Reconstruction dr.shaji HEAD AND NECK RECONSTRUCTIONS

REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer

Reconstructive options after Head and Neck Cancer resections

DR.SHAJI THOMAS MS,MChAdditional Professor

Division of Surgical OncologyRegional Cancer Centre

Trivandrum


Impact of major head and neck surgery

Devastating morbiditiesCosmeticFunctional

PhysicalPsychologicalNutritional

Quality of life


Reconstructive surgeries

Aim : Restoration of form and functionForm: Esthetic

Restoration of contour Expression of face Oral competence

Functions: Speech Mastication Deglutition


Reconstructive ladder

Primary closureSkin graftingLocal flapsRegional flapsDistant flapsFree flaps


How to select

• Select the most appropriate option for the particular defect• Patient factors-Age,perfomance status,comorbidities• Patient choice and expectations• Tissues to be replaced• Occupation• Patient counselling


Primary Closure

Small and moderate defects of – Skin– Soft tissues– Mucosa

Should not cause – Restriction of movements– Tension – Cosmetic disfigurement


Skin Grafts

For small and superficial defects of skin and mucosaSplit thickness skin graftFull thickness skin grafts

Graft ContractureRestriction of movementsTrismus


Full thickness skin Grafts

Ideal for covering small defects after removal of tumours in areas like

1. Tip of nose

2. Parts of the pinna

3. Lower eye lid.


Locoregional Flaps

A local flap implies that the tissue is adjacent to the open wound in need of coverage.

Although Free flaps have taken over, the local flaps still the method of choice for repair of most facial defects which cannot be closed primarily.


Local Flaps in Head and Neck

Rich Vascularity

Lot of local flaps available

Long and thin local flaps can be planned

Good colour and texture match

Good healing of donor site

Less morbidity

Same incision & field

Little expertise

Time saving


Local Flaps

Advancement Flaps

Rotation Flaps

Transposition Flaps

Rhomboid flaps

Bilobed flaps


Local flaps

Random –(skin or mucosal) Rotation,Advancement,Transposition, Interposition & Interpolation

Axial pattern- A distinct blood vessel is identifiable in the pedicle Nasolabial,Forehead


The choice between use of a transposition flap or a rotation flap is often influenced by the nature and size of the defect.

When the defect to be reconstructed is large, a transposition flap is safer and ideal.

Local flaps are usually preferred in scalp defect reconstruction because it is hair bearing.


Regional Flaps

Flaps from adjoining areas

Nasolabial flaps

Forehead flaps

Cervical flaps

Submental flaps


Nasolabial Flaps

Superiorly based Alar defects of nose

Eye lid Cheek

Inferiorly based Lower lip Oral commissure Tongue Floor of mouth Other intraoral defects


Forehead Flaps

Median-both supratrochlear vesselsParamedianSup.temp Artery based-Transverse forehead flapsUsed for-Nasal Med.canthal and eyelid defects Intra oral-transverse flap


Submental artery Island Flap

This is an axial pattern flap based on the submental branch of the facial arteryAdvantages:

Donor defect can be closed primarily on the donor site scar is hidden under the mandible.

Flap has a large and reliable vascular pedicle with excellent reach to most of the oral cavity sites.

Ideal thickness for reconstructing buccal mucosa and tongue defects.Less bulk and less time consuming when compared with free flaps.

Disadvantages: Submental flap harvested with a thick surrounding fibrofatty tissue and tissues

around the facial vessels can compromise the lymphatic clearance. So it is better to avoid this flap in patients with clinically significant node in level IA and IB.


Flap planning

Upper limit within mandibular

margin.

Size of flap depends on the

defect and which allows primary

closure.

Donor defect should be hidden

under mandible.







DELTOPECTORAL FLAP

It served as the premier flap for reconstructing complex head and neck defects until the late 1970s

AdvantagesTechnical simplicity Predictable vascular supplyReconstruction in select cases in which vascularized skin coverage

of the neck is neededThe DP flap also provides a valuable salvage option


Myocutaneous Flaps

• Commonest reconstructive option for major head and neck defects

Pect.major flaps

Sternomastoid flaps

Trapezius myocutaneous flaps

Lat.dorsi flaps


Pectoralis major myocutaneous flap

This is the most frequently used myocutaneous flap for head and neck reconstructions

The workhorse of the head and neck surgeon

The blood supply to pectoralis major flap is consistent and so very reliable.

The donor defect can be closed primarily in majority of cases.



Main uses of Pectoralis major Myocutaneous flap in head and neck: For reconstruction of major intra oral lining defectsFor reconstructing outside skin defects of cheek or full thickness defects of oral

cavity.For covering major neck skin defects following extended radical neck dissection

and in post irradiated patients.For protecting the exposed carotid vessels following neck dissection to prevent

carotid blow out.For augmenting the pharyngeal closure following laryngopharyngectomy when

there is tension in pharyngeal closure especially in salvage set up.For reconstructing circumferential pharyngeal and cervical oesophageal defects.


Platysma flap

An island myocutaneous flap based on the platysma muscle is ideal for reconstructing the superficial lining defects of oral cavity

Disadvantages of platysma flap:Blood supply can be unreliable.Prior neck dissection or any neck surgeries precludes the use of this flapA proper neck dissection may damage the blood supply to the flapRemoval of the platysma interferes with the blood supply to the overlying skin and

can lead to necrosis of skin. Platysma flap is not advisable in patients with prior irradiation to neck.


Sternomastoid flap

Advantages The skin paddle of superiorly based sternomastoid flap is hairless

and thin and is an ideal reconstructive option for medium sized cheek defects.

It does not produce excessive bulk in the face or mouth Disadvantages

A proper neck dissection is likely to cause damage to the vascular pedicle. Hence a previous neck surgery or concurrent lymphadenectomy preclude the use of this flap





Trapezius Myocutaneous Flap

The trapezius myocutaneous flap can be used for reconstructing defects of head and neck region and upper back.

Its location makes it the flap of choice for defects of the occipital, parotid and cervical spine regions.



Free flaps

Microvascular free tissue transfer

Not constrained by size and reach

All types of defects can be reconstructed

Skin, soft tissue, bone defects all can be reconstructed


Free Flaps

Radial Forearm flapAntero lateral Thigh flapFree Fibula flapLatissimus Dorsi flapDCIA flapTRAM flapOthers


Bony Defects

• Mandibular Reconstruction• Is it a must to reconstruct all mandibular defects?• Yes in all young patients and cenral mandibular defects• Better cosmesis,prevents mandibular deviation,teeth can

be implanted• Maxillectomy Defects• Prosthesis vs reconstruction


Free fibula flap


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


Conclusion

Most of these reconstrucive procedures can be performed in medium level hospitals.

Since head and neck cancer is a common problem in our population all general surgeons need a good exposure to head and neck resections and reconstructions

Health & Medicine

Reconstruction dr.shaji HEAD AND NECK RECONSTRUCTIONS