Download Free Medical Free Flap Reconstruction in Head and Neck PowerPoint Presentation

Free Flap Reconstruction in Head and Neck PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : free flap reconstruction in head and neck

Tags : ent, head,neck

Published on : Dec 21, 2020 | Views : 6343 | Downloads : 60

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Free Flap Reconstruction of Head and Neck Defects Parag Parikh, MD UC-Irvine April 7, 2004
Slide 2-

ppt slide no 2 content not found
Slide 3-

Introduction Prior to 3 Decades Ago Majority of Head and Neck Defects closed with Local Tissue Local Skin Flaps from other sites to the H/N Forehead Flap…Indians then McGregor in 1963 1965 Bakamjian…Deltopectoral Flap Limited Reach
Slide 4-

Introduction Early 1900’s Alexis Carrel Free tissue transfer in animals (jejunum to neck) 1950’s Jacobsen and Suarez-- first anastomoses in animal 1959 Seidenberg– free jejunum segments to repair pharyngoesophageal defects 1973 Daniels and Taylor– “free flap” First free cutaneous flap
Slide 5-

History 1976 Baker and Panje– first free flap in head and neck cancer reconstruction Groin pedicled on the circumflex iliac artery Other cutaneous flaps Axillary Dorsalis pedis
Slide 6-

Introduction Free flaps grew out of favor in the late 1970s to early 80s Few donor sites Inconsistent small pedicles Technically difficult High morbidity
Slide 7-

Introduction Pedicled flaps grew in favor (70s and 80s) 1976 – Tansini – Latissimus dorsi Pectoralis major Trapezius Sternocleidomastoid 1979 – Ariyan – harvest rib with PMC 1979 – Demergasso and Piazza – harvest spine of the scapula with trapezius flap
Slide 8-

Regional Flaps Advantages/Uses: Bulky Quick and easy to harvest Single stage Minimal donor site morbidity Required one surgical team Large Tongue Base/TG Defects Carotid Coverage Disadvantages: Bulky Downward Pull of Flap Atrophy Arc of Rotation Limiting Distal Flap Necrosis
Slide 9-

Free Tissue Transfer 1979 – Taylor et al. – iliac crest composite flap 1980 – dos Santos et al. – scapular cutaneous flap 1981 – Yang et al. – radial forearm free flap 1982 – Nassif et al. – parascapular cutaneous flap 1982 – Song et al. – lateral arm fasciocutaneous flap 1983 – Baek et al. – lateral cutaneous thigh flap 1985 – Drever et al. – rectus Abdominis myocutaneous flap 1986 – scapular osseocutaneous flap
Slide 10-

Advantages of Free Tissue Transfer Two team approach Improved vascularity and wound healing Low rate of resorption Defect size little consequence Potential for sensory and motor innervation Permits use of osseointegrated implants
Slide 11-

Advantages of Free Tissue Transfer Wide variety of available tissue types Large amount of composite tissue Tailored to match defect Wide range of skin characteristics More efficient use of harvested tissue Immediate reconstruction
Slide 12-

Disadvantages of Free Tissue Transfer Technically demanding Increased operating room time Increased flap failure rate Functional disability at donor site
Slide 13-

Preoperative Planning Amount and type of tissue required Bone, soft tissue bulk, external vs. internal lining Anticipated functional gains History of previous surgery or injury around the donor site Donor morbidity Patient positioning and donor location Operative time Need for carotid coverage Patient factors General medical status Wishes and expectations
Slide 14-

Preoperative Planning Patient selection Age Diabetes Arteriosclerosis/Cardiac Tobacco use Collagen vascular disease Coagulopathies Hypercoagulable states
Slide 15-

Reconstructive Planning Must consider all options for particular defect and patient Options Secondary intent Primary closure Skin grafts Local flaps Myocutaneous flaps Free flaps
Slide 16-

Fasciocutaneous Free Flaps Radial forearm Lateral arm Lateral thigh
Slide 17-

Radial Forearm Free Flap Arterial source Radial artery Venous Source Paired vena commitantes and/or cephalic vein
Slide 18-

ppt slide no 18 content not found
Slide 19-

Radial Forearm Free Flap Forearm Radial a. w/ vena commitantes Lateral intermusc-ular septum Antebrachial cutaneous n.
Slide 20-

Radial Forearm Free Flap Advantages Thin, pliable skin with long, large pedicle Easy positioning Potential for sensate flap Potential for unusual shapes Potential for vascularized bone Ease of preoperative evaluation Disadvantages Loss of hand Poorly aesthetic donor site Requires skin graft Potential for pathologic fractures Loss of hand function
Slide 21-

ppt slide no 21 content not found
Slide 22-

Radial Forearm Free Flap Choose the nondominant hand No venous access in the chosen donor arm Avoid raising the flap over the ulnar artery Volar splint X 2 weeks 10-15 degrees of extension
Slide 23-

Lateral Arm Free Flap Arterial supply Posterior radial collateral artery from profunda brachii artery Venous supply Vena commitantes in spiral groove of humerus
Slide 24-

ppt slide no 24 content not found
Slide 25-

Lateral Arm Free Flap Advantages Low donor site morbidity (vertical scar) Easy positioning Potential for sensory innervation via posterior cutaneous nerve Disadvantages Short and smaller caliber artery (1.55 mm, up to 8-10 cm) Longer dissection than RFFF Thicker subcutaneous tissue Pressure dressing Risk to radial n.
Slide 26-

ppt slide no 26 content not found
Slide 27-

ppt slide no 27 content not found
Slide 28-

Lateral Thigh Free Flap Arterial supply is from third perforator of profunda femoris artery Venous output from associated vena commitantes
Slide 29-

ppt slide no 29 content not found
Slide 30-

ppt slide no 30 content not found
Slide 31-

ppt slide no 31 content not found
Slide 32-

ppt slide no 32 content not found
Slide 33-

Lateral Thigh Free Flap Advantages Large amount of thin, hairless skin Low donor site morbidity (primary closure) Easy positioning Sensation potential with lateral femoral cutaneous nerve Disadvantages Difficult dissection Retraction of vastus lateralis Short, variable pedicle 15 cm, 2-4mm
Slide 34-

Muscle and Musculocutaneous Free Flaps Rectus abdominis Latissimus dorsi
Slide 35-

Rectus Abdominus Free Flap Arterial supply based on deep inferior epigastric artery Venous supply form vena commitantes joining external iliac vein
Slide 36-

Rectus Abdominis Free Flap Versatility of the inf epig. a. Periumbilical perforators A. Transverse B. Extended C. Extended Less muscle D. Longitudinal Thick E. Subarcuate Thinner
Slide 37-

ppt slide no 37 content not found
Slide 38-

Rectus Abdominus Free Flap Advantages Easy positioning and harvest Constant anatomy Long (8-10 cm) and large caliber vessel (avg 3.4 mm) Donor site closed primarily Large flap obtained Anterior rectus sheath durable Disadvantages Often bulky No sensation potential Potential for hernia formation if dissection below arcuate line
Slide 39-

Rectus Abdominis Free Flap Preoperative evaluation Previous abdominal surgery Presence of umbilical hernia Presence of rectus diastasis
Slide 40-

Latissimus Dorsi Free Flap Arterial supply based on thoracodorsal artery Venous drainage from thoracodorsal vein Motor nerve innervation potential with thoracodorsal nerve
Slide 41-

ppt slide no 41 content not found
Slide 42-

ppt slide no 42 content not found
Slide 43-

Latissimus Dorsi Free Flap Advantages Large flap with long pedicle ( artery 2-3 mm, vein 3-5 mm, length: 7-10 cm) 2nd largest skin paddle Possibility for “axillary megaflap” Multiple skin paddles Low donor site morbidity Possibility of muscle reinnervation via thoracodorsal nerve Disadvantages Difficult positioning and two team harvest Postoperative seroma formation Bulky flap Unable to tube
Slide 44-

ppt slide no 44 content not found
Slide 45-

ppt slide no 45 content not found
Slide 46-

ppt slide no 46 content not found
Slide 47-

Composite Free Flaps Radial forearm Fibula Scapular/Parascapular Ilium
Slide 48-

Fibular Free Flap Arterial supply – peroneal artery Dual supply Endosteal Periosteal Venous supply – vena commitantes
Slide 49-

ppt slide no 49 content not found
Slide 50-

Fibular Free Flap Advantages Longest and strongest bone stock (25 cm of bone) Pedicle 12 cm Can be a sensate flap Lateral sural n. Low donor site morbidity Easy positioning Excellent periosteal blood supply (contouring) Support osseointegrated implants Disadvantages High incidence of peripheral vascular disease Small cutaneous paddle Decreased ankle strength and toe flexion Small risk chronic ankle pain Requires invasive study for preop. evaluation
Slide 51-

Fibula Free Flap Fibula is outlined Skin paddle centered over junction of middle and distal third to encompass dominant septoperforators
Slide 52-

Fibula Free Flap Leave 6 cm of proximal and distal fibula
Slide 53-

ppt slide no 53 content not found
Slide 54-

ppt slide no 54 content not found
Slide 55-

Fibula Free Flap Aberrations in blood supply (10%) Peripheral vascular disease
Slide 56-

ppt slide no 56 content not found
Slide 57-

ppt slide no 57 content not found
Slide 58-

ppt slide no 58 content not found
Slide 59-

ppt slide no 59 content not found
Slide 60-

ppt slide no 60 content not found
Slide 61-

ppt slide no 61 content not found
Slide 62-

ppt slide no 62 content not found
Slide 63-

Iliac Crest Free Flap Arterial supply from deep circumflex iliac artery Venous supply deep circumflex vein
Slide 64-

Iliac Crest Free Flap Advantages Thick bone stock Easy positioning Defect closed primarily Minimal donor deformity Support osseointegrated implants Disadvantages Bulky soft tissue component Poor reliability of skin paddle Pelvic pain and risk for hernia formation Decreased postop ambulation Risk to peritoneum
Slide 65-

Iliac Crest Free Flap Most commonly used for mandibular defects in the head and neck best for angle/body defects can be used for symphyseal and parasymphyseal defects
Slide 66-

Iliac Crest Free Flap
Slide 67-

ppt slide no 67 content not found
Slide 68-

ppt slide no 68 content not found
Slide 69-

Iliac Crest Free Flap Skin paddle based on cutaneous perforators must be made large enough to incorporate perforators has poor mobility Can be improved by placing the paddle more cephalad
Slide 70-

Iliac Crest Free Flap Postoperative care Progressive mobilization Assisted ambulation POD # 3 or 4 Stair climbing 3 weeks
Slide 71-

Scapular/Parascapular Free Flap Arterial supply Circumflex scapular Venous Supply Vena commitantes
Slide 72-

ppt slide no 72 content not found
Slide 73-

ppt slide no 73 content not found
Slide 74-

ppt slide no 74 content not found
Slide 75-

Scapular/Parascapular Free Flap Advantages Large skin paddle Easy to harvest Low donor site morbidity (closes primarily) Availability for bone Disadvantages Thick skin Difficult positioning
Slide 76-

Jejunum Free Flap Seidenberg (1959) - First case report in a human Roberts and Douglas (1961) – first patient to survive Primarily use for reconstruction of pharyngoesophageal defects
Slide 77-

Jejunum Free Flap Arterial supply from portion of superior mesenteric arterial arcade (2nd or 3rd arcade) Venous supply from venous branches along arcade
Slide 78-

ppt slide no 78 content not found
Slide 79-

Jejunum Free Flap Advantages Tubular Mucosal surface may help with lubrication Minimal donor defect Disadvantages Bowel or pharynx fistulas Need for laparotomy Gen. Surg. team No neovascularization Reverse peristalsis Poor TE speech Short pedicle Difficult in obese persons
Slide 80-

Jejunum Free Flap Contraindications Ascites History of extensive abdominal surgery Involvement of the thoracic esophagus H/o of intestinal disease (Crohn's)
Slide 81-

Intraoperative Management Operating microscope, instruments, sutures Irrigation supplies Anticoagulants and volume expanders No pressors Patency assessment (15-20 minutes) Pulsation Doppler
Slide 82-

Postoperative Management Skilled nursing important No pressure on pedicle (no ties on neck) Eliminate cooling of flap Keep head in neutral position No pressors– keep BP stable Hematocrit important Frequent inspections and doppler pedicle
Slide 83-

Postoperative Management Inspection and prick test Arterial vs. venous insufficiency Pharmacotherapy Heparin, dextran, aspirin
Slide 84-

Oral Cavity and Oropharynx Reconstruction Thin pliable mucosa Possibilities Radial Forearm Scapular/Parascapular Lateral Arm Lateral thigh
Slide 85-

Tongue Reconstruction Reconstruction aimed at preserving what has not been resected Less than 1/3-1/2– primary closure vs. STSG Over ½--consider free free flap if expected contracture makes speech/bolus transit difficult (sensate) Anterior 2/3–consider coned RFFF (sensate
Slide 86-

Tongue Reconstruction For tongue base and total glossectomy defects—need adequate oral mound to approximate with palate for speech and bolus transit May consider rectus abdominus and latissimus dorsi free flaps
Slide 87-

Hypopharynx and Cervical Esophageal Reconstruction Must be prepared for possibility of complete circumferential pharyngeal defect Over 3 cm remains– primary closure Less than 3 cm—pec flap vs. RFFF Total loss above thoracic inlet– tubed pec flap, RFFF, scapular FF, lateral thigh free flap, or free jejunum flap Total loss below thoracic inlet– gastric pull-up
Slide 88-

Mandibular Reconstruction Loss of anterior mandibular arch Loss of chin/lip support Sensory loss Malocclusion Retrognathia Lack of oral competence/eating/speaking Consider osteocutaneous free flaps-- fibula, iliac crest, scapula, radius
Slide 89-

Mandibular Reconstruction Loss of lateral mandible Concavity of cheek Mandible rotation to defect side with cross bite Remnant rotation superiorly and medially Mental nerve loss Easier for patient to adjust Consider osteocutaneous free flap
Slide 90-

ppt slide no 90 content not found