In the midface, is it critical to assess which tissue types are missing and to reconstruct them accordingly. At this juncture, skin excision from the free flap with full-thickness skin grafting from a donor site similar in color and texture to the facial subunit, remains an option. 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. It is imperative to recognize that aesthetic facial subunits are not just “skin deep.” Each facial region is comprised of vertical and horizontal skeletal buttresses that provide critical soft tissue support and shape.  A full-thickness skin graft will yield superior cosmetic results and provides durable coverage of exposed muscles and tendons. 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. 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. The inclusion of ample volumes of well-vascularized fat in particular will minimize subsequent fat necrosis and soft tissue resorption. Both are important in establishing a reconstructive goal. Their application to a variety of anatomic locations, including the scalp, periorbital region, midface, and mandible, is now described with corresponding cases and figures. One of our practice team will be in touch with you as soon as possible. Another option is the appendix, which can be used as the TE conduit for communication between the esophagus and trachea. 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. The arterial pedicle length can be maximally harvested to the take off of the common interosseus artery (about 15 cm), and will consistently be shorter than the arterial pedicle of the radial artery forearm flap, which can be dissected to the bifurcation of the brachial artery. 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. Esophageal reconstruction can be accomplished using multiple tissue types as conduits. 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. The skeletal buttresses are areas of thick bone that function to transfer forces from mastication to the cranial base. 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. This can be accomplished by re-creating the glossoalveolar and buccoalveolar sulcii, with the option of laryngeal suspension and esophageal widening depending on anatomic flap inset. Management of head and neck cancer has undergone many significant changes during the past two decades. With the understanding that secondary revisions are often inevitable in optimizing complex defects, the initial reconstructive procedure no longer assumes the burden of complete reconstruction but is the first of multiple approaches. The purpose of this chapter is to provide a methodological approach to microvascular reconstruction of the head and neck while optimizing aesthetic and functional outcomes, as well as developing an effective means of achieving reliable and replicable results. Pedicled flaps in head and neck surgery 1. Another 131 cases undergone the same surgery were included for system verification. 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”. These intricate surgeries enable both cosmetic repair and enable restoration of speech, swallowing and other important functioning. Options for debulking via direct excision and/or liposuction in a revisionary procedure allow the surgeon to focus on cosmesis after the initial healing period and after flap survival is assured. The boundaries of the defect will often spare adjacent structures and preserved tissue of the tongue will retain partial function, at which point a thin and smaller flap is optimal because it is less likely to impede an already functioning tongue. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Functional Muscle Transfers for Various Purposes, Problem Analysis in Reconstructive Surgery: Reconstructive Ladders, Elevators, and Surgical Judgment, Anterolateral and Anteromedial Thigh Flaps, Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection. Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. Alloplastic materials are prone to late infection and tend to extrude over time, leading to implant exposure. The fibula free flap is an excellent choice with adequate length and thickness. The denervated flap may thin over time, which is why an already minimal volume of soft tissue can thin and may expose underlying hardware. The vast experience accrued with microvascular reconstructive surgery has meant a significant expansion in the options available. Latissimus dorsi flap 3. The vertical buttresses, inferior orbital rim, and alveolar ridge fall within the scope of midface reconstruction. Uncheck All . The goal of such surgeries … This means that large tumours can now be safely removed with good margins and the holes or defects that are created can be restored. 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. Ensuring ample tissue may be a challenge in the pediatric patient, especially when considering free tissue transfer to the pediatric craniofacial region. The right method for your specific situation. Glossectomy has a larger impact on quality of life than other resections of head and neck structures. Free jejunum and ileocolon flaps ( Figs 14.2 , 14.3 ) are able to restore voice with excellent long-term patency while simultaneously serving as conduits in esophageal reconstruction. 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. When smaller defects are encountered, preservation of remaining tongue tissue is of paramount importance to restoring optimal mobility of the tongue and subsequent free flap. Dissection of the ulnar artery (and the basilic vein) is continued proximally to achieve sufficient pedicle length. 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. Vanderbilt Head and Neck Surgery fellows become leaders in the field, both in academic and clinical settings. 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. These techniques allow surgeons to provide increasingly personalized reconstruction, improving the average results and reducing surgical time. The donor site is also prone to superior skin graft take because the ulnar region is subjected to less tendon glide and mechanical shear forces as there are more underlying muscle bellies rather than tendons in this region. Further detail is given in the related videos. In the face of trauma or oncologic resection, the microsurgeon must not prolong the time to reconstruction. For instance, the variability in subcutaneous fat among patients is apparent when considering an anterolateral thigh (ALT) flap. The aforementioned concept of aesthetic subunits and establishing homogeneity of skin characteristics is reiterated as the eventual need for revisionary procedures should be anticipated at the time of the initial free tissue transfer. 14.4 ), which incorporates a cecal anastomosis to the esophageal wall, preserves the ileocecal valve, and requires an ileal anastomosis to the trachea. Surgeons at Perlmutter Cancer Center are pioneers in using reconstructive techniques, which are usually performed at the same time as tumor removal. 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. Furthermore, a subset of patients may require a second reconstruction due to complications of the initial reconstruction requiring microsurgical free tissue transfer. 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. There are two positions available per year, beginning in July. The perception of facial aesthetic subunit is actually dependent on multiple elements, representing an amalgam of interactions between composite soft and hard tissue. Defects of the orbital rim and skeletal buttresses are best reconstructed with vascularized bone. 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. Vascularized bone is the preferred choice when defects of the midface require free tissue transfer (such as a free fibula flap). The inset of the flap may require increasing the anterior mediastinal space that can be accomplished with partial manubrial excision, extending the diaphragmatic esophageal hiatus, and tunneling a pliable, soft dilating catheter from the stomach to the mediastinum. Flap homogeneity throughout the entire subunit conforms to a more uniform distribution of color, thickness, and texture while disguising incisions at the junctions of subunits. Tongue defects vary in size and location (tongue base, oral tongue, or both). 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 technique is one of the most advanced surgical options available for rehabilitating surgical defects that are caused by the removal of head and neck tumors. 2018 Dec;34(6):597-604. doi: 10.1055/s-0038-1676076. Tumors that affect the regions of the head and neck may require surgery. The artery is dissected from the nerve and ligated distally. This approach ensures that all lining deficiency is addressed. The ulnar artery courses ulnar and deep to the pronator teres, flexor carpi radialis, and flexor digitorum superficialis running along the flexor digitorum profundus. We are still able to provide private curative cancer treatments. Various options are available for head and neck reconstructions and has to select the appropriate one … With the synthesis of microsurgery and craniofacial surgery, surgeons now recognize the importance of reconstructing both soft and hard tissue. The hairline varies with age, among genders, and ethnicities. 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. Alternatively, if bulk and a short pedicle are needed, the groin flap may be used. The periorbital region supports for the orbit and extraocular function. Similarly, attachments of the medial and lateral canthi must be precisely re-created to achieve a symmetric and aesthetic result. The Vanderbilt Head and Neck, Cranial Base and Microvascular Reconstructive Surgery Fellowship is an outstanding one-year clinical position with the option to extend the fellowship to a second year to focus on clinical or basic science research. Both the FFF and DCIA contain the elements necessary to restore oral mucosal defects, soft tissue, and bony deformities. For example, latissimus dorsi muscle flaps have been considered the workhorse flap and traditional choice for scalp coverage of titanium mesh cranioplasties, but such flaps have shown to thin significantly over time, often resulting in tenuous coverage or ultimate exposure of the underlying mesh. Head and Neck Reconstruction SURGERY RESULTING FROM CANCER TREATMENT IS KNOWN AS HEAD AND NECK CANCER RECONSTRUCTION. 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. It is known to be the first part of the face that a stranger sees. Once identified, vessel replantation may require supermicrosurgery. Adhering to the principles of replacing missing components such as bone, soft tissue, or oral lining can guide the surgeon in planning and executing the replacement of “like with like” tissue to herald better results. The challenge for reconstruction is not only the aesthetic result, but the functional repair. Additionally, the close relationship of the ulnar artery and nerve has evoked concerns about injury to the nerve during flap elevation. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. 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. Add to My Interests . In pediatric esophageal replacement, a meta-analysis found that stricture rates were higher in jejunal free flaps compared with colonic and gastric conduits. 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. Cleveland Clinic's craniofacial surgery for adults includes restoration or reconstruction of the head and neck area. There are a number of methods your surgeon may use to perform your reconstruction following treatment for head and neck cancer. Typically, selected free flaps have contained the necessary components for reconstructing nasal mucosa, bone, cartilage, and skin. The field of head and neck surgery has gone through numerous changes in the past two decades. Injury can affect multiple subunits or portions of subunits that makes flap selection more challenging. Guided by the critical concepts described above, soft tissue reconstruction should include excess soft tissue with the expectation that volume loss will occur. Some head and neck cancer patients need to have part of the jaw removed during surgery, affecting speech and function. Postoperatively, all patients should be enrolled in speech and swallowing rehabilitation with a skilled professional to optimize speech intelligibility, swallowing time, and palatal-tongue articulation, and improve their overall quality of life. Ambitious single-stage procedures do not capture all of the tools in the plastic surgeon’s armamentarium in solving large craniofacial defects. Soft-tissue requirements differ throughout the periorbital areas and should be matched by thickness, texture, and color. Historically, replantation of composite nasal tissue defects following traumatic amputation (often a dog bite or a form punishment) have resulted in a high failure rate or led to deforming contracture and nasal passage stenosis. However, a systematic approach to craniofacial reconstruction that abides by several tenets is essential in optimizing outcomes. Their prevention and repair is a major functional goal in periorbital reconstruction. 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