Literature Reading:

Reconstructive
Surgery
Ratna Windyaningrum

Supervisor: dr. Nur Akbar Aroeman, Sp. T.H.T.K.L (K)

OTOLARYNGOLOGY – HEAD AND NECK SURGERY

DEPARTMENT
PADJADJARAN UNIVERSITY
BANDUNG
2021
 Introduction

The extent of tissue loss from cancer ablative surgery

Planning for reconstructive surgery relates to the loss of soft tissue and bone

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Anatomic Considerations
Scalp, skin, and soft tissue of the face and neck

■ The skin of the scalp, face, or neck can often be replaced easily with a skin
graft or local flaps.
■ when extirpation involves the underlying soft tissues with creation of
surgical dead space → more complex reconstructive efforts required
■ Solutions → regional flaps, free flaps

Paranasal sinuses, orbit, and skull base

■ Following major resections of the paranasal sinuses, orbit, or skull base, certain
situations mandate reconstruction.
■ Repair of the skull base can be performed without bone → galeal pericranial or
free flap.
■ Reconstruction of the floor of the orbit → with of a free osteocutaneous flap or
by combining a bone graft with a soft tissue free flap.
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Anatomic Considerations

(a) Reconstruction with a rectus abdominis free flap for a composite three-dimensional
defect after radical temporal bone resection and amputation of the pinna. (b) after use
of a prosthesis for the external ear
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 Anatomic Considerations
Oral cavity

■ The goals of oral cavity reconstruction include both functional (oral competency,
clarity of speech, etc.) and aesthetic restoration (restoration of facial height, soft
tissue contour, etc.)
■ Major ablative surgery in the oral cavity may result in an oral cripple if appropriate
reconstructive efforts are not made
■ Solutions → dental prosthesis, free flaps

Pharynx

■ The goal should be to restore the ability of the patient to resume oral
alimentation as soon as possible
■ Reconstruction of the surface lining of the pharyngeal wall does not require any
major reconstructive effort
■ full-thickness resection of the pharyngeal wall → regional myocutaneous flap
or a free flap
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Impact of Cancer Ablative Surgery of the
Oral Cavity
Aestethic Functional

01 Contour Speech 01

02 Expression Mastication 02

03 Competence Swallowing 03

04 Lip Support Dental rehabilitation 04

with fixed or
removable implant
based dentures

Oral Cripple
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Skin Grafts

■ Small superficial defects of the mucosa or skin that are not amenable to
repair by primary closure or rearrangement of adjacent tissue →
reconstruction with skin graft.
■ Full-thickness skin grafts → better cosmetic appearance and less
secondary contracture but are limited in size.
■ Split-thickness grafts are abundantly available but can undergo significant
contracture → limit movement of functional areas such as the eyelids or
tongue.
■ Split-thickness grafts are more suitable for poorly vascularized areas
because low metabolic requirement for healing
■ In short, for external skin coverage, skin grafts are best applied to the parts
of the scalp or face that are relatively immobile.

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
Reconstruction with Skin Grafts

(a) A full-thickness defect of the left nasal sidewall after removal of a melanoma
before secondary application of full-thickness skin graft. (b) 1 year following surgery
showing complete healing and an excellent aesthetic outcome with a full-thickness
skin graft.
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 Reconstruction with Skin Grafts

Lesions suitable for skin graft repair inthe oral cavity

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5. 9
 Reconstruction with Cutaneous Flaps
■ Adjacent tissues may be elevated to reconstruct small surgical defects that
cannot be repaired primarily (local flap). adjacent tissues may be mucosal
or cutaneous.
■ These flaps have a limited number of specific applications → surgeons are
often unfamiliar with the technique → these options may be perceived as
unreliable.
■ Local flaps are preferable for repair of skin and soft tissue defects on the
face because of superior color match and skin texture.

Regional Cutaneous Flaps

■ are skin flaps that are available in the head and neck region for transfer
from one area to another to cover a surgical defect that cannot be repaired
by primary closure or by advancement of local tissues or local flaps.

10

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Cutaneous Flaps
Regional Cutaneous Flaps
Cervical Flap

• is a regional flap with a random pattern blood supply and should

have a width to length ratio of 1:2 – 1:3
• When the skin of the anterior aspect of the neck is used → anterior
cervical flap, when the skin of the posterior aspect of the neck is used
→ posterior cervical flap
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Cutaneous Flaps
Regional Cutaneous Flaps
Cervical Flap

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Cutaneous Flaps
Regional Cutaneous Flaps
Deltopectoral Flap

• Deltopectoral fasciocutaneous flap was considered a main method

for reconstruction of oropharyngeal and pharyngoesophageal defects.
• The deltopectoral flap is an ideal choice for coverage of the skin
defects of the lateral aspect of the neck.

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Myocutaneous Flaps

■ Myocutaneous flaps provide an excellent

means of reconstruction of defects in the head
and neck region, particularly when free tissue
transfer capabilities are not available.
■ The pectoralis major, the trapezius, and the
latissimus dorsi myocutaneous flaps have been
described for reconstruction in the head and
neck region.

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Myocutaneous Flaps

Pectoralis major myocutaneous (PMMC) flap

• Has many advantages, including Technical ease of flap elevation, generous amount of
skin and soft tissue, consistent and reliable blood supply, and adequate arc of rotation
for most oropharyngeal and skin and soft tissue defects up to the skull base.

15

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Myocutaneous Flaps

Pectoralis major myocutaneous (PMMC) flap

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction with Myocutaneous Flaps
Trapezius Myocutaneous Flap

• Although the feeding artery is reliable, its venous drainage is not constant and
sometimes is inadequate.
• Patient must be positioned laterally or prone to elevate the flap.
• Under ideal conditions, this flap provides a generous amount of soft tissue and a
large skin island for repair of major surgical defects, including those in the mastoid
and occipital regions. 17

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Microvascular Free Tissue Transfer

• Microsurgical free tissue transfer has been used routinely for the past 30
years and has become the primary method of reconstruction for the majority
of large or complex defects in the head and neck area.
• When local or regional tissues are unavailable/inadequate, the application of
locoregional tissues would result in significant functional loss or aesthetic
deformity → Free tissue transfer should be considered
• The success of microvascular free tissue transfer depends on multiple
factors, including appropriate patient selection, adequate recipient vessels,
quality donor tissue, recipient site, and the technical proficiency of the
microsurgeon.

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Microvascular Free Tissue Transfer

• Resection of head and neck tumors may result in loss of skin, soft
tissues, mucosa, bone, cartilage, or any combination of these.
• Free flaps are available with a variety of tissue type combinations and
should be thoughtfully selected based upon the defect.
• The free flaps used most commonly in the head and neck region are the
radial forearm, anterolateral thigh, rectus abdominis, fibula, jejunum,
scapula, and iliac crest flaps.

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Microvascular Free Tissue Transfer

Radial Forearm Free Flap Reconstruction of Skin and Soft Tissues of the Face

• The radial forearm free flap is a prominent technique for reconstruction of

mucosal defects in the oral cavity, oropharynx, and even hypopharynx. The
laxity of the flap permits contouring of the tongue, floor of mouth, and
oropharynx.
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Microvascular Free Tissue Transfer
Radial Forearm Free Flap Reconstruction of Skin and Soft Tissues of the Face

A radial forearm free flap A radial forearm free flap Radial forearm free flap
used for a skin defect of the used for a skin and soft- reconstruction of a nasolabial defect
parotid region. tissue defect of the cheek after resection of a fibrosarcoma.
after excision of a
melanoma.

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Microvascular Free Tissue Transfer
Reconstruction of Skin and Soft Tissues With a Rectus Abdominis Free Flap

• The rectus abdominis free flap provides abundant soft tissue and skin. Thus it is
an ideal flap where large soft-tissue defects result from resection of massive
tumors.
• Rectus abdominis free flap can be folded over with two islands of skin to
provide mucosal and external skin coverage.
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Microvascular Free Tissue Transfer
Reconstruction of Skin and Soft Tissues With a Rectus Abdominis Free Flap

• A patient with recurrent multifocal basal cell carcinomas of the scalp following
multiple surgical procedures and two courses ofradiation therapy.
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Microvascular Free Tissue Transfer
Reconstruction Using an Anterolateral Thigh Flap

• The ALT is a versatile fasciocutaneous flap that can provide a large amount of skin for
resurfacing. In certain patients, the flap can be quite thin and thus may be used as an
alternative to the radial forearm flap for resurfacing when minimal soft-tissue
• Rectus abdominis free flap can be folded over with two islands of skin to provide mucosal
and external skin coverage.
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible

• Involves several important functional, anatomic, and aesthetic

considerations to achieve the goal of restoration of form and
function as close to normal as possible.
• The current standard of care for mandible reconstruction
consists of free flaps of bone with or without soft tissue and
skin.
• Free flap mandible reconstruction provides significant
advantages, the only disadvantage is that the procedure is
technically more challenging than soft-tissue flaps.
25

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible

• Resection of the ascending ramus of the mandible causes loss of ipsilateral

pterygoid muscle function and thus causes deviation of the mandible leading to
malocclusion.
• Resection of the anterior aspect of the body of the mandible, and particularly the
anterior arch, produces unacceptable functional and aesthetic morbidity that
mandates an appropriate reconstructive effort to restore form and function.
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible
Reconstruction With Radial Forearm Osteocutaneous Free Flap

• The radial forearm osteocutaneous free flap offers excellent skin and soft-tissue
characteristics.
• However, the length of bone available is limited, and only half of the circumference of the
cortex of the bone can be harvested as part of the flap.

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible
Reconstruction With Scapula Free Flap

• The scapula free flap is an ideal “chimeric” flap, because it provides abundant soft tissue
with separate skin and bone components stemming from a common vascular pedicle.
• The blood vessels are reliable, and there is minimal donor site morbidity. However, the
bone stock of this flap is less than ideal, because the thickness is inadequate for
osseointegrated implants, and the maximum length that can be harvested is limited.
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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible
Reconstruction With an Iliac Crest Free Flap

• A composite flap of ilium with the overlying skin (the iliac crest free flap) is often of
limited value in mandible reconstruction
• Although the amount of the bone available is virtually unlimited, the shape has fixed
characteristics and therefore is unfavorable
• Blood supply to the bone is nonsegmental, and the overlying skin may be bulky,
immobile, and often unreliable 29

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible

Reconstruction With the Fibula Free Flap

• The fibula free flap is the prominent choice for mandible reconstruction
because of its reliability, excellent bone stock, overlying protective
muscle, and optional skin paddle, as well as the acceptable donor site
morbidity.
• Bone lengths up to 25 cm are available. The bone flap consists of
circumferential cortical bone, and it has segmental blood supply, which
makes multiple osteotomies feasible and safe. 30

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible
Osseointegrated Implants in a Reconstructed Mandible

■ The advantages of osseointegrated implants are improvements in the

aesthetic appearance of the patient as well as restoration of clarity of speech,
oral competence, and mastication
■ The requirements for successful osseointegration of implants include the
availability of adequate bone stock and pliable soft tissue covering the bone

Reconstruction of the Maxilla With CAD-CAM Design for Fibula Free Flap

■ The availability of CAD-CAM models has greatly facilitated preplanning

of the proposed reconstruction of bone.
■ CAD-CAM creates a model and prepares predesigned guide planes to
precisely perform osteotomies in the free bone flap to create a desired
reconstruction.

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Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5.
 Reconstruction of the Mandible

A computer-aided design/computer-assisted manufacturing model of the

proposed fibula free flap reconstruction and the fixation plate.

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5. 32
 Reconstruction of the Mandible

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5. 33
 Reconstruction of the Mandible

The postoperative appearance of the patient 6 weeks following surgery shows excellent restoration of the
facial contour.

Shah JP, Patel SG, Singh B. Jatin Shah's Head and Neck Surgery and Oncology E-Book. Elsevier Health Sciences; 2012 Feb 5. 34
Highlight

■ The impact of major ablative surgery for cancer in the head

and neck region can be devastating for the patient,
aesthetically and often functionally.
■ Reconstruction of oncologic defects is necessary to restore
function and appearance
■ If primary closure is not feasible, then viable tissue should
be introduced to repair the surgical defect

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THANK YOU

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