POST ONCOSURGICAL RECONSTRUCTION IN

HEAD & NECK

DR.HARSH AMIN

In india->30% of all cancers are head neck ca. In head neck ca. upper aerodigestive tract is

most common site- with oral cavity being most common site followed by oropharynx followed by larynx

90% of all upper aerodigestive tract ca. is SCC.

Problem

Relevant anatomy

Upper aerodigestive tract constists of

-oral cavity-oropharynx

-hypopharynx-larynx

-nasopharynx and paranasal sinuses

Oral cavity Function

Mastication/ Bolus/deglutition

Speech Sphinchter/seal Direction of saliva

Oropharynx-Hypopharynx

Deglutition Pessage Seal

Larynx

Respiratory pessage Speech Prvent aspiration seal

mandible Contouring Teeth bearing Mastication/

swallowing/speech

External carotid and its branches

Veins

Skin quality-color, texture, hair bearing etc. Middle lamella-muscles of facial expression, muscles of mastication Deeper tissue-bone (contour) and soft tissue Mucosal lining

Things to consider for best functional and aesthetic

result

Goals for reconstruction

Integrity (must)Function

Form

continence (feeding) Protect vital structures from Blow Outs Separation from intracranial structures in skull

base (to prevent infection in/leak out) Prevent aspiration

So must for survival

Why Integrity is must?

E.g. Restoration of tongue bulk Restoration of floor Restoration of mandible

So better Quality of life

Function (Minimal goal if patient fit)

E.g. Maxillary defect- obturator vs free fibula

(projection and implant) Aesthetic subunits Secondary surgeries Free flaps instead of pedicle

Form-aesthetics

If possible reconstruction should be done

primary -as post operative and post radiotherapy scarred tissue hampers recipient vessel dissection. -vein grafts to opposite side has more chances of thrombosis

Factors affecting planning

DefectDonor site

PatientDoctor

Surface area(cutaneous/mucosal) (2D) Volume (bulk/support) (3D) Type of tissue involved Vessels (proximity/caliber/flow/) Radiation (pre-op ?/post-op)

Defect

Availability ( previous operations / trauma /vessel) Donor site (so that 2 team approach) Tissue quality (according to plan) -to restore coverage (skin , mucosa, muscle to mucolise) -bulk ,support (flap thickness, muscle, fat, bone ,cartilage) -if possible function For free flaps- also Pedicle (length/caliber/no. of

veins/nerve/direction) Residual donor defect

Donor site

Fitness/age Preference (expectation/stages) compliance Post op radiotherapy

Patient

Experience Set up/ team

Doctor

Reconstructive options(Even though actual defect only known

intra-operatively reconstruction must be planned )

Primary closure/secondary healingGrafts-skin/bone..

Local flap/Regional flapFree flap---single/chimeric/compound/flow through

Robust new tissue with own blood supply Enough volume Variety of Aesthetically pleasing combinations More radioresistant Osteo-integrated implants Cost??

Why Reverse ladder ?

1951-Edgerton-concept of immediate

reconstruction 1959-1st free jejunum for esophagus 1963-McGregor-laterally based forehead flap 1965-Bakamijan-deltopectoral flap 1976-Panje and Harashina described free flap

for oral defects 1979-Ariyan-PMMC flap 1980s and early 1990-osteocutaneous free flaps

for mandibular defects.

History

1979 – Taylor et al. – iliac crest composite flap 1980 – dos Santos et al. – scapular cutaneous flap 1981 – Yang et al. – radial forearm free flap 1982 – Nassif et al. – parascapular cutaneous flap 1982 – Song et al. – lateral arm fasciocutaneous flap1984 –Song et al. – Antero lateral thigh flap1983 – Baek et al. – lateral cutaneous thigh flap 1985 – Drever et al. – rectus Abdominis myocutaneous flap1986 – scapular osseocutaneous flap

Primary closure – for small defects of lateral

tongue / buccal mucosa. Small defects of buccal mucosa, sulcus, floor

of mouth, hard palate left open or packed with xeroform to allow healing by secondary intention

Primary closure & secondary healing

STSG – used to close superficial defects of alveolus,

palate, dorsum or lateral edge of tongue. Contraction of graft unlikely to cause a functional

problem in these areas.

Disadvantages –

Tendency to contract in extensile areas like floor of mouth / buccal surface makes them less useful.

Increased risk of partial / total graft loss due to scarring & radiation.

Immobilization of intraoral grafts -challenging

Skin grafts

Tongue flaps- used to close small oral defects in past,

fallen into disfavor because of tethering & resulting functional disturbances.

Forehead, temporalis muscle flaps rarely used now because of free tissue transfer.

Facial artery musculomucosal flap for small defects of hard palate, alveolus, tonsillar fossa & floor of mouth, but limited application.

Deltopectoral flap- an axial –pattern cutaneous flap based on 2-4 the branch of internal mammary artery Revolutionalized head & neck reconstruction, but fallen into disfavor- questionable reliability without delay.

Local & regional flaps

Submental flap

Based on submental artery Elevation started from inferior border of

mandible between 2 angles Plane is under plastysma Anterior belly of digastric incuded to ensure

inclusion of perforator

Facial artery myomucosal flap

• Based on facial artery

• Course within buccinator

• 2x9 cm

Nasolabial flap

Based on angular artery

2x5 cm Superiorly or

inferiorly based Temporary

orocutaneous fistula Best for old age with

lax skin It requires bite block

for 14 days

Deltopectoral flap

Anatomic landmarks

Superiorly based sternocleidomastoid flap- useful

to augment mandibular coverage, but unreliable & rarely used.

Lateral & inferior trapezius flap used for intraoral defects; lateral- poor flap reliability, inferior – reliable (intraoperative positioning difficulties).

Latissimus dorsi- safe & reliable , but patient must be repositioned for access to donor site, extensive dissection required, used in salvage situations.

Pectoralis major still widely used platysma limited role

Musculocutaneous flaps

PMMC flap

Flap design

Preserve 2nd 3rd perforator for future DP flap

Microvascular surgery revolutionalized management of

carcinoma of head & neck. Reliable immediate single- stage reconstruction yields

superior functional & aesthetic results,reduces mortality & maximizes quality of life in patients with reduced life expectancy.

Introduction of well vascularized bed increases chances of primary wound healing.

Free flaps demand microsurgical expertise, patient management skills,proper anesthesia, appropriate instrumentation,well equipped postoperative care unit

Favorite flaps –ALT,radial forearm & rectus abdominis, second line flaps- lateral thigh, parascapular, LD

Free flaps

Antero lateral thigh

Radial forearm

Arterial source Radial artery

Venous Source Paired vena commitantes and/or cephalic vein

Ractus abdominis musculo-cutaneous

Arterial supply based on deep inferior epigastric artery

Venous supply form vena commitantes joining external iliac vein

Lateral arm

Latissimus Dorsi Free Flap

Arterial supply based on thoracodorsal arteryVenous drainage from thoracodorsal vein Motor nerveinnervation potential with thoracodorsalnerve

Latissimus Dorsi Free Flap

Advantages Large flap with long pedicle

( artery 2-3 mm, vein 3-5 mm, length: 7-10 cm)

2nd largest skin paddle Possibility for “axillary megaflap”

Multiple skin paddles Low donor site morbidity Possibility of muscle

reinnervation via thoracodorsal nerve

Disadvantages Difficult positioning and two team harvest

30-45% LD Postoperative seroma formation

Bulky flap Unable to tube

Jejunum Free FlapSeidenberg (1959) - First case report in a human

Roberts and Douglas (1961) – first patient to survive

Primarily use for reconstruction of pharyngoesophageal defects

Jejunum Free FlapArterial supply from portion of superior mesenteric arterial arcade (2nd or 3rd

arcade)

Venous supply from venous branches along arcade

--·---

t - - - - .- -

Jejunum Free FlapAdvantages

Tubular

Mucosal surface may help with lubrication

Minimal donor defect

DisadvantagesBowel or pharynx fistulas

Need for laparotomy• Gen. Surg. team

No neovascularization

Reverse peristalsis

Poor TE speech

Short pedicleDifficult in obese persons

Jejunum Free FlapContraindications

Ascites

History of extensive abdominal surgery

Involvement of the thoracic esophagus

H/o of intestinal disease (Crohn's)

Osteo-cutaneous flaps

Scapula osteocutaneous free flap

DCIA osteocutaneous flap

Radial forearm

Free fibula

Look for atherosclerosis, previous surgery, radiotherapy Some may prefer to dissect it prior to flap dissection Best if more than one recipient artery is available to

choose best if location permits.

At least 2 veins anastomosis should be goal

2 major sources for recipient arteries-ext.carotid system

and thyrocervical system

Recipient vessels

Superior thyroid is most suitable when anastomosis with ext.carotid- 2-3 cm

after bifurcation. When prior radiation, surgery, age limit use of

ext. carotid –thyrocervical system Benefit of transverse cervical artery-less

atherosclerosis and as it riches mid neck greter caliber donor artery can be used as no trimming is required as in ext.carotid.

artery

Extternal jugular, transeverse cervical best(if

not ligated during dissection) Anterior jugular if not demaged while

tracheostomy Cephalic vein-mosrtly pos irradited areas.

Veins

Delay flap mobilization till creation of defect Preserve recipient vessels (atleast 1 cm) Select vessel with similar lumen size Pedicle lengh carefully measured Better to give inset 1st-to avoid maneuvering

of completed anastomosis/suturing of bleeding flap and misjudgment of pedicle length

Tissues sculpted once vascularization completed

Principles of microvascular surgery

Site specific treatment goals

Size of the defect is measured with mouth fully

open Soft, pliable, sizable flap is bestDefect if- Thin defect -radial/ulnar forearm fasciocutaneous Thicker defect-thin ALT Full thickness defect-thick fasciocutaneous or

musculocutaneous Marginal mandibulectomy-ALT myocutaneous Reconstruction goal-Avoid trismus

Buccal mucosa

Flaps

Small superficial defects- closed primarily or

allowed to heal by secondary intention.(this may make sulcus shallow)

Large defects- skin / mucosal grafts / mucosal rotation flaps- limited by loss of excursion ,

so thin , pliable flaps( platysma, radial forearm free flap)

Marginal mandibulectomy-ALT myocutaneous Excess bulk avoided- patient tends to bite the flap..

Reconstruction goal- to maintain the sulcus

Buccal sulcus

Defect here may expose mandible Direct closure may distort tongue and pillar

Trigone

Reconstruction goal- tongue mobility and

restore bulk Less than 1/3-1/2– primary closure vs. STSG

Tongue

Soft, sensate, mobile with Preservation of tongue

mobility. Small defects-heal secondarily / skin grafting. Flap- thin & supple ( free radial forearm ); reliable Anterior segmental mandibulectomy-

osteocutaneous flap (free fibula).

Reconstruction goal- to maintain lingual vestibule, sufficient height to floor of mouth avoiding pooling of saliva & food particles

Floor of mouth

Tumors of lower gingiva - involve bone requiring

partial mandibular resection. For small cancers- adequate remaining mucosa-

direct closure over bone, if not- raw surface accepts a skin graft.

After extensive marginal- reinforcement with a low- profile reconstruction plate, when postoperative radiotherapy planned covering it with well vascularised soft tissue, preserving sulcus ( e.g.. radial forearm free flap)

If segmental mandibulectomy- osteocutaneous Maxillary- small superficial cancers- excised, left to

heal by secondarily, large- alveolectomy/ maxillectomy

Lower and upper alveolar ridge

Hard palate- minor salivary gland tumors

predominate. Small defects- skin grafting/ heal secondarily. Bone involvement- alveolectomy / partial / total

maxillectomy- palatal obturator, Osseo integrated implants, osteocutaneous flap.

Hard Palate

Soft palate- large defects, best prosthetically as

flaps sag & ineffective in this highly dynamic region.

A delayed surgical prosthesis followed by a definitive obturator , interacts with the normally functioning velopharyngeal complex on the opposite side to help restore speech & swallowing.

if flaps used till radition completed and dentures fitted—they must be tight enough to prevent respiratory obstrction

Soft palate

Mandible

Free fibula

Scapula osteocutaneous free flap

DCIA osteocutaneous flap

Oropharynx-esophagus

Radial forearm

jejunum

Position- supine with shoulder roll to extend

neck. Prepare potential flap donor sites /skin / vein

graft donor sites. Through out the operation strict sterile

precations are important Ther has to be different trolley for oncosurgery

and reconstruction. Adequate exposure for resection &

reconstruction.

Algorithm for surgical treatment

Tumor removed with frozen section control of margins.

Once nature of defect known- reconstruction team begins to harvest flap.

If free flap- best to evaluate recipient vessels before raising the flap.

Recipient vessels prepared. An A-V loop created before flap harvest to

minimize ischemia time. Defect measured , tissue needs (bulk, lining )

identified

Flap designed & elevated. Flap rotated into position / harvested & brought

to recipient site.

For free flap orientation of flap is very important to ensure most vascularized portion for water tight seal of gullet.

In free flap, some insetting done before anastomosis to allow accurate placement of sutures.

Insetting done with vertical or horizontal mattress or tightly spaced interrupted sutures of 3-0 vicryl attempting to secure a water- tight closure.

Simultaneously closure of donor site/STG done

Before starting anastomosis remove sand bag. Microvascular anastomosis performed to large high-

flow vessels. End to side to external carotid artery / internal jugular

vein preferred. If atherosclerosis suspected, branch of external carotid to

minimize risk of embolic stroke.

It’s most important to prevent infection in this region and protect it from any leakage with adequate tissue.

Drains are placed as indicated. A site for external doppler monitoring marked with a

suture on flap skin. Neck incision closed in layers. Donor site closed over drains / grafted,dressed & splinted

as needed

Postoperative ManagementSkilled nursing important

No pressure on pedicle (no ties on neck)

Eliminate cooling of flap

Keep head in neutral position

No pressors– keep BP stable

Hematocrit important

Frequent inspections and doppler pedicle

Postoperative Management

Inspection and prick testArterial vs. venous insufficiency

PharmacotherapyHeparin, dextran, aspirin

Postoperative Management

Temperature measurements

SPECT scanning

Infrared spectroscopy

Transcutaneous and intravascular devices

Technicium scanning

Thank You