head

Head and Neck Reconstruction

Drs. N. Afridi and S. Morris

Introduction

Goals of Reconstruction

1. Ablative cure

2. Restoration of function

3. Restoration of form

Introduction

Functional Objectives– Restore sensation– Maintain oral continence– Facilitate swallowing– Prevent aspiration– Preserve speech– Protect vital structures– Achieve primary wound healing– Obtain cosmesis

Introduction

Multidisciplinary team– Head and neck

surgeon– Plastic surgeon– Radiation oncologist– Medical oncologist– Maxillofacial

prosthodontist– Dentist

– Radiologist– Pathologist– Speech and

occupational therapists

– Dietician– Psychologist– Social worker

Introduction

Preoperative Evaluation– Tumor histology/TNM and prognosis– Ablative procedure– Size of defect– Types of tissue involved– History of cigarettes and ETOH– Previous limb surgery– Peripheral vascular disease– Cerebrovascular disease– Medical comorbidities – DM, CPD– Nutritional state

Introduction

Procedure selection– Always tailor to patient– Reduce operative time

• Synchronous resection and flap elevation• Avoid multiple flaps• Use flaps not requiring positioning changes

– Dental rehabilitation• Use bone graft of adequate height to

accommodate osseointegrated implants

Introduction

Procedure selection– Reconstructive ladder

• Primary closure– Restricted to small lesions lateral tongue, buccal

mucosa, larynx-hypopharynx

• Split thickness skin grafts– Maxilla, alveolar ridge, anterior buccal mucosa,

dorsal surface of tongue, posterior esophageal wall

• Flaps– Indicated when thick, pliable, self supporting

tissue is needed

Introduction

Procedure Selection– Reconstructive ladder cont’d

• Musculocutaneous or fasciocutaneous flaps– Maintain tongue mobility in floor of mouth defects– Allow mandibular excursion in retromolar trigone

and posterolateral oropharynx– Protect the great vessels of neck from salivary

pool

• Free tissue transfer– Precise match of appropriate tissue for specific

area

Reconstructive options

Local flaps– Tongue flap

• Lexer 1909• Posteriorly based pedicle tongue flap• Reconstruction of retromolar trigone, tonsillar

area, and palate• Blood supply: lingual artery, enters the

undersurface of tongue near posterior aspect• 20-40% of lateral tongue elevated• Donor site closed primarily


Local flaps– Tongue flap cont’d

• Variations– Base anteriorly on marginal artery– Preserve dorsolingual branch of lingual artery and

detach hemitongue posteriorly• Can advance flap significantly

• Venous drainage– Hypoglossal nerve vein > epiglottic valleculate

vein > lingual nerve vein > lingual root vein > accompanying vein of lingual artery


Local flaps– Nasolabial flap

• Cohen and Edgerton• Inferiorly based flaps to anterior floor of mouth• 5 mm below the medial canthus to oral commissure• Tunneled through cheek mucosa• Two staged when based on skin pedicle• Single stage if subcutaneous or arteriovenous pedicle• Flap viability relies on transverse facial artery

– Viable when anterior facial artery divided


Local flaps– Masseter crossover flap

• Tiwari and Snow• Inferiorly based flap• Small to moderate defects of oropharynx

– Palatoglossal fold– Tonsillar fossa– Tonsillolingual sulcus– Lateral base of tongue

• Blood supply: masseteric branches of transverse facial artery, facial artery, maxillary artery, or external carotid artery

Reconstructive optionsAxial flaps

– Forehead flap• McGregor• Superficial temporal

vessels• Folded and tunneled

through cheek below zygomatic arch

• Pedicle divided at second stage

• Entire forehead as aesthetic unit

– Delay procedure mandatory

– 5-15% distal tip necrosis

• Poor cosmetic option


Axial flaps– Superficial temporal artery fascial flap

• Double layered fascial flap– Temporoparietal fascia and temporalis muscle

fascia

• Superficial temporal artery• Cover parotid bed after parotidectomy• Decreased incidence of gustatory sweating

(Frey’s syndrome)• Decreased post parotidectomy hollow


Axial flaps– Temporalis muscle flap

• Bradley and Brockbank• Floor of mouth defects• Muscle used for soft tissue fill• Increased mobility of flap

– Temporarily remove zygomatic arch


Axial flaps– Deltopectoral flap

• Bakamjian 1965• Pharyngoesophageal reconstruction with

medially based flap– Transferred in two stages

• McGregor and Jackson 1970– Extended range– Undelayed flap

• Skin paddle in deltoid portion distal to cephalic groove 1:1 ratio


Axial flaps– Deltopectoral flap cont’d

• Three main vascular contributions– 1st four perforating branches of internal mammary artery

– Thoracoacromial artery supplies upper midportion of deltopectoral flap

– Perforating vessels from deltoid muscle

• Deltoid portion is random flap• Pectoral skin axial blood supply• Delay procedure raises tip of flap lateral to D of

deltopectoral groove• 15-25% incidence of tip necrosis


Axial flaps– Facial artery musculomucosal flap

(FAMM)• Mucosa, submucosa, buccinatory, buccal fat

and facial artery• Superior or inferior based• Oropharyngeal reconstruction

– Small to medium sized defects

• Narrow flap with wide arc of rotation• Anterior to parotid duct


Axial flaps– Buccinator musculomucosal flap

• Buccal artery principal arterial pedicle• Supplies posterior half of muscle• All incisions intraoral• Mean dimensions

– 3.5 cm width and 7 cm length

• Anterior and lateral floor of the mouth• Must preserve facial artery with neck

dissection• Ipsilateral molars should be extracted


Axial flaps– Submental flap

• Musculocutaneous island flap• Submental artery• Skin paddle

– 7 x 18 cm

• Ipsilateral oral cavity and face• Scar hidden under mandible


Musculocutaneous flaps– Neck flaps

• Potential involvement of metastatic spread• Risk of circulatory interruption by the

excisional surgery• Damage inflicted by preoperative irradiation

– Chest flaps• Not affected by treatment of 1º disease• Wider and more extensive surgical dissection• Pectoralis major and latissimus dorsi are

workhorses

Reconstructive optionsMusculocutaneous

flaps– Pectoralis major

musculocutaneous flap (PMMF)

• Ariyan 1979• Mathes and Nahai

type V– Thoracoacromial

major pedicle– Secondary

segmental parasternal perforators from internal mammary artery


Musculocutaneous flaps– PMMF

• Pectoral branch of thoracoacromial– Exits subclavian at midclavicle– Medial to insertion of pectoralis minor tendon– Runs with lateral pectoral nerve

• Line from tip of should through xiphoid

• Skin island can be centered over lower portion of muscle in line of pedicle



• Disadvantages of classic design:– Disfiguring donor site in women– Hair bearing skin paddle in men– Bulky skin paddle– Limited arc of rotation– Muscle pedicle bulges in the neck– Occasional shoulder dysfunction



• Modifications– Women

• Skin flap medial beyond edge of muscle• Skin flap placed under the breast• Vertical parasternal paddle• Sickle shaped parasternal paddle into IMF

– Men• Replace cutaneous portion of skin paddle with

STSG



• Flap without skin paddle– Pectoralis major musculofascial flap– Leave outer surface raw– Mucosalizes– Ideal for small to medium sized oral cavity and

pharyngeal defects



• Modifications– Bulk

• Parasternal skin paddle• Prefabricated with STSG over muscle

– Arc of rotation• Skin paddle lower portion of muscle onto

rectus abdominis• Resect medial half of clavicle (2.5 – 3 cm of

length to flap)



• Modifications– Muscle bulk in neck

• Transect medial and lateral pectoral nerves• Exteriorize and later resect muscle

– Shoulder function• Sternocostal portion leaves functioning

muscle on chest with clavicular head– Bone

• Incorporate 5th rib



• Modifications– Splitting muscle

• Split longitudinally• Double skin paddles• Sternal portion blood supply from pectoral

branch of thoracoacromial artery• Lateral portion perfused by lateral thoracic

artery



• Complications– Kroll et al. MD Anderson– 63% of cases

• Most self limiting– Increased in smokers– Total flap loss 2.4%, most were women

• Thicker adipose tissue between muscle and skin

– Overall hospital cost 30% more than free flap


Musculocutaneous flaps– Latissimus dorsi flap (LDMF)

• Tansini 1896 chest wall reconstruction• 1st musculocutaneous flap described in the literature• Head and neck reconstruction 1978• Type V muscle

– Dominant vascular pedicle thoracodorsal artery and runs with thoracodorsal nerve

– Thoracodorsal artery branches

• Anterior branch runs 2.5 cm medial to free border

– Segmental pedicles from intercostal perforators and lumbar vessels


Musculocutaneous flaps– LDMF

• Three angiosomes– Proximal portion supplied by thoracodorsal artery– Medial portion supplied by posterior intercostals– Caudal portion supplied by lumbar vessels

• Muscle and skin can be harvested from adjacent angiosomes by crossing one system of choke vessels

• Flap elevation– Division of collateral branches of thoracodorsal– Muscle detached from insertion on humerus



• Skin islands placed over upper 2/3 of muscle consistently survive

• Thoracodorsal pedicle divides into medial and lateral branches

– Can design two separate skin paddles



• Advantages:– Large size– Wide excursion– Donor site morbidity negligible

• Disadvantages:– Positioning– Intricate dissection– Complexity of tunneling



• Potential problems:– Marginal fat necrosis– Compression or twisting of pedicle when tunneled

between pectoralis major and minor pedicles– Nerve injury

• Long thoracic nerve• Antebrachial cutaneous nerve• Brachial plexus with positioning



• Complications– 26% with failure rate of 5%– Greater in men than in women– Radiotherapy, site of reconstruction, type of flap

and age not significant risk factors


Musculocutaneous flaps– Sternocleidomastoid flap (SCMF)

• Moderately useful• Partial flap loss in 50% of patients• Most reliable when based on the occipital

artery and retained skin bridge• Arc of rotation determined by the course of

the spinal accessory nerve within the muscle• Improved vascularity with preservation of

superior thyroid artery and vein• Can include clavicle in the flap



• Advantages:– One stage immediate reconstruction– Rapid and technical ease of elevation– Option to use contralateral flap to malignancy

resection– Modification using SCM musculoperiosteal flap for

tracheal reconstruction



• Disadvantages:– Loss of protection of great vessels– Contraindicated ipsilateral flap in clinically positive

neck– Contour deformity– Unreliable distal skin paddle


Musculocutaneous flaps– Platysma flap

• Contains lower cervical skin on superiorly based platysma

• Turned to resurface anterior floor of mouth or cheek

• Intact facial artery not crucial to survival of flap

• External jugular and anterior communicating veins should be included to improve venous drainage



• Advantages– Thin and pliable muscle skin paddle

• Ideal for floor of mouth where bulk undesirable– Negligible functional impairment of deglutition,

speech and denture fitting– Cosmetic donor site



• Contraindications– previous irradiation to the neck– Surgery in the head and neck– Neoadjuvant chemotherapy– Nodal disease– Large defects


Musculocutaneous flaps– Infrahyoid flap

• Modification of midline cervical flap• Includes strap muscles

– Sternohyoid and sternothyroid

• Includes main trunk of superior thyroid artery• Useful in closure of medium sized defects

– Floor of mouth

– Tongue

– Buccal mucosa

– Lateral pharyngeal wall

• Motor capability useful in swallowing and speech


Musculocutaneous flaps– Trapezius flap

• McGraw– Based on proximal occipital artery

• Mathes and Vasconez– Cervicohumeral modification included transverse

cervical artery

• Demergasso and Piazza– Designed skin island over the acromioclavicular

joint– Carried on transverse cervical artery– Muscle kept attached proximally



• Bertotti– Only included muscle under skin island– Based on superficial ascending branch of

transverse cervical artery– Deep descending branch divided to increase

reach



• Yang and Morris– Three main vascular sources

• Transverse cervical artery (TCA)• Dorsal scapular artery (DSA)• Posterior intercostal arterial branches

– TCA dominant pedicle– TCA and DSA supply most of muscle



• Advantages:– Proximity to the operative field– Thin, pliable skin of deltoid area

• Disadvantages– Variable vasculature– Limited by neck dissection or irradiation– Donor site morbidity

• Shoulder drop

• Must ensure transverse cervical artery intact if neck dissection previously done



• Modification– Lower trapezius flap

• Deep (descending) branch of transverse cervical artery

• Innervated by posterior branch of spinal accessory nerve

• Posterior and lateral head and neck defects



• Modification– Advantages

• Skin between posterior midline and scapula carried

• Upper trapezius remains innervated and functional therefore no shoulder drop

• Inconspicuous donor site– Disadvantages

• Shorter pedicle• Limited reach


Musculocutaneous flaps– Serratus anterior flap

• Fasciocutaneous extension of serratus anterior muscle from 6th to 8th ribs

• Long pedicle 15-20 cm• Rib can be included• Latissimus dorsi flap can be included in same

pedicle– Can cover large soft tissue defects


Free tissue transfer– High success rates– Superior aesthetic and functional results– Advantages

• Vascular pedicle anastomosed to most appropriate recipient

• Ease of flap insetting and orientation• Closure of massive defects feasible• Option of restoration of sensation

– Sensory nerve harvest

– 95% flap survival– Complication rate approximately 20%

• Salivary fistula 12%

Regional reconstruction

Outline– Oral cavity

• Floor of mouth• Soft palate• Hard palate• Tongue

– Oropharynx– Hypopharynx and esophagus– Mandible


Oral cavity– Frequently repaired by skin graft or local

flap– Large defects require regional or distant

flaps– Key to success

• Preservation of tongue mobility


Oral cavity– Six contiguous

mucosal vascular territories

• Labial • Buccal • Inferior alveolar• Lingual• Ascending

pharyngeal• Ascending palatine


Oral cavity– Floor of mouth

• Primary closure• Palatal mucoperiosteal grafts

– Useful for medium sized defects– Little contracture allows good tongue mobility– Thick graft prevents contour deformity– Donor site left to granulate


Oral cavity– Soft palate

• Traditionally non surgical• Lateral pharyngeal walls

– Skin graft– Flap – Obturator

• Sensation helps initiate oral phase of deglutition


Oral cavity– Soft palate

• Thin fasciocutaneous free flaps useful• Cutaneous segment of free flap should be

placed tightly across soft palate– Eliminates redundancy

• Velopharyngeal competency requires redundant tissue to meet posterior pharyngeal wall

– Reconstructed tissues have no dynamic activity– Can deepithelialize opposing surfaces of

midportion of flap and suture raw surfaces


Oral cavity– Hard palate

• Difficult area to reconstruct• Prosthesis as an obturator

– Large– Difficult to stabilize unless osseointegrated– Insensible

• Alternatives to obturator– Osseocutaneous radial forearm free flap– Osseocutaneous scapular flap


Oral cavity– Tongue

• Most common site of oral cavity cancer• Frequent locus of invasion

– Floor of mouth– Oropharyngeal cancer– Hypopharyngeal cancer

• Reconstruction of tongue in total or near total glossectomy difficult



• Priorities of tongue reconstruction– Airway protection

– Swallowing

– Articulation

• Donor tissue should be bulky• Need to create shelf above laryngeal inlet to direct

food bolus down the posterior pharyngeal wall• Tissue should be pliable and capable of movement

– Sensory innervation ideal



• Options– PMMF

• Problems with excessive bulk• Good short term results• Muscle atrophy and gravity diminish outcome



• Options cont’d– Musculocutaneous free flap

• Cylindrical in shape• Obliterate oral cavity with jaw closed• Anterior sulcus shallower than lateral sulci to

enhance salivary drainage and prevent pooling

• Lower lip sutured over wide base to improve support, decrease inner lip height and tighter oral seal

• Can support the flap with bone on oral floor



• Options cont’d– Innervated latissimus dorsi

• Muscle fibers transverse to axis of skin • Create contractile muscle sling• Suspend by suturing tendinous inscriptions to

the mandible for support• Reinnervate by coaptation to hypoglossal

nerve– Peroneal fasciocutaneous flap– Sensory radial forearm/ iliac crest combination



• Options cont’d– Radial forearm with brachioradialis

• Medial or lateral antebrachial cutaneous nerves coapted to lingual nerve

• Sensation improved • No major advantage with intraoral function

– Free groin flap– Rectus abdominis

• Harvest 10th intercostal nerve – Ulnar forearm– Iliac crest



• Options cont’d– Vastus lateralis musculocutaneous free flap

• Long, high caliber vascular pedicle– Innervated gracilis musculocutaneous flap

• Obturator nerve coapted to hypoglossal nerve

• All patients should be followed by a speech pathologist


Oropharynx– Radial forearm flap

• 1981 Yang et al• Fasciocutaneous flap• Arterial supply: radial artery• Venous drainage: venae comitantes or

superficial vein ie cephalic• Can be used as a conduit for blood to a

second flap• Radius can be harvested

– Small portion of FPL muscle required


Oropharynx– Radial forearm flap cont’d

• Tubed flap useful in laryngeal reconstruction– Partial laryngectomy

– Helps with speech rehabilitation

– Stiffer resonating chamber for speech production

– No peristalsis or mucus secretion as with visceral flaps

• More reliable than PMMF• Large series

– Infection fistula rate 24%

– Revisional surgery required in 19%

– 19% had donor site complications



• Applications– Every site of oral cavity– Palatal reconstruction– Upper lip reconstruction

• brachioradialis muscle– Total lower lip reconstruction

• Sensory flap with palmaris longus tendon– Vascularized nerve graft– Vascularized bone graft– Pharyngoesophageal reconstruction



• Donor site morbidity– Distal skin island

• 33% graft failure • Exposed wrist tendons



• Decrease morbidity– Improved graft take if proximally based flap– Shorter vascular pedicle– Can use turnover flaps of FPL and FDS to cover

FCR– May also preserve deep fascia– Ulnar transposition flap and V-Y closure– Skin grafted fascial forearm flap no donor skin– Full thickness skin graft to forearm– Bevel osteotomy, use 1/3 of radial diameter


Oropharynx– Large defects with mandibulectomy

• Radial forearm and iliac crest free flaps• Separate tissue units advocated

– No single large area of anaesthesia– Allows better oral function

• Can anastomose lingual nerve to antebrachial cutaneous nerve of forearm


Oropharynx– Scapular flap

• Subscapular artery • Scapular, parascapular, latissimus dorsi and

serratus muscles– Can support vascularized bone from border of

scapula– Circumflex scapular artery supplies lateral border

of scapula• Can harvest 14 cm bone segment


Oropharynx– Scapular flap

• Thoma et al– Medial ridge of scapula– Abundant hairless skin and soft tissue– Inconspicuous donor site– Longer vascular pedicle– Independent of parascapular artery– Thinner bone

• ? Placement of osseointegrated implants


Oropharynx– Rectus abdominis musculocutaneous flap

• Inferior epigastric vessels• Same bulk as pectoralis major, latissimus, trapezius• Kroll compared the two

– Complications

• PMMF 44%

• Rectus 13%

– Flap loss

• PMMF 10%

• Rectus none

• Can harvest segment of peritoneum at lateral border of rectus abdominis


Oropharynx– Lateral arm free flap

• Posterior radial collateral artery (profunda brachii)• Sensory soft tissue

– Good quality for head and neck reconstruction

• Donor defect closed with linear scar• Versatile• Low donor site morbidity• Thin skin of proximal forearm and thick skin of the

upper arm– Thin skin useful for posterior oral cavity

– Thicker portion in tongue base


Oropharynx– Lateral arm free flap cont’d

• Osseocutaneous flap– Harvest segment of humerus– 1 x 10 cm– Septal perforators extend to the periosteum– Muscular cuff of triceps and brachioradialis is

necessary

• Sensation– Posterior cutaneous nerve of the arm and forearm

allow for sensory neurotization


Hypopharynx and esophagus

– Cervical esophagus difficult to repair• Narrow lumen• Compressed position in the neck• Skeletal restrictions at the thoracic outlet and

posterior to larynx


Hypopharynx and esophagus– Partial esophageal defects

• Skin flaps• Musculocutaneous flaps• Myoplasty with skin graft

– Complete esophageal defects• Skin flaps• Fasciocutaneous flaps/musculocutaneous

flaps• Microvascular bowel transfers or pedicled

viscera


Hypopharynx and esophagus– Skin flaps

• Historical interest• Bakamjian 1965• Medially based deltopectoral flap for

pharyngo-esophageal reconstruction• Two operative stages• Temporary pharyngocutaneous fistula• Useful in partial esophageal reconstruction• Late stricture at lower anastomosis in

circumferential replacement


Hypopharynx and esophagus– Fasciocutaneous flaps

• Radial forearm flap– Thin and pliable– Ample vascular supply– Large paddle to form circumferential segment

reconstruction



• Lateral thigh flap– Baek 1983– Third perforator of profunda femoris artery

• Runs in the lateral intermuscular septum between vastus lateralis and biceps femoris

– Sensory restoration• Medial and lateral femoral cutaneous nerves

of the thigh– Largest cutaneous surface area flap available– Thin, pliable and often hairless– Proximal fat portion used for bulk



• Lateral thigh flap– Advantages

• Thin, pliable and hairless• 8-12 cm long pedicle, 2-3 mm diameter• Pedicle enters midportion of skin paddle• Allows two team ablation and harvest• Minimal donor site morbidity

– Disadvantages• Occasionally need to include 2nd or 4th

perforator• Atherosclerosis in profunda femoris branches


Hypopharynx and esophagus– Musculocutaneous flaps

• Latissimus dorsi and pectoralis major• PMMF

– Useful – High success rate– Useful in concerns with wound breakdown– Advantage of single stage closure– Reliable blood supply


Hypopharynx and esophagus– Free visceral flaps

• Segmental jejunum– Most popular– Regarded as method of choice– 85% success rate– >80% patients resume oral feeding– Used for cervical esophagus as well as after

subtotal laryngopharyngectomy– Can harvest additional mesentery for coverage of

exposed vessels and STSG



• Segmental jejunum– Lower risk for fistula formation than free radial

forearm• Fewer suture lines

– Preoperative radiotherapy preferable• Decreased radiation mucositis, late stricture or

fistula– Maximum usable length of jejunum is 20 cm



• Segmental jejunum– Lowest median hospital stay– Shortest time to resumption of oral intake– Complications

• 17% in neck• 2.5% abdomen• Average time to swallowing 11days

– No coordinated peristaltic activity– Passive conduit with time after diminution of

peristalsis



• Segmental jejunum– Stricture

• Minimize by incising distal end 2cm anteriorly• Increase size of distal anatomosis• Avoid autostaples• Avoid end to side anastomoses

– Monitoring• May exteriorize segment or create surgical

window• Look for peristalsis and color



• Gastric omental flaps– Papachristou– Antral segment from greater curvature of stomach

• Avoids parietal cell acid secretion– Gastroepiploic vessels– 10 x 10 cm flaps– Pedicle 30 cm in length



• Gastric omental flaps– Omentum used to fill dead space and contouring

in radical neck dissection• Atrophies to 50% of size

– Drawbacks• Mucosal hypersecretion• Possible aspiration

Regional Reconstruction


• Free jejunum and gastric antrum– Partial defects of cervical esophagus– Circumferential defects extending into

nasopharynx– Total cervical esophageal replacement when

larynx is preserved


Hypopharynx and esophagus– Pedicled viscera

• Colon interposition– Historical use– No longer used– Multiple complications



• Gastric esophagoplasty– 1960 Ong and Lee

• Advanced gastric fundus into cervical area to replace thoracic esophagus

– Ample blood supply, mobility and length– Modern technique

• Dividing left gastric, left gastroepiploic and short gastric arteries

• Kocher maneuver, vagotomy and pyloroplasty• Thoracic esophagus is anastomosed to

hypopharynx



• Gastric esophagoplasty– Advantages

• Easy to prepare and use• Excellent blood supply• Away from irradiated field• One anastomosis

– Disadvantages• Infection, bleeding, anastomotic leaks• Operative mortality 31%

– Procedure of choice for replacement of thoracic esophagus



• Gastric esophagoplasty– Free jejunum

• 94% success• Satisfactory swallowing 88%• Discharge several days sooner• Fistula rate 16%• Late stricture 22%

– Gastric pull up• 87% success• 87% swallowing• 20% fistula rate• Late stricture 13%


Mandible– Requires replacement of missing

mandibular segment of bone– Vascularized bone

• Promotes primary healing• Resists radiotherapy• Allows dental reconstruction with

osseointegrated implants


Mandible– Defect classification

• C = central segment– Between two canines

• L = lateral segment• H = hemimandible

– Similar to lateral segment but includes the condyle on the affected side

• Variable combinations– LC, HC, LCL


Mandible– Bardenheuer 1892

• Composite flap of skin, periosteum and bone from forehead to replace missing jaw

– Sykoff 1900• First non-vascularized bone graft

– Risdon and Waldron 1919• Iliac crest grafts to the mandible


Mandible– Non vascularized bone grafts

• Rib or iliac crest• Balance of cortical and cancellous bone• 1969 Millard

– Immediate rib bone grafts• 30% failure rate

– Recommended delaying bone grafting to 6 weeks after soft tissue reconstruction


Mandible– Sterilized autogenous bone

• Sterilizing resected mandibular segment• Replaced biologically inert mandible

– Scaffold for new bone growth

• Freeze dried– -50ºC to –60ºC with liquid nitrogen

• Alternate technique is irradiation• All such methods abandoned


Mandible– Alloplasts

• 1976 Boyne and Zarem– Titanium mesh tray and cancellous bone chips– Postponed if postoperative radiation– Metallic tray increases absorbed radiation by 29-

36%• Increased risk to soft tissue envelope

• 1972 Leake and Rappoport– Dacron urethane mesh– Biocompatible and malleable alternative– Easy to handle, simple fixation, no heat

conduction or radiation scatter



• Temporary spacers – Kellman and Gullane– AO stainless steel plates– 23 patients; 90% irradiated– 17% exposure rate in lateral mandibular

reconstructions– 48% exposure rate with anterior arch



• Titanium coated Hollow Screw and Reconstruction Plate (THORP) system

– Raveh– Use of hollow screws– New bone is integrated into the prosthesis– “Integrated osteosynthesis”

• Greater stability• Less need for direct contact between plate

and mandibular cortex• 85% success rate



• Temporary spacers pending definitive reconstruction with vascularized bone

• High extrusion rates– Anterior mandibular defects– Poor quality lining – Irradiated soft tissues


Mandible– Vascularized bone

• Transfer of vascularized bone by microanastomoses

• Low morbidity• Negligible mortality• Tolerated in any age group• Primary healing• Tolerates radiotherapy• Allows dental restoration with

osseointegrated implants



• Improves facial for and quality of life• 96% success rates, low complication rate• Most common sources

– Fibula – Iliac crest– Radius – Lateral scapular border

• Less common– Rib– Second metatarsal



• Free fibular flap– Hidalgo– Published initial 12 cases

• Half were anterior arch– Peroneal artery and vein– Can include a skin paddle

• Reliability increased if include cuff of soleus and FHL preserved around bone

– Considered method of choice in most mandibular reconstruction



• Free fibular flap– Advantages

• Up to 25 cm of bone to span defect any size• Supine flap dissection• Two team ablation harvest possible• Segmental perforators from peroneal vessels

allow multiple osteotomies• Adequate bone stock for osseointegrated

implants– Disadvantage

• Contraindicated in severe PVD



• Free fibular flap– Complications

• Exposure of bone and hardware• Orocutaneous fistula• Osteoradionecrosis• Partial or complete flap loss• Cervical contracture

– MD Anderson large series• 42% cases had one complication• Radiotherapy equivocal• Free fibular preserved bone mass best compared to

other techniques



• Free circumflex iliac osseocutaneous flap (CIOCF)

– Taylor et al 1979– Deep circumflex iliac vessels– Groin skin and iliac crest– Useful in reconstruction of a hemimandible– Jewer et al

• 60 cases• 95% flap survival• 86% patients returning to previous activities



• CIOCF– Advantages

• Good caliber of vessels• Broad surface of bone for contouring mandible• Segmental nutrient vessels allow osteotomies

– Disadvantages• Bulky skin paddle can be unreliable with

multiple osteotomies• Abdominal wall weakness and hernia• Contour deformity at donor site



• CIOCF– Shenaq et al

• Modified flap to avoid donor site morbidity• Split inner cortex iliac crest free flap• Inner cortex of iliac crest used• No abdominal wall weakness or hernias



• Free radial forearm flap– Segment of radius for mandibular reconstruction– Inner volar cortex of radius divided – Available segment of bone

• Distal to insertion of pronator teres• Maximum length of bone 10-12 cm in adults• Use 1/3 thickness of bone

– Should use full length plaster cast for 3-4 weeks



• Iliac crest versus radial forearm– Boyd et al– Iliac crest

• Ideal for massive defects• Natural curvature follows mandibular contour• Obstacle in small defects• Higher incidence of intraoral wound

breakdown and bone exposure– Radial forearm

• Better skin paddle• Useful in smaller defects less than 9 cm



• Free scapular flap– Teot et al 1981– Lateral border of scapula transferred with muscle

cuff– Circumflex scapular vessels– 7 cm of bone safely harvested– Cutaneous paddle – Protects from shoulder immobility with pedicled

trapezius



• Free dorsalis pedis osseocutaneous flap– 2nd metatarsal 4-7 cm of bone– Segmental blood supply allows osteotomies

• Masseter osseomuscular flap– Central mandible segment– Preserves bone viability– Maintains form and function of mandible– Local flap– Low donor site morbidity and short operative time



• Trapezius osseomusculocutaneous flap• Sternocleidomastoid musculoosseus flap• Free rib • Sternum and muscle flap• Temporalis myoosseus flap


Mandible– Composite mandibular defects

• Defect encompasses oral mucosa or overlying soft tissue

• Dual free flaps versus composite free flaps• Combinations endless

head

Documents

based flaps

vein of lingual artery

flap elevation

marginal artery

maxillary artery

anterior facial artery

based flap small

fasciocutaneous flaps