The advent of prosthetic implants, fixation plates, and non-vascularized bone grafts has bridged the surgeon’s understanding of the crucial relationship of bony stabilization and soft tissue re-draping. Perhaps, these principles were considered secondary because early microvascular flap failure rates were initially too high. 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. 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. Healthy adipose tissue will also provide the necessary volume for future revisionary reshaping procedures as the transferred tissue settles. However, concerns about donor site morbidity have prevented the ulnar forearm flap from achieving the popularity of its radial counterpart. Additionally, the close relationship of the ulnar artery and nerve has evoked concerns about injury to the nerve during flap elevation. Uncheck All . 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. Aesthetic outcomes are largely dependent on the underlying skeletal structure of the region. Pedicled flaps in head and neck surgery 1. 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. A total of 45 cases of late free flap fail- ure in the head and neck were identified. Although a combination of the aforementioned nasal reconstructive techniques can be successfully used in composite tissue nose defects, the following text focuses on microsurgical reconstruction of the nose. This iatrogenic fistula is subject to reflux of esophageal content, secretions, and subject to aspiration and stricture. The weaker, horizontal buttresses are comprised of the superior and inferior orbital rims and the alveolar ridge. Alternatively, a more accurate method of tracing the ulnar artery is completed with a Doppler probe. When considering resection of additional local tissue the degree of resection may be dictated by plans for future revisionary procedures. 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. In the midface, is it critical to assess which tissue types are missing and to reconstruct them accordingly. To aid these patients, Johns Hopkins has a dental implant team composed of a maxillofacial prosthodontist and an oral surgeon. 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. The superficial system consists of the basilic vein and its associated branching veins. The complexity of the tongue includes its innervations and proprioceptive biofeedback, and specialized movements make full functional recovery extremely challenging. If the basilic vein can be identified, it is ligated at this time. In addition, blink can be disrupted by ectropion, entropion, exophthalmos, enophthalmos, and eyelid ptosis or retraction. The basilic vein drains the dorsum of the hand via the dorsal venous complex of the hand running proximally along the dorsal ulnar aspect of the forearm. 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. This article gives an overview of the major areas in the head and neck, highlighting current practice and more recent trends in reconstruction choices. Any of these may be present as a result of the original defect or may occur during reconstruction. This type of procedure is often referred to as microvascular reconstruction surgery (also known as "free flap" or "free tissue transfer" surgery). Alternatively, the anterolateral thigh flap may be used if large amount of skin and soft tissue is required. (Reprinted from Fisher M, Dorafshar A, Bojovic B, et al. 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. Guided by the critical concepts described above, soft tissue reconstruction should include excess soft tissue with the expectation that volume loss will occur. Beyond the forehead lies the scalp, which poses unique challenges. Free tissue transfer allows for scars to be hidden in the pretrichial hairline and just superior to the eyebrows. Raising the skin paddle begins in the suprafascial plane, oriented from radial to ulnar direction until the muscular septum, found between the flexor digitorum superficialis and flexor carpi ulnaris is encountered. This can cause significant eyebrow ptosis with subsequent asymmetry and may require botulism toxin injection or secondary revisions. Trapezius flap 4. The concept of extending the boundary of defects when >60% deformity to an aesthetic subunit is present, is not absolute. Alter­natively, if bulk and a short pedicle are needed, the groin flap may be used. For instance, the variability in subcutaneous fat among patients is apparent when considering an anterolateral thigh (ALT) flap. In addition, the subcutaneous fat is partitioned into discrete compartments of the face, a concept championed in cosmetic facial surgery. 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. Scalp reconstruction often involves a hair-bearing region that is unique to patient identity. In the face of trauma or oncologic resection, the microsurgeon must not prolong the time to reconstruction. Microvascular Reconstruction Surgery. At this level of complexity, although feasible, successful outcomes may vary in each individual surgeon’s hands. We offer a range of reconstruction options to minimise the visual impact of cancer treatment. COVID‐19 pandemic: Effects and evidence‐based recommendations for otolaryngology and head and neck surgery practice. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. However, strict adherence to several critical principles specific to the demands of craniofacial surgery is paramount to addressing complex injury or deformity of the head and neck. Head and Neck Reconstruction SURGERY RESULTING FROM CANCER TREATMENT IS KNOWN AS HEAD AND NECK CANCER RECONSTRUCTION. Epub 2018 Dec 28. However, novel modalities of reconstruction have introduced several flaps that attempt to augment the voice. 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. 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 ulnar nerve is intimately associated with the ulnar artery as it courses over the distal two-thirds of the forearm and is found just ulnar and slightly superficial to the artery. Alloplastic materials are prone to late infection and tend to extrude over time, leading to implant exposure. Once the fascia is identified it is incised, and the ulnar vessels are elevated with the skin flap to preserve septocutaneous perforators. However, the advantages of the ulnar flap are its similar skin composition of facial components and relative soft tissue paucity that can act as a “double-edged sword,” in scenarios where more soft tissue is necessary. The workhorse flaps used in reconstructing the various regions of the head and neck are described with an emphasis on their application to the craniofacial segments, their advantages, and disadvantages. Along with treating disorders and cancers of these regions he also does advanced complex reconstructions. The evolution of critical concepts in aesthetic craniofacial microsurgical reconstruction. If postoperative radiation therapy is anticipated, the excess volume should be further increased, since significant soft tissue contraction can result from radiation exposure. Moreover, interpersonal communication and recognition of social cues are all delivered and interpreted via facial contour and movement. 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. All Publications. The Division of Head and Neck Surgery boasts a robust reconstructive practice to match the high volume ablative oncology practice. Examples of such flaps include the radial forearm flap and the ALT flap, which allow for nerve coaptation of the lingual nerve for sensation and hypoglossal nerve to minimize atrophy and maximize function. 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. Plast Reconstr Surg 2012;130:389–98. Traveling between the flexor digitorum superficialis and flexor carpi ulnaris, it then passes through Guyon’s canal at the wrist and divides into superficial and deep palmar branches. Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. Selecting subcutaneous veins may be advantageous when named veins are difficult to isolate within an amputated segment, but Stillaert et al. 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. 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 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. As with all types of reconstructive surgery, the goal of head and neck reconstruction is to restore and/or maximize patients’ function and appearance. Reestablishing a conduit for appropriate gastrointestinal continuity for transit of solid and liquid food contents is the primary goal of reconstruction. 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 tissue most commonly comes from the arms, legs, or back, and can include bone, skin, fat, and/or muscle. 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. It assumes an ulnar route as it reaches the midpoint of the forearm. 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. The application of microsurgery to craniofacial surgery has been successfully established, largely due to the synthesis of multiple disciplines and their respective collaborations in the treatment of complex disease processes. All cases were identified from theatre log books, a head and neck database and laboratory log books. The donor site is best closed over a closed suction drain due to the potential space created by the flap harvest. The central subunit is bordered by the medial eyebrows and extends vertically from the glabella to the frontal hairline. 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. The brachial artery, which can be used the 1990s heralded an era of using... 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