Because the head and neck are vital to eating, breathing, blood flow, and communication – and due to the visibility of these areas – reconstructive surgery has unique challenges and goals. The choice of free flap should not only include the adequate components required for skin coverage, soft tissue bulk, and skeletal support, but also a surplus of skin, fascia, or muscle that can be used to provide lining. Head and Neck Reconstruction Surgery. The maximum skin paddle size measures approximately 15 × 10 cm, similar to the area of the radial forearm skin paddle. Using these data, strong predictive models were able to be created for presence of a G/GJ, NE, or tracheostomy tube at 30 days postoperatively, and conversion from a NE to a G/GJ tube. Examples of such flaps include the radial forearm flap and the ALT flap, which allow for nerve coaptation of the … Some head and neck cancer patients need to have part of the jaw removed during surgery, affecting speech and function. This may be due to small anatomy and local ischemic effects or a discrepancy in the rate of anatomic growth in the growing infant/child, but to date, there is a lack of consensus regarding optimal conduit selection in all ages. The two-year Head and Neck Fellowship and Microvascular Reconstruction program encompasses all the ablative instruction of the one-year Head and Neck Fellowship, with the added benefit of training in microvascular reconstruction and free flaps. 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. 14.4 ), which incorporates a cecal anastomosis to the esophageal wall, preserves the ileocecal valve, and requires an ileal anastomosis to the trachea. Head and neck reconstruction cannot be described in the 21st century without including free tissue transfer as an integral component in the current standard of care for various traumatic, oncologic, and congenital defects of the head and neck region. In accordance with the concept of defect boundaries, if a defect comprises <60% of the unit, maximal preservation of local surrounding tissue is required, as it may be successively recruited with local tissue rearrangement during secondary procedures. Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. Additionally, there is a midline frontoethmoid-vomerine buttress. Our program brings together experts in reconstructive surgery, speech and swallowing therapy, nutrition, oral surgery, and prosthodontics, to help maximize your quality of life before, during, and after treatment. 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. Pedicled flaps in head and neck surgery 1. When thin soft tissue is needed with a long pedicle, the ulnar forearm flap is a good choice, with the additional benefit of a favorable donor site and hairless skin. Finally, the lateral subunit spans the area lateral to the paramedian subunit until the temporal hairline. First, dissection of the recipient site and its vessels is simplified when not operating in a scarred bed. However, anatomic variations in the origin of the ulnar artery do exist. Prior to the adoption of clinical microsurgery, the traditional tongue reconstruction following total or subtotal glossectomy was pectoralis or trapezius pedicled flaps, primarily to achieve wound closure. The superficial system consists of the basilic vein and its associated branching veins. Microvascular reconstruction is a surgical procedure that involves moving a composite piece of tissue from another part of the body to the head and neck. Reconstructive surgery allows for patients to achieve the best possible result to maintain as much function as possible. The advantages of the jejunal free flap include its durability, sufficient quantity, and limited effect on physiologic effect of gastrointestinal function. This is depicted in Figure 14.1 , where a large forehead defect prompts extension of the borders of resection, making the forehead defect larger than initially encountered. Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care Facial Plast Surg. 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. Guided by the critical concepts described above, soft tissue reconstruction should include excess soft tissue with the expectation that volume loss will occur. Recruiting distant tissue transfer serves as a base for local tissue advancement and resurfaced to provide a more favorable cutaneous texture and color match. Microvascular head and neck reconstruction is used to treat head and neck cancers, including those of the larynx and pharynx, oral cavity, salivary glands, jaws, calvarium, sinuses, tongue and skin. Selecting subcutaneous veins may be advantageous when named veins are difficult to isolate within an amputated segment, but Stillaert et al. The ulnar artery courses ulnar and deep to the pronator teres, flexor carpi radialis, and flexor digitorum superficialis running along the flexor digitorum profundus. The donor site is best closed over a closed suction drain due to the potential space created by the flap harvest. 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. The skeletal buttresses are areas of thick bone that function to transfer forces from mastication to the cranial base. The Division of Head and Neck Surgery boasts a robust reconstructive practice to match the high volume ablative oncology practice. With time, free tissue transfer has become the gold standard in reconstructing large or total tongue defects with multiple flaps including the radial forearm flap; ALT flap; infrahyoid myofacial flaps; latissimus dorsi; rectus abdominis muscle flap; gracilis flap; medial gastrocnemius flap; pectoralis flap; parascapular flap; DCIA flap; and fibula flap; all serve as suitable options depending on the details and extent of the defect. Vascularized bone obviates many of the unforeseen complications that are associated with non-vascularized bone grafts and alloplastic materials, and therefore should be used for hard tissue reconstruction whenever possible. Excision of the entire unit during the first reconstruction is not ideal because this leaves an obvious area of color-mismatched and hair-bearing skin, demarcating a stark contrast of the cheek aesthetic unit. The anterior branch follows the course of the basilic vein distal to the elbow and innervates the medial half of the anterior forearm. This means that large tumours can now be safely removed with good margins and the holes or defects that are created can be restored. As with the radial forearm flap, the ulnar flap provides a thin, pliable skin paddle with lengthy vascular pedicle of relatively large caliber. The soft tissue volume included in a free flap should be in slight excess of the actual amount of tissue that is deficient. Free tissue reconstruction of the scalp and forehead is generally reserved for large, full-thickness defects. The tissue most commonly comes from the arms, legs, or back, and can include bone, skin, fat, and/or muscle. In order to reconstruct this complex defects great skill is required as well as … Management of head and neck cancer has undergone many significant changes during the past two decades. Reconstructive surgery can involve one or more of the following procedures: Your referral enquiry has been successfully submitted – thank you for referring a patient to us. Cancer may involve The rate of conduit stricture following gastric reconstruction is approximately 14%, and colonic interposition grafts are more likely to manifest redundancy and subsequent recurrent luminal collapse in 15–30% of cases. Healthy adipose tissue will also provide the necessary volume for future revisionary reshaping procedures as the transferred tissue settles. These intricate surgeries enable both cosmetic repair and enable restoration of speech, swallowing and other important functioning. Head and neck reconstruction cannot be described in the 21st century without including free tissue transfer as an integral component in the current standard of care for various traumatic, oncologic, and congenital defects of the head and neck region. In the event of a unilateral deficit, a unilateral Z-plasty can tailor a neotip (from the intact tongue to cross toward the flap site) to improve tongue tip function and sensation. The periorbital region is composed of the superior, lateral, and inferior orbit and anteromedial portion of the temporal region. Scalp reconstruction often involves a hair-bearing region that is unique to patient identity. The technique is one of the most advanced surgical options available for rehabilitating surgical defects that are caused by the removal of head and neck tumours. Ambitious single-stage procedures do not capture all of the tools in the plastic surgeon’s armamentarium in solving large craniofacial defects. Flaps with excess bulk and length facilitate contact between the palate and tongue owing to improved long-term outcomes in deglutition and speech. Add to My Interests . The vast experience accrued with microvascular reconstructive surgery has meant a significant expansion in the options available. This type of procedure is often referred to as microvascular reconstruction surgery (also known as "free flap" or "free tissue transfer" surgery). The disadvantage of non-vascularized bone grafts includes unpredictable resorption rates and the inability to replace large structural defects. The fibular free flap has become the workhorse flap due to its shape and long pedicle. tive day 7 in head and neck surgery from January 1990 to January 2018. Performing more than 150 pedicled and microvascular flaps per year, the nationally recognized UNC Head and Neck Reconstructive Team of Drs. SURGERY RESULTING FROM CANCER TREATMENT IS KNOWN AS HEAD AND NECK CANCER RECONSTRUCTION. Wolters Kluwer Health, 2012.). In the midface, is it critical to assess which tissue types are missing and to reconstruct them accordingly. (B) Iatrogenic extension of the wound boundaries allows for the incision line to be hidden in the hairline. This can leave large defects that have a major impact on function as well as appearance. As a result, microsurgeons attempt single-stage procedures aimed at definitive reconstruction. Epub 2018 Dec 28. Ongoing child development and whether he or she will ultimately “outgrow” their free flap reconstruction is difficult to predict, which significantly contributes to the decision-making process of timing reconstruction. Certain principles can be broadly applied to forehead reconstruction to obtain a successful result: Hairline symmetry (frontal and temporal) must be maintained. The vast experience accrued with microvascular reconstructive surgery has meant a significant expansion in the options available. In the face of trauma or oncologic resection, the microsurgeon must not prolong the time to reconstruction. Scars should be concealed within relaxed skin tension lines, borders of aesthetic subunits, or within the hairline. Vascularized bone is the preferred choice when defects of the midface require free tissue transfer (such as a free fibula flap). Perhaps, these principles were considered secondary because early microvascular flap failure rates were initially too high. Reconstructing a composite tissue defect of an aesthetic subunit of the face with free tissue transfer requires the necessary elements that are absent in a wound including the underlying skeletal support with the coverage of soft tissue. Critical Concepts of Craniofacial Microvascular Reconstruction Aesthetic Subunit Appearance . Microvascular Reconstruction Surgery. Although the midface is an area that tends to be reconstructed with soft tissue free flaps, bone is necessary to restore the skeletal buttresses and maintain projection of the midface. 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. The present paper will present an algorithmic approach to head and neck reconstruction of various subsites, using an evidence-based ap… The foresight of future revisions allows initial free tissue transfer to be planned and executed with more success. The head and neck fellowship is divided into major areas, including surgical oncology and microvascular reconstruction, TORS, skull base surgery, radiation oncology, and medical oncology. 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. This can leave large defects that have a major impact on function as well as appearance. Chair: Urjeet Patel, MD Vice-Chair: Derrick Lin, MD 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 […] The advantages of initiating early free tissue transfer to avoid these effects are two-fold. Microsurgical Reconstruction of the Head and Neck is a master work representing a unique collaboration among the world's leading microsurgeons who share their expertise and insights on the latest advances and techniques in head and neck reconstruction.. Comprehensive Coverage. We are proud to offer a comprehensive and multi-disciplinary program in Head & Neck Surgery — Reconstruction Surgery. The direct result is a profound alteration in speech or a complete impairment of vocal function that is largely responsible for psychosocial and emotional patient anguish. Explore the latest in head and neck reconstruction, including advances in reconstructive techniques and approaches following trauma and cancer. Selection of the donor site for free soft tissue transfer must be guided in a patient-centered, individualized basis. 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. Expansion or rearrangement of wound borders allows for a decreased microbial burden and a healthy wound edge comprised of collagenous, elastic, and a well-vascularized environment facilitating better wound healing. Glossectomy has a larger impact on quality of life than other resections of head and neck structures. 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. The challenge for reconstruction is not only the aesthetic result, but the functional repair. 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”. The inherent characteristics of the subunit at hand must dictate the reconstructive effort because not all aesthetic subunits are as easy to re-create as others with free tissue transfer. If postoperative radiation therapy is anticipated, the excess volume should be further increased, since significant soft tissue contraction can result from radiation exposure. Free tissue transfer to the head and neck is most frequently incorporated following oncologic resection, trauma, infection, osteoradionecrosis, or congenital deformity or malformation, or as a means of reconstructing a failed prior flap. Although prosthetic one-way valves are low-cost, easily reproducible, and attempt to mitigate these risks, there are several surgical methods of voice reconstruction that may obviate their use. It is aimed at restoring the function and appearance of the face, mouth, neck, and throat. The weaker, horizontal buttresses are comprised of the superior and inferior orbital rims and the alveolar ridge. 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. In some situations, tissue from a patient’s own body outside of the head and neck region is "transplanted" to reconstruct areas of the face, mouth, throat or neck. The use of functional muscle flaps for tongue reconstruction boasts increased speech intelligibility, better palatal occlusion, and improvement in deglutition. There are two positions available per year, beginning in July. This can be as simple as closing a cut on the head to a major surgery after a car accident. At this level of complexity, although feasible, successful outcomes may vary in each individual surgeon’s hands. The flap is designed with its central axis along the course of the ulnar artery in the mid- and distal forearm. The right method for your specific situation. 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. In contrast to adipose tissue, denervated muscle flaps tend to atrophy significantly over time, compromising long-term aesthetic outcome and failing to provide durable coverage for alloplastic implants. The Location of a tumour, the surgery to remove a cancer could cause significant deformities of the face. The periorbital region supports for the orbit and extraocular function. Rama raju 2. Head and Neck Reconstruction. Defects >5 cm are best reconstructed with free tissue, whereas smaller defects may be reconstructed with bone grafts or hardware in select cases. In addition, the subcutaneous fat is partitioned into discrete compartments of the face, a concept championed in cosmetic facial surgery. The complexity of the tongue includes its innervations and proprioceptive biofeedback, and specialized movements make full functional recovery extremely challenging. The extent of resection, involvement of esophageal resection, exposure to radiation, prognosis, prior abdominal surgeries, and previously failed voice rehabilitation aid the microsurgeon in selecting optimal patients and optimal approaches to reconstruction. 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