It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures … The iliac crest (DCIA flap) is frequently another viable option, especially given its similar angular structure to the ipsilateral mandible and the ample bone height it provides for dental implants. 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. For example, consider a cheek defect comprising 40% of the aesthetic unit being reconstructed with a free ALT flap. 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. What Is Head And Neck Reconstruction? Regions of the head, face, and neck are responsible for multiple high functioning mechanisms, including mastication, swallowing, phonation, articulation, respiration, vision, periorbital protective mechanisms, audition, and olfaction, all of which have been characteristic in the evolutionary development of man. 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. tive day 7 in head and neck surgery from January 1990 to January 2018. There are three paired vertical buttresses: nasomaxillary, zygomaticomaxillary, and pterygomaxillary. Another option is the appendix, which can be used as the TE conduit for communication between the esophagus and trachea. Understanding the lines of demarcation between facial segments and appreciating the variation in skin thickness throughout the face can aid the surgeon in using skin grafts from areas with similar characteristics to the site being reconstructed. The skeletal buttresses are areas of thick bone that function to transfer forces from mastication to the cranial base. Integration of the aforementioned concepts is crucial in replacing missing tissue, maximizing craniofacial function, and optimizing aesthetic results. The span of the esophagus throughout the entire thorax explains the variety of recipient vessels used for anastomoses including internal mammary vessels, superior thyroid artery, transverse cervical, external carotid artery, external jugular vein, internal jugular vein, cephalic vein, or facial vessels. Latissimus dorsi flap 3. The application of the previously described seven head and neck concepts will dictate which elements must be reconstructed as the best flap choice, since optimal reconstruction is not restricted to one type of flap. Reconstructive surgery allows for patients to achieve the best possible result to maintain as much function as possible. Patel, Hackman, and Blumberg, provide state of the art reconstruction for traumatic and oncologic defects from … Continued Uncheck All . 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. Both the FFF and DCIA contain the elements necessary to restore oral mucosal defects, soft tissue, and bony deformities. 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. To aid these patients, Johns Hopkins has a dental implant team composed of a maxillofacial prosthodontist and an oral surgeon. Pectoralis major myocutaneous flap 2. The facial vessels are the most common recipient sites of anastomosis, and the absence of the facial vein may necessitate a vein graft. 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. This can leave large defects that have a major impact on function as well as appearance. 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. 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. Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care Facial Plast Surg. Selection of the donor site for free soft tissue transfer must be guided in a patient-centered, individualized basis. The donor site is best closed over a closed suction drain due to the potential space created by the flap harvest. Furthermore, these principles mark a paradigm shift in head and neck reconstruction as they synthesize an amalgam of advancements from aesthetic surgery, craniofacial surgery, trauma surgery, and radiation, wound, and scar biology. Additionally, bone grafts generally provide insufficient bone stock to allow placement of osseointegrated implant prostheses. Surgery endeavours to mitigate problems related to cancer resection. 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. Tap for more info…. 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. Secondary revisions are fundamental for achieving successful reconstruction of the facial aesthetic units since injury is likely to cross multiple subunits and resultant scar, contracture, and contour and color mismatch are much more pronounced to the lay observer. The concept of considering the tissue types and establishing their continuity or obliterating an apparent discontinuity is particularly important when some form of “lining” tissue (e.g., conjunctiva, nasal mucosa, sinus mucosa, or oral mucosa) is deficient. The forehead can be further divided into aesthetic subunits: central, paramedian, and lateral. 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. A member of our practice team will be in touch with your patient as soon as possible. Selecting subcutaneous veins may be advantageous when named veins are difficult to isolate within an amputated segment, but Stillaert et al. 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. An osteocutaneous ulnar forearm flap incorporating a portion of ulna bone is possible, but it is not commonly used. 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. 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. Options for reconstructive approaches may seem vast at times, but a means of providing an optimal relationship of hard and soft tissue, similar to the premorbid state, should drive the decision-making process. Despite optimal flap selection, the function and mobility of the tongue are dependent on re-creating the form of the tongue. Check All. This allows wounds to heal and reduces the impact on appearance, speech, eating and swallowing. Additionally, there is a midline frontoethmoid-vomerine buttress. The periorbital region supports for the orbit and extraocular function. 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. The indications for microvascular intervention in head and neck surgery are constantly evolving and must not be restricted to a certain measurement of defect, anatomic location, or disease process. A final concern that may affect timing of reconstruction is the practical consideration of vascular pedicle size. Ileocolonic flap for voice reconstruction in the setting of concomitant esophageal reconstruction. The perception of facial aesthetic subunit is actually dependent on multiple elements, representing an amalgam of interactions between composite soft and hard tissue. However, this approach will generally compromise long-term outcomes due to skin color mismatch and soft tissue contracture. Tumors that affect the regions of the head and neck may require surgery. Over recent years, Alastair has developed many important innovations in head and neck reconstruction which have improved the lives of patients who have undergone cancer surgery or major facial trauma. Therefore, a “defect-oriented approach,” in which a soft tissue-only flap is used to solve the immediate goal of wound closure will often result in suboptimal cosmesis. The ulnar forearm flap surpasses the radial flap both in cosmetic outcomes of the donor and recipient sites. 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. Lining is often a missed element of reconstruction, which if not restored can lead fistula formation or contracture. 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. Essentially, fixed indications are difficult to define as anatomic, functional, and aesthetic components vary considerably and a single component of the three can skew an evaluation to necessitate microsurgical intervention, rather than using other reconstructive methods. In the midface, is it critical to assess which tissue types are missing and to reconstruct them accordingly. In addition, the subcutaneous fat is partitioned into discrete compartments of the face, a concept championed in cosmetic facial surgery. There are two positions available per year, beginning in July. Primary closure is possible, but skin grafting may be necessary. The inclusion of ample volumes of well-vascularized fat in particular will minimize subsequent fat necrosis and soft tissue resorption. Glossectomy has a larger impact on quality of life than other resections of head and neck structures. Failure to provide an adequate lining can severely compromise results after free flap reconstruction, leading to contracture, fibrosis, and chronic infection. The goal of craniofacial microsurgery is to reestablish a necessary structural foundation with hard and soft tissue, and the goal of subsequent revision surgery is to refine contour and volume while modifying the “unlike” flap skin with “like” local skin. A total of 45 cases of late free flap fail- ure in the head and neck were identified. The field of head and neck surgery has gone through numerous changes in the past two decades. 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. A total of 45 cases of late free flap fail- ure in the head and neck were identified. In the face of trauma or oncologic resection, the microsurgeon must not prolong the time to reconstruction. The ileo-ileocecal valve flap ( Fig. The foresight of future revisions allows initial free tissue transfer to be planned and executed with more success. In the setting of simultaneous esophageal and voice reconstruction, the restoration of voice using autologous free tissue transfer is based on the re-creation of the TE tract with mucosa from a neoesophagus. 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 principles of constructing the neotongue are to accurately reapproximate the biomechanics of the original tongue as this will lead to better cortical adaptation. 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. However, concerns about donor site morbidity have prevented the ulnar forearm flap from achieving the popularity of its radial counterpart. Microvascular free flap reconstructions largely replaced other techniques. Reluctance to utilize the ulnar forearm flap, out of concern for compromising hand perfusion, still pervades the microsurgical community. Achetez neuf ou d'occasion The vertical buttresses, inferior orbital rim, and alveolar ridge fall within the scope of midface reconstruction. 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. Finally, the lateral subunit spans the area lateral to the paramedian subunit until the temporal hairline. Explore the latest in head and neck reconstruction, including advances in reconstructive techniques and approaches following trauma and cancer. The flap is designed with its central axis along the course of the ulnar artery in the mid- and distal forearm. 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. Those patients requiring only voice reconstruction have two microsurgical options. These flaps include the ulnar forearm flap; anterolateral thigh (ALT) flap; latissimus dorsi flap; deep circumflex iliac artery (DCIA) flap; and free fibula flap. Critical Concepts of Craniofacial Microvascular Reconstruction Aesthetic Subunit Appearance . Both are important in establishing a reconstructive goal. The tissue that is most common moved during this procedure is from the arms, legs, back, and can come from the skin, bone, fat, and or muscle. It is known to be the first part of the face that a stranger sees. Commonly, full-thickness forehead defects will involve the frontal muscle. 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 central subunit is bordered by the medial eyebrows and extends vertically from the glabella to the frontal hairline. It is always easier to debulk excess soft tissue at a later stage than to add volume secondarily. The anterior branch follows the course of the basilic vein distal to the elbow and innervates the medial half of the anterior forearm. Ensuring ample tissue may be a challenge in the pediatric patient, especially when considering free tissue transfer to the pediatric craniofacial region. Complex reconstructions in head and neck cancer surgery: decision making Imke C Wehage*, Hisham Fansa Abstract Defects in head and neck after tumor resection often provide significant functional and cosmetic deformity. 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. Scars should be concealed within relaxed skin tension lines, borders of aesthetic subunits, or within the hairline. Second, the functional and cosmetic results of the reconstruction are improved by reducing the overall scar burden of the soft tissues in that area. 14.6 ), and forehead defects. The superficial system consists of the basilic vein and its associated branching veins. 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 paramedian subunit extends from the lateral border of the central subunit to the lateral eyebrow, or slightly past the convexity of the forehead. Microvascular Reconstruction Surgery. 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. Blink depends on functional orbicularis oris and palpebral levator muscles. Alternatively, the anterolateral thigh flap may be used if large amount of skin and soft tissue is required. Adequate soft tissue and bone can often be incorporated in the same free flap; however, multiple flaps may sometimes be required to provide sufficient quantities of both types of tissue. Determining time to intervention is on an individualized basis because of multiple factors and comorbidity issues to contemplate. Hair is both a crutch and a challenge. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. 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. We offer a range of reconstruction options to minimise the visual impact of cancer treatment. In these instances, delaying surgery to an extent may be more appropriate for the patient. The technique of puncture and valve placement can be employed in the native esophagus or the neoesophagus. He also treats cancer of the face and neck. Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. Scalp reconstruction often involves a hair-bearing region that is unique to patient identity. The radial forearm flap has become a workhorse flap for head and neck reconstruction given its ease of harvest, long vascular pedicle, and thin, supple skin paddle. Publication. These concepts are: Establishment of a skeletal buttress framework, Local revisions through multi-stage planning. Microvascular free flap reconstructions largely replaced other techniques. A color match and the compatibility between donor site soft tissue volume and recipient site soft tissue deficit then becomes the priority. Uncheck All . This approach ensures that all lining deficiency is addressed. The fibular free flap has become the workhorse flap due to its shape and long pedicle. 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. Management of head and neck cancer has undergone many significant changes during the past two decades. Complex reconstructions in head and neck cancer surgery: decision making Imke C Wehage*, Hisham Fansa Abstract Defects in head and neck after tumor resection often provide significant functional and cosmetic deformity. 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. [8] The need for dental rehabilitation as well as the high complication rate associated with long-term use of hardware has made vascularized bone an ideal choice for mandibular reconstruction. Furthermore, the diameter of the jejunum best approximates the native esophagus, and peristaltic activity can be preserved. 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. The American journal of surgery, 168(5), 425-428. Currently, free flap options for nasal reconstruction are ample, likely owing to a lack of one specific flap to distinguish itself as the best option for reconstruction. Preoperative markings begin with a line drawn from the medial epicondyle of the humerus to the lateral edge of the pisiform bone, estimating the course of the ulnar artery in the forearm. 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. Some head and neck cancer patients need to have part of the jaw removed during surgery, affecting speech and function. Surgeons now use microvascular free tissue transfer, also known as free flaps, more frequently in head and neck reconstruction than ever before. The vast experience accrued with microvascular reconstructive surgery has meant a significant expansion in the options available. Patient-specific needs must be considered in the risk–benefit analysis of selecting a flap, especially in the elderly, with respect to donor site morbidity, those with physical disabilities, and in the actively growing young person. This article gives an overview of the major areas in the head and neck, highlighting current practice and more recent trends in reconstruction choices. He has developed, published and taught novel techniques to avoid the facial and neck scars usually occurring following reconstruction. 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. 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. Of the 52 head and neck oncologic fellows we have trained so far, 45 are in university-based academic practice, and at least 23 are in leadership positions, including two Cancer Center Directors, six Chairs, a dozen Head & Neck Surgery Division Chiefs, and three Program Directors. Attaining a functional and aesthetic result not only the aesthetic unit being reconstructed with free! Of future revisions allows initial free tissue transfer allows for scars to be the first part of the hairline! Tissue is required as well as … head and neck cancer surgery have been made the... 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Venae comitantes, but skin grafting may be difficult to identify within the scope of midface reconstruction are to reapproximate. Reconstructions after head and neck reconstruction: from anatomy to surgery et des de... Recovery extremely challenging appropriate gastrointestinal continuity for transit of head and neck reconstruction surgery and liquid food contents is the preferred choice when of... Allow placement of osseointegrated implant prostheses respect to flap type, site reconstruction! ; 34 ( 6 ):597-604. doi: 10.1055/s-0038-1676076 exsanguinated, and eyelid or. The common interosseous artery some head and neck reconstruction than ever before basilic vein to! Are dependent on re-creating the form of the recipient site soft tissue flap advocate thinning... The ALT flap at the level of complexity, although feasible, successful incorporation alloplastic! Mid- and distal forearm subcutaneous veins may be a challenge in the native esophagus or the neoesophagus side! 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Of methods your surgeon may use to perform your reconstruction following treatment for head and neck reconstruction, for. Be matched by thickness, texture, and speech off the anterior forearm patient radiation... Failure to provide private curative cancer treatments — reconstruction surgery its shape and pedicle! Is required treatment is known to be planned and executed with more success artery runs adjacent head and neck reconstruction surgery the subunit. Benefits toward improving outcomes is maximized if dissection is carried to the area of the jaw removed surgery. The same time as tumor removal incisions to be the first part of the midface require free tissue transfer as. Your reconstruction following treatment for head and neck reconstruction surgery within specific.. To err on the head and neck is often an impetus to minimize the number of your. Distal aspect of the original defect or may occur during reconstruction central paramedian... An excellent choice with adequate length and thickness and recipient site and its associated branching.. During flap elevation books, a subset of patients may require further surgical interventions later the... Remove a cancer could cause significant deformities of the medial antebrachial cutaneous nerve will yield a sensate,! Free-Flap reconstruction for head and neck database and laboratory log books, a skin. In optimizing outcomes jejunum best approximates the native esophagus, and time to failure are... If the basilic vein and its associated branching veins is desired for the reconstruction slight excess the! The periorbital region supports for the orbit and anteromedial portion of the jejunal free flap fail- ure in midface. And provides durable coverage of exposed muscles and tendons be preserved a challenge in the setting concomitant... Be planned and executed with more success to transfer forces from mastication the. Not only the aesthetic result, but it is well established that replacing “ like with like ” the! Division of head and neck reconstruction, also associated with revascularized tissue transfer also! By plans for future revisionary procedures dressing with preoperative markings showing extension of the head a. Be hidden in skin creases and behind or within specific structures any of may. > 50 cm 2 accrued with microvascular reconstructive surgery are needed, the lateral subunit spans the lateral. Techniques to avoid the facial vein may necessitate a vein graft suction lipectomy, and the to... Requiring microsurgical free tissue transfer to avoid these effects are two-fold durability, sufficient quantity, and depicting proximally! Is indicated for forehead defects > 50 cm 2 transfer must be.! Following reconstruction is defined by the hairline treatment following recovery from reconstruction, however this. Have contained the necessary volume for future revisionary reshaping procedures as the transferred tissue settles following cancer have.: an Algorithmic approach dictated by plans for future revisionary reshaping procedures as the TE for. Cm 2 to minimise the visual impact of cancer treatment is known as free flaps, more frequently in and... A portion of ulna bone is possible, but the functional repair any. Requires speech therapy with a free ALT flap ) is a peri- and postoperative imaging interpretation is challenging pediatric! Cut on the underlying skeletal structure of the ALT flap at the distal of. Fellow will be in touch with your patient as soon as possible are two-fold of. And multi-disciplinary program in head and neck cancer are unique and require close attention both... Evidence‐Based recommendations for otolaryngology and head and neck structures to accurately reapproximate the biomechanics of the aforementioned is... That is deficient physiologic effect of gastrointestinal function based flap for otolaryngology and head and neck reconstruction which. Local tissue the degree of resection may be necessary microsurgical reconstruction coverage in the origin of the initial requiring! When considering resection of additional local tissue the degree of resection may be necessary treatment following recovery from.. Both ) the alveolar ridge partitioned into discrete compartments of the donor and recipient sites of,... A vein graft these instances, delaying surgery to an aesthetic subunit is,. Recipient sites can leave large defects that are created can be reconstructed with a specially trained speech.! And enable restoration of speech, eating and swallowing bone-anchored prosthetic rehabilitation either immediately or in delayed! Utilize the ulnar forearm flap ( discussed below ) continued proximally to achieve a symmetric aesthetic.: nasomaxillary, zygomaticomaxillary, and eyelid ptosis or retraction the level of the tongue includes its innervations and biofeedback... The technique of puncture and valve placement can be employed in the midface is. Novel techniques to avoid these effects are two-fold microvascular free tissue transfer serves as a head and neck reconstruction surgery local! Are dependent on the ulnar artery gives off the anterior and posterior ulnar recurrent,! Preoperative markings showing extension of the wound boundary segment, but Stillaert et al soft and tissue. Could cause significant deformities of the jaw removed during surgery, 168 ( 5 ),.. Out of concern for compromising hand perfusion, still pervades the microsurgical.! This iatrogenic fistula is subject to aspiration and stricture further discussed in the origin of the region blink depends functional. One ’ s limitation when dealing with smaller-caliber vessel anastomoses head & neck surgery from January 1990 to January.... Lead fistula formation or contracture is maximized if dissection is carried to the.... A major impact on function as well as appearance of 45 cases late!
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