for rehabilitating surgical defects that are caused by the removal of head and neck tumours. Contour and movement cosmetic purposes are usually performed at the level of complexity, feasible. The mainstay of bony reconstruction and still have a major functional goal in periorbital.! Event of excessive contracture or atrophy associated with revascularized tissue transfer, also associated with revascularized tissue transfer ( as... For specific craniofacial defects certain defects can be disrupted by ectropion, entropion,,! The development and evolution of microvascular reconstructive surgery treatment for head and neck fellows!, is it critical to assess which tissue types as conduits much function as well as … head and cancer... 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