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Reconstructive head and neck surgery
Terms in this set (24)
Healing by secondary intention
Skin, cartilage, bone, nerve, and composite grafting
Microneurovascular free tissue transfer
Skin graft healing
Imbibition = first 24-48 hours. Obtaining nutrients from wound bed.
Inosculation = after 48 hours. Vessels in graft meet recipient vessels.
Angiogenesis occurs over days 4-7
Split thickness skin graft
Thickness from 0.012 - 0.016in. Thinner = more reliable neovascularization, but more contracture.
Poor color match, texture, possible contracture.
Small oral cavity defects, inner lining of maxillectomy cheek flap defect, Temporalis fascial flap cover, auricular reconstruction, coverage of free flap donor sites
Full thickness skin grafts
Graft is defatted and donor site is closed primarily.
Appropriate for small (1-5cm) externally visible facial defects.
Cortical free bone grafts
Harvest sites = split calvarium, split rib, iliac crest.
Applications = nasal dorsal augmentation, malar and chin augmentation, reconstruction of facial buttresses, prevention of relapse in orthognathic surgery
Cancellous bone grafts
More quickly vascularized than cortical bone, but no structural integrity so can't be used for load bearing.
Harvest sites = iliac crest, tibia.
Applications = repair of mandible nonunion, small segmental mandibular defects, alveolar bone grafting, sinus obliteration, repair of small cranial contour defects.
Local flaps vs regional flaps
Local flaps are AKA random pattern flaps because they are based on subdermal plexuses and do not have a dominant vessel supply.
Regional flaps have an axial pattern based on one or more dominant vessel.
Pectoralis major flap
Based on pectoral branch of thoracoacromial artery.
Can harvest a segment of rib for mandible reconstruction, but blood supply to the bony segment is tenuous.
Rotation is limited by the clavicle. Can remove a segment of clavicle which can help with reach of the flap for superior defects.
Can be used for intraoral repair = can remove skin and then skin graft to avoid transfer of hair-bearing skin into the mouth.
Disadvantages: Inferiorly based pedicle, so has a tendency for dehiscence superiorly which is often the part that is doing the work for the recon.
Temporoparietal fascia free flap
Based on superficial temporal vessels.
Can take calvarial bone with it.
Applications: Oral mucosal defects, facial contouring, orbital and temporal bone defects, hemilaryngectomy defects.
Disadvantages: Small caliber vessels, vein is superficial making it vulnerable to damage with harvest, risk of injury to frontal branch of facial nerve, risk of alopecia
Radial forearm free flap
Based on long, large caliber radial vessels. Perforators to the skin paddle through lateral intermuscular septum.
Can get sensation via lateral and medial antebrachial cutaneous vessels.
Must have a complete palmar arch.
Can take 10cm segment of monocortical bone from radius. Needs to be plated right away. Inadequate segment of bone for dental implants.
Lateral arm free flap
Based on the posterior branches of the radial collateral vessels.
Sensate capabilities through posterior cutaneous nerve of forearm.
Donor site can be closed primarily. Can take a piece of humerus with it.
Skin here is a better color match for facial skin of all free flaps.
Pedicle enters at the center of the flap.
Based on lateral circumflex femoral artery.
Sensate capability through lateral femoral cutaneous nerve.
Can harvest multiple skin and/or muscle paddles for complex defects.
Inconspicuous donor site.
Lateral thigh free flap
Based on perforators of profunda femoris vessels.
Large surface area - up to 25 x 14cm.
Less pliable than forearm, but can be tubed. Thickness correlates with body habitus.
Rectus abdominus free flap
Based on inferior epigastric vascular pedicle
Less pliable than forearm, but can be tubed.
Makes abdominal wall weaker, thickness of flap correlates with body habitus.
Gracilis free flap
Artery = adductor artery, branch of profunda femoris.
Motor capability through anterior branch of obturator nerve.
Main application is facial reanimation due to capacity for motor innervation.
Fibula free flap
Bone only or osseocutanoues based on peroneal vessels.
Sensation via lateral sural cutaneous nerve.
Need pre-op CTA to ensure vessels are present and patent.
Can recon the entire mandible.
May not be enough bone stock for implants.
Iliac crest free flap
Consists of skin, subQ tissue, internal oblique, and iliac crest based on deep circumflex iliac artery.
Volume of tissue and lack of rotation of soft tissue component with respect to bone can make inset difficult.
Significant donor site morbidity including chronic pain, gait issues, risk of hernia.
Scapular free flaps
Based on circumflex scapular artery - branch of subscapular artery.
Can separate soft tissue from bone flap, so most freedom of rotation for inset.
Can harvest a straight segment of bone up to 3cm x 14cm
Jejunal free flap
Tubed interposition graft for segmental pharyngoesophageal recon.
Offers a secretary mucosal surface.
Cons: Need for laparotomy and enteric anastomosis, two enteric anastomoses are needed in the neck.
Risk of intrathoracic leak.
Feeding jejunostomy may be required.
Postoperative dysphagia due to peristalsis that is not coordinated with native swallowing.
Significant donor site morbidity.
Omental free flap
Based on right gastroepiploic vessels.
Ideal for infected or irradiated sites.
Applications: Resurfacing of large scalp defect, closure of pharyngocutaneous fistula, treatment of ORN, augmentation of facial soft tissue defects.
Cons: Prior abdominal surgery or peritonitis causes significant scarring and contracture and makes omentum unsuitable.
Synergistic nerve crossover for facial paralysis
Sufficient proximal motor input is lacking, but muscle atrophy has not yet occurred. One or more peirpheral facial nerve branches is intact on the affected side.
Have to transect preexisting innervation because innervated muscle fibers will not accept new innervation.
Connects contralateral buccal branch nerve to paralyzed side with sural nerve graft.
Commonly used as a first step in facial paralysis surgery.
Upper lip defects not involving the philtrum
Less than 1/4 of the lip width can be closed primarily.
1/4 - 1/3 of the lip can be closed with unilateral perialar advancements.
Entire lateral subunit, but sparing the commissure are repaired using an Abbe flap.
Entire lateral subunit and oral commissure corrected with Estlander flap
Upper lip defects involving the philtrum
Central defects involving philtrum only can be repaired primarily or an Abbe flap.
Defects of less than 3/4 lip width: Bilateral advancements with Abbe for central subunity OR bilateral Karapandzic with or without Abbe for central subunit.
Lower lip defect reconstruction
1/4-1/3 of lip width can be closed primarily.
1/3-1/2 of lip width: BIlateral advancement flaps, Abbe if not involving commissure, Estlander if involving commissure.
1/2 - 2/3 with bilateral karapandzic
THIS SET IS OFTEN IN FOLDERS WITH...
Vestibular and Balance disorders
Neck spaces and fascial planes
Facial plastic surgery
Congenital hearing loss
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