Vascularized free-tissue transfer in head and neck surgery

Interdisciplinary plastic and reconstructive surgery of head and neck squamous cell carcinomas

Squamous cell carcinomas are the most common malignancies in the oral cavity, pharynx, and larynx. Even in the age of the most modern drug treatment methods, radical resection of these tumors is and currently remains the therapeutic gold standard. The loss of anatomical structures associated with surgery inevitably increases the functional deficits caused by the tumor itself. In this context, the extent of functional deficits is largely determined by the extent of resection. Complete organ resections, such as glossectomy, complete palate resection, laryngectomy, or transverse pharyngo-laryngectomy, lead to severe functional deficits, such as swallowing disturbances with life-threatening aspiration and articulation disorders up to the inability to speak. With the help of plastic reconstructive surgery, the lost tissue can be replaced and the specific functions of the upper aerodigestive tract can be preserved or restored.In recent decades, reconstructive surgical procedures have developed enormously in the treatment of malignant tumors of the head and neck. In order to make optimal use of them, a comprehensive, interdisciplinary therapy concept is a prerequisite for positive oncological and functional outcome. In addition to general medical and social parameters, surgical parameters play a crucial role in the choice of the reconstruction method. The extent to which the surgical measures must be interdisciplinary depends on the localization of the defects in the head and neck region and on the type of replacement tissue required. Here, the expertise of plastic surgery, oral and maxillofacial surgery, and abdominal surgery comes into play in particular. The use of different tissues, the combination of different grafts and flaps, or the preforming of donor regions allow reconstructions far beyond the level of simply restoring surface integrity. The functional results and thus the quality of life of patients after surgical therapy of extensive tumors of the mentioned localizations depend decisively on the type of reconstruction. Therefore, in the following review, special emphasis 1 be placed on the choice of reconstruction method and reconstruction technique for tissue loss after resections of HNSCC.

Surgical Management of Melanoma

The surgical management of melanoma has undergone considerable changes over the past several decades, as new strategies and treatments have become available. Surgeons play a pivotal role in all aspects of melanoma care: diagnostic, curative, and palliative. There is a high potential for cure in patients with early-stage melanoma and the selection of an appropriate operation is very important for this reason. Staging the nodal basin has become widespread since the adoption of sentinel lymph node biopsy (SLNB) for the management of melanoma. This operation provides the best prognostic information that is currently available for patients with melanoma. The surgeon plays a central role in the palliation of symptoms resulting from nodal disease and metastases, as melanoma has a propensity to spread to almost any site in the body.

Laryngotracheal reconstruction using prefabricated and preconditioned composite radial forearm free flaps

OBJECTIVE

Total or subtotal laryngectomy performed as surgical treatment of locally advanced laryngeal tumors requires a permanent laryngostomy or tracheostomy, and are both associated with severe and lifelong disability. The hitherto published reconstructive methods for the rehabilitation of patients after subtotal anterior laryngotracheal resection of extended laryngotracheal malignancies have not been thoroughly convincing.

METHODS

We present a successful method of extended laryngotracheal reconstruction that combines modern surgical and biomedical techniques.

RESULTS

A stable three-dimensional anterior neolarynx was prefabricated, including the use of vacuum-assisted prelamination and preconditioning of a composite radial forearm free flap, which was then transferred to the neck and vascularized by microvascular anastomosis to the cervical vessels. This reconstructive procedure permitted the restoration of a stable laryngotracheal conduit in two cases, with the subsequent successful closure of the tracheo-laryngostomy.

CONCLUSION

In the reported cases the pre- or post-operative irradiation did not compromise the success of reconstruction. Not only did our technique facilitate the rehabilitation of patients suffering from drawbacks of the laryngo-tracheofissure, but it also assisted in avoiding total laryngectomy in cases of advanced anterior laryngeal cancer by extending the indications for subtotal anterior laryngeal resections followed by reconstructive surgery.

Microvascular surgery

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Describe the common room set-up, medical considerations, and technical equipment necessary to perform microvascular surgery. 2. Describe the common arterial and venous techniques in performing microvascular surgery. 3. Recognize the common flap types along with their vascular supply and innervation used for microvascular surgery. 4. Describe common techniques for flap monitoring. 5. Describe techniques and medications for thrombolytic therapy. 6. Describe common medical conditions that may preclude an optimal result in microvascular surgery.

SUMMARY

This article will explore common approaches to microsurgery. It is anticipated that the readers can utilize this article for maintenance of certification educational components and take the principles outlined and apply them to their daily practice.

Clinical outcome and technical aspects of 263 radial forearm free flaps used in reconstruction of the oral cavity

BACKGROUND

The aim of this study was to report the applications, complications, and limitations of the radial forearm flap when used for reconstruction after excision of cancers in the mouth.

PATIENTS AND METHODS

We reviewed records in our database from October 1987 to December 2002; a total of 505 patients had surgical defects of the head and neck reconstructed with a radial forearm flap: 258 patients had oral cancers, of whom 173 were men and 85 women, median age was 70 years. Five patients had two reconstructions (total 263), of which 247 were fasciocutaneous and 16 osseofasciocutaneous flaps. Mucosal squamous carcinoma accounted for 97% of the primary cancers.

RESULTS

There were nine failures of the flap (3.4%) and four episodes of partial necrosis. Four patients (2%) died within 30 days of operation. Orocutaneous fistulas appeared in nine patients (3.4%), 10 patients had wound infections, and nine had haematomas. The nine failed flaps were replaced by a second free flap in one patient, a pectoralis major flap in three, a buccinator myomucosal flap in one, a skin graft in one, and the remaining three defects healed by secondary intention. There was one failure and one partial failure among the 16 osseofasciocutaneous flaps.

[Vascularised osteocutaneous scapular flap in the reconstruction of mandibular defects after war wounding]

Vascularized osteocutaneous scapular flaps belong into the most convenient ones in reconstruction of mandibular defects followed by massive loss of adjacent skin and mucous membrane due to its vascular supply, bulkiness, suitability and mobility of cutaneous component of the flap. In seven wounded patients such defects of the mandible and adjacent soft tissues after war wounding have been reconstructed at the Clinic for Maxillofacial Surgery of the Military Medical Academy - Belgrade during the six years period with vascularized osteocutaneous scapular grafts. Here we present localization and structure of the defect, features of harvested compound graft, the procedure of reestablishment of mandibular continuity, immediate and late complications during the consolidation period, as well as the analysis of the success rate.

Outcome after radial forearm, gastro-omental, and jejunal free flaps in oral and oropharyngeal reconstruction

We undertook a retrospective study of the outcome of radial forearm, gastro-omental, and jejunal free tissue transfer for oral and oropharyngeal reconstruction in 30 patients (10 in each group). No significant differences were found between the type of free flap and the clinical outcome. More long-term difficulties were experienced with swallowing than with speech. The selection of free flap did not correlate with speech function (P=0.44), swallowing (P=0.68), or management of saliva (P=0.59). No significant difference was found between the patients' outcome and the site of resection of the tumour. There were more complications after gastro-omental flaps and this may influence the choice of reconstruction.

The free radical forearm flap: a reliable method for reconstruction of the laryngohypopharynx after in-continuity resection

Between 1992 and 1996 14 patients with a squamous cell carcinoma of the laryngohypopharynx underwent tumour resection and primary reconstruction with the free volar forearm flap. Tumour resection was performed by a head and neck surgeon and reconstruction by a plastic surgeon. Preoperative radiotherapy was given to 13 patients and postoperative radiation to one patient. Thirteen patients were male and one patient was female, with a mean age of 66 years (range 53-79 years). The flap was harvested from the left forearm in 12 cases and from the right in two. The mean operation time was 12 h (range 11-20 h), and the mean intraoperative bleeding volume was 700 ml (range 400-1,000 ml). Twelve of 14 flaps survived. One flap was totally lost 3 weeks postoperatively and another was partially lost 2 weeks after surgery. Overall revisional surgery was carried out in six patients. Infections and fistulae at the neck occurred in six of the 14 patients. Six of the 14 patients were alive at follow-up. One patient died of an acute haemorrhage from an oesophageal ulcer 2 months after surgery, one patient died of a second primary oesophageal cancer and six patients developed recurrences. The mean survival time was 26 months (range 2-43 months).