Oral Cavity Recon Slides 030212

Reconstruction of the Reconstruction of the Oral CavityOral Cavity

Michael Underbrink, M.D.Michael Underbrink, M.D.Anna Pou, M.D.Anna Pou, M.D.

IntroductionIntroduction

!! Difficult challengeDifficult challenge!! Complex anatomy and functionComplex anatomy and function!! Goals Goals

!! Restore preoperative functionRestore preoperative function!! CosmesisCosmesis

!! Patient status is important considerationPatient status is important consideration!! Variety of reconstruction optionsVariety of reconstruction options

AnatomyAnatomy!! Vermilion to junction of Vermilion to junction of

hard and soft palate hard and soft palate superiorlysuperiorly

!! Inferiorly to circumvallate Inferiorly to circumvallate papillaepapillae

!! Structures: lips, alveolar Structures: lips, alveolar ridges, buccal mucosa, ridges, buccal mucosa, retromolar trigone, hard retromolar trigone, hard palate, floor of mouth, palate, floor of mouth, mobile tonguemobile tongue

!! Functions: speech, Functions: speech, mastication, bolus mastication, bolus preparation and initiation preparation and initiation of deglutitionof deglutition

Functional ConsiderationsFunctional Considerations

!! Oral sphincterOral sphincter!! Speech, mastication and deglutitionSpeech, mastication and deglutition!! Provides a watertight closure for bolus Provides a watertight closure for bolus

preparationpreparation!! Prevents escape of salivaPrevents escape of saliva


!! Alveolar RidgesAlveolar Ridges!! Covered with thin, adherent mucosaCovered with thin, adherent mucosa!! Elevated above floor of mouthElevated above floor of mouth!! Lingual and buccal sulci direct the flow of food Lingual and buccal sulci direct the flow of food

and saliva during bolus processingand saliva during bolus processing


!! Floor of the mouthFloor of the mouth!! Allows unrestricted mobility of the oral tongueAllows unrestricted mobility of the oral tongue!! Collects food and saliva (bolus preparation)Collects food and saliva (bolus preparation)


!! Oral (mobile) tongueOral (mobile) tongue!! Speech and deglutitionSpeech and deglutition!! Mobility allows for:Mobility allows for:

!! Articulation of speechArticulation of speech!! Bolus manipulation in preparation for deglutitionBolus manipulation in preparation for deglutition

!! Sensory functions: proprioception, pain, tasteSensory functions: proprioception, pain, taste!! Assists in mastication and bolus processingAssists in mastication and bolus processing


!! Hard palateHard palate!! Opposes tongueOpposes tongue!! Important for speech and bolus preparationImportant for speech and bolus preparation


!! Buccal MucosaBuccal Mucosa!! Lines the cheekLines the cheek!! Functions in mastication and deglutitionFunctions in mastication and deglutition!! Allows expansion for masticationAllows expansion for mastication!! Thin to avoid restriction of dental closureThin to avoid restriction of dental closure


!! Base of tongueBase of tongue!! Often involved with oral cavity defectsOften involved with oral cavity defects!! Participates in taste, deglutition and speechParticipates in taste, deglutition and speech!! Must occlude oropharynx during deglutitionMust occlude oropharynx during deglutition!! Some consonants require BOT to touch hard Some consonants require BOT to touch hard

palatepalate

Patient FactorsPatient Factors

!! Individualize optionsIndividualize options!! Type of tissueType of tissue!! Anticipated functional gainAnticipated functional gain!! Anticipated donor morbidityAnticipated donor morbidity!! Need for innervation Need for innervation !! Success rateSuccess rate!! Intraoperative positioningIntraoperative positioning!! Operative timeOperative time!! Dental restorationDental restoration!! Overall medical statusOverall medical status

Patient FactorsPatient Factors

!! Preoperative counselingPreoperative counseling!! Complete medical historyComplete medical history

!! Diabetes, atherosclerosis, previous radiationDiabetes, atherosclerosis, previous radiation!! Cardiopulmonary status (operating time, Cardiopulmonary status (operating time,

aspiration risk)aspiration risk)

!! Smoking historySmoking history!! Patient expectations and motivation are Patient expectations and motivation are

very importantvery important

Floor of Mouth ReconstructionFloor of Mouth Reconstruction

!! Requires soft and mobile tissueRequires soft and mobile tissue!! Allow mobility of oral tongueAllow mobility of oral tongue!! Avoid scar contracture (i.e., secondary Avoid scar contracture (i.e., secondary

intention)intention)!! Avoid bulk (glossoptosis, obliteration of Avoid bulk (glossoptosis, obliteration of

lower lip sulcus)lower lip sulcus)


!! Smaller defectsSmaller defects!! Split thickness skin graftSplit thickness skin graft

!! Harvest from lateral thigh at 0.017 inHarvest from lateral thigh at 0.017 in!! Provides waterProvides water--tight closure, no hairtight closure, no hair!! Stabilize with bolsterStabilize with bolster!! Survives over muscle and cancellous bone (via Survives over muscle and cancellous bone (via

imbibition and neovascularization)imbibition and neovascularization)!! Also good for lateral FOM and retromolar trigoneAlso good for lateral FOM and retromolar trigone



!! Moderate defects involving a larger Moderate defects involving a larger portion of mylohyoidportion of mylohyoid!! Nasolabial flap Nasolabial flap

!! Based on angular arteryBased on angular artery!! Better for older patients with lax skinBetter for older patients with lax skin!! Requires two stages and temporary fistulaRequires two stages and temporary fistula!! Bite block necessaryBite block necessary



!! Moderate defects (continued)Moderate defects (continued)!! Regional flapsRegional flaps

!! Forehead flap (rarely used)Forehead flap (rarely used)!! Platysma flapPlatysma flap!! Facial artery musculomucosal flap (FAMM)Facial artery musculomucosal flap (FAMM)!! Deltopectoral flap (historical significance)Deltopectoral flap (historical significance)


!! Forehead flapForehead flap!! Superficial temporal arterySuperficial temporal artery!! Reliable 2/3 across the foreheadReliable 2/3 across the forehead!! Tunneled into cheek below zygomaTunneled into cheek below zygoma!! Requires orocutaneous fistulaRequires orocutaneous fistula!! Obvious donor site (skin graft)Obvious donor site (skin graft)!! Second stage to inset flapSecond stage to inset flap


!! SubmentalSubmental artery island flapartery island flap!! Thin, supple skinThin, supple skin!! Submental branch of facial arterySubmental branch of facial artery!! Primary closure of donor sitePrimary closure of donor site!! Poor reliability if:Poor reliability if:

!! Facial artery sacrificedFacial artery sacrificed!! Irradiated necksIrradiated necks

Floor of Mouth Platysma Flap Floor of Mouth Platysma Flap ReconstructionReconstruction


!! FAMM flapFAMM flap!! Branch of facial arteryBranch of facial artery!! Contains mucosa, buccinator muscle, and fatContains mucosa, buccinator muscle, and fat!! 2 x 8 cm flap without injury to facial nerve2 x 8 cm flap without injury to facial nerve



!! Deltopectoral FlapDeltopectoral Flap!! Axial distant flapAxial distant flap!! First four perforators First four perforators

of internal mammaryof internal mammary!! Deltoid portion is Deltoid portion is

randomrandom!! Preliminary delay Preliminary delay

procedureprocedure!! Creates dependent Creates dependent

orocutaneous fistulaorocutaneous fistula


!! Fasciocutaneous free flapsFasciocutaneous free flaps!! Thin nature and pliabilityThin nature and pliability!! Radial forearm has low incidence of failure to Radial forearm has low incidence of failure to

this sitethis site!! Provides tongue mobility and free movement Provides tongue mobility and free movement

of food during deglutitionof food during deglutition


!! Radial forearm free flapRadial forearm free flap!! Based on radial artery Based on radial artery !! Outflow: two venae comitantes, basilic vein, cephalic Outflow: two venae comitantes, basilic vein, cephalic

veinvein!! Long vascular pedicle with dependable supplyLong vascular pedicle with dependable supply!! Potential sensation (posterior cutaneous nerve Potential sensation (posterior cutaneous nerve

anastomosed to lingual)anastomosed to lingual)!! Disadvantage: donor site morbidity (STSG, potential Disadvantage: donor site morbidity (STSG, potential

loss of thumb and index finger, potential decreased loss of thumb and index finger, potential decreased forearm function)forearm function)


Anterior Tongue ReconstructionAnterior Tongue Reconstruction

!! Very difficult to reconstructVery difficult to reconstruct!! Complex intrinsic musculature and Complex intrinsic musculature and

functionfunction!! Redundancy is advantageousRedundancy is advantageous

!! Near hemiglossectomy does not significantly Near hemiglossectomy does not significantly alter functionalter function


!! Defects <50% can be closed primarily +/Defects <50% can be closed primarily +/--STSGSTSG

!! Larger or composite defects require more Larger or composite defects require more bulk (i.e, fasciocutaneous free flap)bulk (i.e, fasciocutaneous free flap)

!! Lateral arm free flap is good for defects Lateral arm free flap is good for defects including posterior aspect of tongue/FOMincluding posterior aspect of tongue/FOM




!! Lateral Arm free flapLateral Arm free flap!! Posterior radial collateral arteryPosterior radial collateral artery!! Paired venae comitantesPaired venae comitantes!! 12 x 18 cm paddle possible (6 x 8 cm allows 12 x 18 cm paddle possible (6 x 8 cm allows

for primary closure)for primary closure)!! Potential sensate flap (posterior cutaneous Potential sensate flap (posterior cutaneous

nerve)nerve)!! Disadvantages: donor site appearance, hair Disadvantages: donor site appearance, hair

growth, elbow pain, lateral forearm growth, elbow pain, lateral forearm numbness numbness


Buccal Cavity ReconstructionBuccal Cavity Reconstruction

!! Small defects Small defects –– primary closure possibleprimary closure possible!! Larger superficial defectsLarger superficial defects

!! Quilted skin/mucosal graftsQuilted skin/mucosal grafts!! Temporoparietal fascial flap (STSG for lining)Temporoparietal fascial flap (STSG for lining)

!! Large fullLarge full--thickness defectsthickness defects!! Pectoralis major myocutaneous flapPectoralis major myocutaneous flap!! Latissimus dorsi Latissimus dorsi myocutaneousmyocutaneous flapflap!! Fasciocutaneous free flapsFasciocutaneous free flaps

Buccal Cavity ReconstructionBuccal Cavity Reconstruction

Mandibular ReconstructionMandibular Reconstruction!! GoalsGoals

!! Reconstitute Reconstitute mandibular continuitymandibular continuity

!! Allow for future dental Allow for future dental restorationrestoration

!! Anterior defectsAnterior defects!! Worst functional Worst functional

defectsdefects!! “Andy Gump” “Andy Gump”

deformitydeformity!! Lateral defectsLateral defects

!! Easier to reconstructEasier to reconstruct!! Less functional Less functional

problemsproblems

Mandibular ReconstructionMandibular Reconstruction

!! Fibula osseocutaneous free flap ideal for Fibula osseocutaneous free flap ideal for anterior defects (minimal soft tissue anterior defects (minimal soft tissue defect)defect)!! Based on peroneal vesselsBased on peroneal vessels!! Multiple osteotomies allowable (for Multiple osteotomies allowable (for

contouring)contouring)!! 25 cm of bone available (entire defects)25 cm of bone available (entire defects)!! Sensate (lateral cutaneous nerve)Sensate (lateral cutaneous nerve)!! Reliable for osseointegrated dental implantsReliable for osseointegrated dental implants

Fibula Free FlapFibula Free Flap

Fibula Free FlapFibula Free Flap


!! Scapular free flap for anterior defects with Scapular free flap for anterior defects with massive soft tissue loss (i.e., total glossectomy)massive soft tissue loss (i.e., total glossectomy)!! Circumflex scapular artery and veinCircumflex scapular artery and vein!! 14 cm of bone available (lateral aspect)14 cm of bone available (lateral aspect)!! Allows osseointegrated implantsAllows osseointegrated implants!! Long pedicle to axillary arteryLong pedicle to axillary artery!! Multiple fasciocutaneous/musculocutaneous flaps Multiple fasciocutaneous/musculocutaneous flaps

available (scapular, parascapular, latissimus dorsi, available (scapular, parascapular, latissimus dorsi, serratus anterior)serratus anterior)

!! Major drawback: patient positioningMajor drawback: patient positioning

Scapula Free FlapScapula Free Flap


!! Lateral mandible defectsLateral mandible defects!! Regional/Distant/Free flap with mandibular Regional/Distant/Free flap with mandibular

swingswing!! Low profile reconstruction plate with soft Low profile reconstruction plate with soft

tissue coveragetissue coverage!! Patient factors which prevent dental restorationPatient factors which prevent dental restoration!! Plate exposure rate of about 5%Plate exposure rate of about 5%!! Compared to anterior exposure rate near 20%Compared to anterior exposure rate near 20%

!! Osseocutaneous free flaps (iliac, scapular, Osseocutaneous free flaps (iliac, scapular, fibula)fibula)



!! Iliac crest free flap for lateral defectsIliac crest free flap for lateral defects!! Internal oblique musculature includedInternal oblique musculature included!! Contour similar to native mandibleContour similar to native mandible!! Reliable for osseointegrated implantsReliable for osseointegrated implants!! Deep circumflex iliac arteryDeep circumflex iliac artery!! Disadvantages (difficult harvest, donor site Disadvantages (difficult harvest, donor site

deformity, abdominal weakness, deformity, abdominal weakness, postoperative hematoma, lateral thigh postoperative hematoma, lateral thigh pain/anesthesia)pain/anesthesia)

!! Split inner cortex modification reduces Split inner cortex modification reduces morbiditymorbidity



Special ConsiderationsSpecial Considerations

!! Total Glossectomy DefectsTotal Glossectomy Defects!! Often accompany oral cavity defects with Often accompany oral cavity defects with

extensive diseaseextensive disease!! Require bulk for reconstructionRequire bulk for reconstruction!! GoalsGoals

!! Direct secretions laterallyDirect secretions laterally!! Provide contact of neoProvide contact of neo--tongue with palatetongue with palate

!! Use flaps which will not atrophy over timeUse flaps which will not atrophy over time!! Palatal drop prosthesisPalatal drop prosthesis


!! Total Glossectomy DefectsTotal Glossectomy Defects!! Rectus abdominis free flapRectus abdominis free flap

!! Inferior and superior epigastric arteriesInferior and superior epigastric arteries!! Motor nerve (intercostal) Motor nerve (intercostal) anastomosisanastomosis retains bulkretains bulk

!! Latissimus dorsi myocutaneous free flapLatissimus dorsi myocutaneous free flap!! Thoracodorsal arteryThoracodorsal artery!! Motor nerve (thoracodorsal)Motor nerve (thoracodorsal)

!! Pedicled flaps (PMMF, latissimus dorsi)Pedicled flaps (PMMF, latissimus dorsi)


!! Total glossectomy with laryngeal Total glossectomy with laryngeal preservationpreservation!! Select patients Select patients

!! Good health without cardiopulmonary diseaseGood health without cardiopulmonary disease!! Can tolerate aspirationCan tolerate aspiration!! Disease does not involve valleculae or Disease does not involve valleculae or

preepiglottic spacepreepiglottic space

!! Must maintain intact superior laryngeal nerveMust maintain intact superior laryngeal nerve!! Laryngeal suspension lessens aspirationLaryngeal suspension lessens aspiration

Decision Making in Oral Cavity ReconstructionDefect Type

Soft Tissue Bone

Floor of Mouth

SmallSTSG

ModerateRegional Flaps

Fasciocutaneous Free FlapsLarge

Pedicled Fasciocutaneous flapFasciocutaneous free flaps

SuperficialPrimary Closure

Skin/Mucosal GraftsFull Thickness Regional Flaps

Fasciocutaneous Free FlapsLarge Full Thickness

Fasciocutaneous Free FlapsPedicled musculocutaneous flaps

Osseocutaneous free flaps

Regional/Distant Flapand Mandibular Swing

Reconstruction Plate andRegional/Distant Flaps

Osseocutaneous Free Flaps

<50% LossPrimary Closure

Skin GraftCombined Defects

Fasciocutaneous free flapsTotal Glossectomy

Myocutaneous free flapsPedicled musculocutaneous flaps

Buccal Mucosa Tongue

Anterior Defect Lateral Defect

ConclusionConclusion

!! Multitude of reconstructive optionsMultitude of reconstructive options!! Remember functional characteristics of Remember functional characteristics of

tissue involvedtissue involved!! Various patient factors to considerVarious patient factors to consider!! Preoperative counseling essentialPreoperative counseling essential!! High success rates possible with proper High success rates possible with proper

patient selection patient selection

ReferencesReferences!! Fong BP, Funk GF. Osseous free tissue transfer in head and neckFong BP, Funk GF. Osseous free tissue transfer in head and neck reconstruction. Facial reconstruction. Facial PlastPlast SurgSurg. 1999; 15(1): 45. 1999; 15(1): 45--5959!!

!! Liu R, Liu R, GullaneGullane P, Brown D, Irish J. P, Brown D, Irish J. PectoralisPectoralis major major myocutaneousmyocutaneous pedicledpedicled flap in head and neck reconstruction: retrospective review flap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronof indications and results in 244 consecutive cases at the Toronto General Hospital. J to General Hospital. J OtolaryngolOtolaryngol. 2001 Feb; 30(1): 34. 2001 Feb; 30(1): 34--4040

!!

!! AbemayorAbemayor E, Blackwell KE. Reconstruction of soft tissue defects in the E, Blackwell KE. Reconstruction of soft tissue defects in the oral cavity and oral cavity and oropharynxoropharynx. Arch . Arch OtolaryngolOtolaryngol Head Neck Head Neck SurgSurg. . 2000 Jul; 126(7): 9092000 Jul; 126(7): 909--1212

!!

!! BerenholzBerenholz L, Kessler A, Segal S. L, Kessler A, Segal S. PlatysmaPlatysma myocutaneousmyocutaneous flap for flap for intraoralintraoral reconstruction: an option in the compromised patient. reconstruction: an option in the compromised patient. Int J Int J Oral Oral MaxillofacMaxillofac SurgSurg. . 1999 Aug; 28(4): 2851999 Aug; 28(4): 285--77

!!

!! BurkeyBurkey BB, Coleman JR BB, Coleman JR JrJr. Current concepts in . Current concepts in oromandibularoromandibular reconstruction. reconstruction. OtolaryngolOtolaryngol ClinClin North Am. 1997 Aug; 30(4): 607North Am. 1997 Aug; 30(4): 607--3030!!

!! Wells MD, Edwards AL, Luce EA. Wells MD, Edwards AL, Luce EA. IntraoralIntraoral reconstructive techniques. reconstructive techniques. Clin Clin PlastPlast SurgSurg. 1995 Jan; 22(1): 91. 1995 Jan; 22(1): 91--108108!!

!! HausamenHausamen JE, JE, NeukamNeukam FW. FW. Resection of tumors in tongue, floor of the mouth, and mandible:Resection of tumors in tongue, floor of the mouth, and mandible: possibilities of primary reconstruction. possibilities of primary reconstruction. Recent Results Cancer Res. 1994; 134:25Recent Results Cancer Res. 1994; 134:25--3535

!!

!! Boyd JB. Use of reconstruction plates in conjunction with softBoyd JB. Use of reconstruction plates in conjunction with soft--tissue free flaps for tissue free flaps for oromandibularoromandibular reconstruction. reconstruction. ClinClin PlastPlast SurgSurg. 1994 . 1994 Jan; 21(1): 69Jan; 21(1): 69--7777

!!

!! YousifYousif NJ, NJ, MatloubMatloub HS, Sanger JR, Campbell B. SoftHS, Sanger JR, Campbell B. Soft--tissue reconstruction of the oral cavity. tissue reconstruction of the oral cavity. ClinClin PlastPlast SurgSurg. 1994 Jan; 21(1): 15. 1994 Jan; 21(1): 15--2323

Health & Medicine

Oral Cavity Recon Slides 030212