Upload
harsh-amin
View
101
Download
0
Tags:
Embed Size (px)
DESCRIPTION
HEAD NECK RECONSTRUCTION
Citation preview
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