The Division of Head and Neck Surgery boasts a robust reconstructive practice to match the high volume ablative oncology practice. Over time, advancements in technique and instrumentation have precluded the surgeon from simply trying to reconstruct a defect by “filling a hole,” and have permitted restoration of entire aesthetic subunits, even when removing healthy tissue may be required. Surgery endeavours to mitigate problems related to cancer resection. Ultimately, the specific defect and its components must guide reconstruction. What Is Head And Neck Reconstruction? Patients may be better candidates for initial reconstruction with microsurgical free tissue transfer in the event of: Extensive oncological extirpation or other tissue damage (lye ingestion) that involves excision of a lengthy esophageal segment, Impaired use of other donor organs such as the stomach, The cervical esophagus (in the setting of laryngectomy or glossectomy) is involved. Contemporary reconstructions attempt sophisticated free flap techniques to preserve motor or sensory innervation to the tongue to maximize function and in turn improve health-related quality of life. First, dissection of the recipient site and its vessels is simplified when not operating in a scarred bed. 14.5 ) shares similar traits and offers additional benefits over the radial forearm flap (discussed below). This fellowship is offered through the A member of our practice team will be in touch with your patient as soon as possible. The Head and Neck-Reconstructive Surgery NSQIP provides a robust, specialty specific platform for data collection in patients undergoing head and neck surgery with flap reconstruction. Preservation of the medial antebrachial cutaneous nerve will yield a sensate flap, if it is desired for the reconstruction. Pectoralis major myocutaneous flap 2. Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. This can be as simple as closing a cut on the head to a major surgery after a car accident. Multiple tissue types that compose the craniofacial region including bone, cartilage, nerve, fat, muscle, mucosa, and varying dermal and epidermal thickness, as well the inherently intricate contours of the craniofacial skeleton can complicate reconstruction. Dissection of the ulnar artery (and the basilic vein) is continued proximally to achieve sufficient pedicle length. Head and Neck Reconstruction Any time the skin, muscle, bone or organs of the head and neck need to be repaired this is called “head and neck reconstruction”. Second, the dogmatic principles of aesthetic subunit reconstruction dictate that certain defects can be made larger in order to resurface the entire unit. [8] Large defects that involve >50% of resection, harvesting 20–30% of excess muscle to accommodate for atrophy, de-epithelialization, and folding a flap will preserve tongue height and length. When facing a large composite facial defect in which both bone and soft tissue are missing, selecting a flap consisting of abundant soft tissue rather than both bone and soft tissue is not recommended. 7 patients underwent TMJ reconstruction with custom made prosthesis and received either pre or post operative radiotherapy. This type of procedure is often referred to as microvascular reconstruction surgery (also known as "free flap" or "free tissue transfer" surgery). A total of 45 cases of late free flap fail- ure in the head and neck were identified. Head and Neck Reconstruction SURGERY RESULTING FROM CANCER TREATMENT IS KNOWN AS HEAD AND NECK CANCER RECONSTRUCTION. Variations of an ear flap have been popularized including the helical rim, chondrocutaneous ear flap (combined with osteocutaneous femur), and reversed superficial temporal artery (STA) auricle flap. The advantages of the jejunal free flap include its durability, sufficient quantity, and limited effect on physiologic effect of gastrointestinal function. Coverage of extensive nasal defects can be completed using a prosthetic attachment or using autologous tissue to permanently restore nasal form, nasal respiration, and vocal tone. As with non-vascularized bone grafts, the long-term complications may require further surgical interventions later down the line. Understanding the Surgery Because the lips, mouth, tongue, throat, and voice box are so vital for normal everyday function and appearance, proper reconstruction is critical. It is preferable to err on the side of caution with a thicker flap, which can be debulked secondarily. Surgeons at Perlmutter Cancer Center are pioneers in using reconstructive techniques, which are usually performed at the same time as tumor removal. Each flap is dynamic and can be altered slightly to incorporate various characteristics necessary for specific craniofacial defects. Microvascular head and neck reconstruction is a technique for rebuilding the face and neck using blood vessels, bone and tissue, including muscle and skin from other parts of the body. A skin incision is made and dissection proceeds to between the flexor carpi ulnaris and flexor digitorum superficialis tendons to identify the ulnar artery and nerve. The reconstructive needs following ablative surgery for head and neck cancer are unique and require close attention to both form and function. It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures … Additionally, bone grafts generally provide insufficient bone stock to allow placement of osseointegrated implant prostheses. Whether they follow cancer or dental treatments, or as an entirely separate procedure, we have unparalleled experience in a range of minimally invasive reconstructive procedures. At this level of complexity, although feasible, successful outcomes may vary in each individual surgeon’s hands. In order to achieve total aesthetic subunit reconstruction, the option for potentially advancing local cutaneous tissue with successive revisionary procedures (or with tissue expansion) can lead to complete excision of the initial free flap skin paddle and reestablish the native skin of the original defect. They also absorb any impact to the facial skeleton and protect surrounding fragile structures. The sophisticated arrangement of multiple tissue types comprises unique physical traits from individual to individual. This concept is further discussed in the revisionary procedures portion of this chapter. Soft tissue–only flaps may be used for small defects, for which the rectus femoris and ALT can both be used depending on the amount of skin required. REGIONAL CANCER CENTRE, TRIVANDRUM Life beyond cancer 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. For defects that comprise >60% of an aesthetic subunit, resection of the entire subunit may be indicated since free flap reconstruction can reconstruct the expanded defect and achieve superior cosmetic results. Various options are available for head and neck reconstructions and has to select the appropriate one … The periorbital region is composed of the superior, lateral, and inferior orbit and anteromedial portion of the temporal region. Head and Neck Reconstruction. More importantly, there has been a paradigm shift toward seeking not only to achieve reliable wound closure to protect vital structures, but also to reestablish normal function and appearance. The principles of constructing the neotongue are to accurately reapproximate the biomechanics of the original tongue as this will lead to better cortical adaptation. COVID‐19 pandemic: Effects and evidence‐based recommendations for otolaryngology and head and neck surgery practice. However, concerns about donor site morbidity have prevented the ulnar forearm flap from achieving the popularity of its radial counterpart. If the basilic vein can be identified, it is ligated at this time. The donor site is also better concealed along the ulnar aspect of the forearm, especially in repose as it sits along the body and out of sight during face-to-face interaction. These flaps include the ulnar forearm flap; anterolateral thigh (ALT) flap; latissimus dorsi flap; deep circumflex iliac artery (DCIA) flap; and free fibula flap. For example, a latissimus dorsi flap can easily cover a large adult scalp defect, but it may not provide sufficient size for coverage in the pediatric patient. The ulnar artery courses ulnar and deep to the pronator teres, flexor carpi radialis, and flexor digitorum superficialis running along the flexor digitorum profundus. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. These intricate surgeries enable both cosmetic repair and enable restoration of speech, swallowing and other important functioning. Consideration of these principles is essential in attaining a functional and aesthetic outcome that is predictable and reproducible. MYOCUTANEOUS FLAPS • Commonest reconstructive option for head and neck defects include: 1. Certain principles can be broadly applied to forehead reconstruction to obtain a successful result: Hairline symmetry (frontal and temporal) must be maintained. Head and Neck Reconstruction and Microvascular Surgery To return to their daily lives, patients may need reconstructive surgery, after cancer treatment or due to a major trauma of the head and neck region. Vascularized bone is the preferred choice when defects of the midface require free tissue transfer (such as a free fibula flap). The major goal of reconstructive surgery is to maintain as much function as possible. The deep system is comprised of two venae comitantes accompanying the ulnar artery along its course through the intermuscular septum and drain into the median cubital vein at the level of the elbow. Charge: The fundamental purpose of the AHNS Reconstructive Head and Neck Surgery Section is to improve and enhance care for patients in the field of head and neck reconstructive surgery through the pillars of education, research and mentorship while focusing on both quality and value of patient care. When bone is required, both the fibula and iliac crest flaps (DCIA flap) are good choices depending on the shape of bone and length of pedicle required. The larynx is the second most common site for cancer in the upper aerodigestive tract and commonly requires total laryngectomy, which involves separation of the aerodigestive tract (tracheostoma) and closure of the pharynx or reestablishing a conduit for swallowing. Noté /5. Tongue defects vary in size and location (tongue base, oral tongue, or both). The facial vessels are the most common recipient sites of anastomosis, and the absence of the facial vein may necessitate a vein graft. Scalp reconstruction often involves a hair-bearing region that is unique to patient identity. The use of functional muscle flaps for tongue reconstruction boasts increased speech intelligibility, better palatal occlusion, and improvement in deglutition. PEDICLED FLAPS IN HEAD AND NECK SURGERY Dr . Hair is both a crutch and a challenge. Although soft tissue alone may be used to camouflage small skeletal defects, the lack of bony attachment for surrounding soft tissue increases the risk of the aforementioned complications. The titanium condyle was usually placed in the glenoid fossa without using a prosthetic fossa or any xenografts. Various options are available for head and neck reconstructions and has to select the appropriate one … It is well established that replacing “like with like” is the gold standard of aesthetically pleasing reconstructions. The maximum skin paddle size measures approximately 15 × 10 cm, similar to the area of the radial forearm skin paddle. In the case of a partial vermillion lip defect, resection and replacement of the entire unit would not result in a superior aesthetic outcome. Additionally, the close relationship of the ulnar artery and nerve has evoked concerns about injury to the nerve during flap elevation. The fibula free flap is an excellent choice with adequate length and thickness. However, this is often difficult to achieve because the face can be divided into discrete aesthetic subunits based on variations in skin texture, color, thickness, and histology. We offer a range of reconstruction options to minimise the visual impact of cancer treatment. An osteocutaneous ulnar forearm flap incorporating a portion of ulna bone is possible, but it is not commonly used. Ensuring ample tissue may be a challenge in the pediatric patient, especially when considering free tissue transfer to the pediatric craniofacial region. However, anatomic variations in the origin of the ulnar artery do exist. This can leave large defects that have a major impact on function as well as appearance. Their repair is critical to midface reconstruction. The challenge of nasal microsurgical replantation is two-fold. Other tissue types such as pedicled muscle flaps, colon interposition (based on the ascending branch of the left colic artery), and pedicled jejunal flaps (often supercharged) have been successfully employed. For instance, the variability in subcutaneous fat among patients is apparent when considering an anterolateral thigh (ALT) flap. 7 patients underwent TMJ reconstruction with custom made prosthesis and received either pre or post operative radiotherapy. Wong S(1), Melin A(2), Reilly D(2). Conscientiously reconstructing the nasal mucosa is critical in avoiding stenosis, and the liberal use of skin grafts or flap folding is recommended in achieving adequate nasal lining. Our consultant plastic surgeons work as part of a multidisciplinary team with the Trust’s ear nose and throat (ENT) department, to provide reconstructive surgery at Charing Cross Hospital following treatment for head and neck cancers.. We have an international reputation and extensive experience in treating skull base cancers and are experts in both soft tissue and bone-based reconstructions. The ulnar forearm flap can be utilized in small, soft tissue midface defects, periorbital contracture or missing tissue ( Fig. Known disadvantages of the stomach and colonic conduits include insufficient length, tenuous blood supply following gastric surgery, and aberrant colonic vascular anatomy, and grafts are susceptibility to gastric reflux resulting in secondary metaplastic changes. 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