MICROVASCULAR AND

MAXILLOFACIAL SURGERY

Microvascular surgeryMicrovascular reconstructive surgery involves the

transfer of autogenous vascularized tissue to reconstruct extensive tissue defects.

Areas commonly reconstructed include the jaws and mouth, the throat, and all areas of the face, scalp, and neck.

Microsurgery uses the operating room microscope or high-powered loupe magnification to aid in the techniques of microvascular surgery to anastomose small vessels and nerves

How does it help?With intimal injury, exposed collagen triggers platelet

adhesion. Platelets aggregate and activate fibrinogen, which adheres to platelets and acts to link platelets together to form a platelet plug. Fibrinogen is converted to fibrin, strengthening the platelet plug. If the vessel walls are not damaged and the anastomosis is secure, the platelet plug gradually disappears over the first 3-5 days. New endothelium covers the anastomotic site 1-2 weeks later.

Reconstructive LadderThe term coined by reconstructive plastic

surgeons to describe levels of increasingly complex management of wounds.

Rung 1: Healing by secondary intentionRung 2: Primary closureRung 3: Delayed primary closureRung 4: Split thickness graftRung 5: Full thickness skin graftRung 6: Tissue expansionRung 7: Random flapRung 8: Axial flapRung 9: Free flap

Free Tissue TransferDefect Type Tissue Defect Common Flaps

Coverage of exposed structures

Open tibial fractures in the distal third of the leg

Latissimus dorsi muscle free flap; gracilis muscle free flap

Dead space Obliteration of maxilla defect after maxillectomy for cancer

Rectus abdominus muscle free flap

Tissue defect Breast reconstruction Transverse rectus abdominus myocutaneous (TRAM) free flap; deep inferior epigastric perforator (DIEP) flap; superior gluteal artery perforator (SGAP) free flap

Facial muscle denervation

Facial paralysis with muscular atrophy

Gracilis muscle free flap

Digital amputation

Thumb amputation Great toe composite free flap

Digestive tract defect

Esophageal reconstruction

Jejunum free flap; anterior lateral thigh (ALT) free flap

Work upPreoperative planning includes finding the optimal donor

site and designing the flap to maximize soft tissue coverage, functionality, and appearance and to minimize complications. In oncologic cases, the timing of free flap reconstruction should be coordinated with the oncology team, taking into consideration chemotherapy and radiation treatments.

After the decision has been made to proceed with a microsurgical reconstruction, the optimal flap must be chosen. This decision is based on the size of the defect, the type of tissue required for the repair (bone, muscle, fascia, tendon, nerve, skin), and the reliability of the flap.

Common FlapsAnterior lateral thigh flapRadial forearm flapLateral arm flapScapular flapLatissimus dorsi flapRectus abdominis flapSuperficial inferior epigastric artery flap (SIEA)Gracilis flapTensor fascia lata flapOmental flap Jejunal flapFibula flapGreat toe flap

Gracilis Flap

Gracilis Flap

Gracilis Flap

Gracilis Flap

Antero lateral thigh Flap

Antero lateral thigh Flap

Antero lateral thigh Flap

Antero lateral thigh Flap

ComplicationsPostoperative complications include the following:Flap compromise due to vein or artery thrombosisFlap congestionFat necrosisHematoma with pedicle compromise and need for

transfusionInfectionWound breakdownWound complication associated with the donor siteSystemic complications associated with anesthesiaDeep vein thrombosis and pulmonary emboli

Maxillofacial SurgeryOral and maxillofacial surgery is a branch of surgery to

correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region.

It is a recognized international surgical specialty.

Treatments performed by maxillofacial surgeons include:Dentoalveolar surgeryDiagnosis and treatment of benign and malignant

pathology, cysts, tumors etc.Diagnosis and treatment of congenital craniofacial

malformations such as cleft lip and palateDiagnosis and treatment of soft and hard tissue trauma of

the oral and maxillofacial region (jaw fractures, cheek bone fractures, nasal fractures, LeFort fracture, skull fractures and eye socket fractures).

Diagnosis and treatment of chronic facial pain disorders.Diagnosis and treatment of temporomandibular joint

(TMJ) disorders.

Craniofacial SurgeryCraniofacial surgery is a

surgical subspeciality of plastic surgery and oral and maxillofacial surgery that deals with congenital and acquired deformities of the skull, face, and jaws.

Defects typically treated by craniofacial surgeons

include rare craniofacial clefts, acute and chronic sequellae of facial fractures, cleft lip and palate, micrognathia, and many others.

Cleft lip

Cleft lip

Cleft lip

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