RECONSTRUCTION IN HEAD

AND NECK MALIGNANCIES

DR.I.DAVID THANKA EDISON2nd YEAR MS PG

RECONSTRUCTIVE SURGERIES

Aim : Restoration of form and function

Form: cosmetic

Restoration of contour Expression of face Oral competence

Functions: Speech Mastication Deglutition

Reconstructive ladder It consists of following steps starting from

simplest to most complexPrimary closure

Skin grafting

Local flaps

Regional flaps

Distant flaps

Free flaps

Patient selection and decision making

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 closureSmall and moderate

defects of SkinSoft tissuesMucosa

Should not cause Restriction of

movementsTension Cosmetic disfigurement

Skin grafts

For small and superficial

defects of skin and mucosa

Split thickness skin graft

Full thickness skin grafts

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.

Limitation of skin graft:

Colour mismatch,

contour irregularity,

graft contracture

Locoregional flaps

Local Flap:

skin flap taken from anarea close to the wound.

E.g.

Abbe transoral cross – Lip flap A wound on the lip may be repaired by a flap from the adjacent cheek. Eslander flapBernad –Burrow flap

Local Flaps features: 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

Regional Flap:

Skin flap is not from theadjacent area, but is from the same region of the body.

e.g

Nasolabial flaps

Forehead flaps

Cervical flaps

Submental flaps

Submental artery Island Flap This is an axial pattern flap based on the submental branch of the facial arteryAdvantages:

The donor site scar is hidden under the mandible. Flap has a large and reliable vascular pedicle with excellentreach to most of the oral cavity. Ideal thickness forreconstructing buccal mucosaand 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.

DELTOPECTORAL FLAP

It served as the premier flap forreconstructing complex head andneck defects LIKE oral cavity&cheek

Advantages

Technical simplicity

Predictable vascular supply

The DP flap also provides a valuable salvage option

The deltopectoral flap is based on perforators from the internal mammary artery, usually perforators passing through the second and third intercostal spaces.

Myocutaneous Flaps

• Commonest reconstructive option for major head and neck defects Pectoralis major flaps Sternomastoid flaps Trapezius myocutaneous flaps Latissimuss dorsi flaps

Pectoralis major myocutaneous flap

The most frequently used myocutaneous flap

The workhorse of the headand 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

o For reconstruction of major intra oral

lining defects

o For reconstructing outside skin defects of

cheek or full thickness defects of oral cavity.

o For covering major neck skin defects

following extended radical neck dissection

and in post irradiated patients.

o For protecting the exposed carotid vessels following neck dissection to prevent carotid blow out.

o For augmenting the pharyngeal closure following laryngopharyngectomy when there is tension in pharyngeal closure especially in salvage set up.

o For reconstructing circumferential pharyngeal and cervical oesophageal defects.

Platysma flap Ideal for reconstructing the

superficial lining defects of oral cavity

Disadvantages Blood supply can be unreliable. Prior neck dissection or any necksurgeries precludes the use of this flap Improper neck dissection may

damage the blood supply to the flap Removal of the platysma interferes

with the blood supply lead to necrosis of skin. Platysma flap is not advisable inpatients with prior irradiation to neck.

Sternomastoid flapAdvantages

The skin is hairless and thin An ideal reconstructive option for medium sized cheekdefects. It does not produce excessive bulk in the face or mouth

Disadvantages

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

Trapezius Myocutaneous Flap It is 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 FlapsFeatures

Pliable so as not to impair movement in head and neck Consistent, large and long pedicle Possibility of variable size& thicknesse.g Radial Forearm flap Antero lateral Thigh flap Free Fibula flap Latissimus Dorsi flap DCIA flap TRAM flap

MANDIBULAR RECONSTRUCTIONFIBULA FLAP It consists of the fibula

bone & soft tissues

ADVANTAGES 25 cm of fibula can be

harvested Extensive periosteal

vascular supply allows functional reconstruction of the mandibule

Others Iliac crest flap scapular 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

Thank you THANK YOU