Principles of flap reconstruction in ORL-HN defects NOTES/1/2/OM... · reconstruction in ORL-HN...

Principles of flapreconstruction in ORL-HN

defects

O.M. OluwatosinDepartment of Surgery

• Nasal defects and deformities• Cleft palate and Velopharyngeal

incompetence• Pharyngeal and oesophageal defects• Pinnal defects and deformities• Facial palsy

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Wound closureWound closure

Timing and cleanlinessNature of wound

Timing and cleanlinessNature of wound

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Closure based on nature ofwound:

• Flap• Graft• Direct closure• Do nothing

• Flap• Graft• Direct closure• Do nothing

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Fundamentals of Direct Closure:

a) Incisions should follow skin tensionlines

b) Gentle handling of tissues withadequate debridement

c) Haemostasisd) Eliminate tension at edgese) Use fine sutures.f) Evert wound edges during closure

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Skin Graft

• A piece of skin transferred fromone part of the body to the otherwhile it is completely detatchedfrom its blood supply or donor siteattachment

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Tissue grafts:

• Skin• Fascia• Tendon• Nerve

• Vessel• Bone• Organ• Fat

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Sources of skin graft

• Autograft• Isograft• Allograft• Heterograft

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Indications for skin Grafting

• Significant gap in a wound suchthat it cannot be closed withouttension. Such may be due totrauma, after excision oftumours, and scars.

• Treatment of non neoplasticulcers and full thickness skinburn

Post Auricular graft

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Flaps

• A flap is a mass of tissuetransferred from one part ofthe body to another with itsblood supply intact.

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Indications for flap transfer

• SIGNIFICANT GAPin which the bedis NOT ADEQUATELYVASCULAR e.g.,bare bone, baretendon

• Transfer ofCOMPOSITETISSUE, e.g.,bone and skin

Nasal defects and deformities

• Congenital - clefts• Acquired:

trauma – sports, human biteinfection and inflammationneoplasiaaltered body image

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NASALRECONSTRUCTION

Nasal aesthetic subunits.

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Basic principles• Restoration of “normal”.• Replace missing parts with like tissue.• Create template for replacing missing parts.• At skin level, replace entire aesthetic subunits

where practical.• Scar placement.• Anticipate final stage in which subcutaneous

tissue is sculpted to replicate delicateconfiguration.

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Bilobed flap

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The forehead flap

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Forehead flap

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Flap elevation

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Pharyngoplasty

Pharyngoplasty

• The surgical management of velopharyngealincompetence usually consists of pharyngealflap or sphincter pharyngoplasty.

• The sphincter is constructed from theposterior tonsillar pillars, and thepalatopharyngeus muscle is included in theflaps.

• Pharyngeal flaps may be superiorly orinferiorly based.

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Aim of pharyngoplasty

• The aim of the procedure is to attachtissue from the posterior pharyngeal wall tothe soft palate so as to create a midlineobstruction of the oral and nasal cavitieswith two lateral openings (ports).

• Flap width is determined by the degree oflateral pharyngeal wall motion: flap lengthdepends on the space to be bridged.

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PHARYNGEAL ANDOESOPHAGEAL

RECONSTRUCTION

Indications• Resection of oesophagus

– Neoplasm– Dysfunctional esophagus

• Oesophagectomy/gastrectomy complications– Fistula– Stricture– Length

• Failed oesophageal continuity procedures– Dehiscence– Stricture– Dysfunction

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• Supraclavicular Artery Island Flap• Deltopectoral flap• Pectoralis major flap• Gastric pull though• Jejunal, ileal flap• Colonic interpositioning

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Supraclavicular artery flap

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Supraclavicular artery flap

Deltopectoral flap

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Pectoralis major flap

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EAR RECONSTRUCTION

Surgical considerations and limitations

• the ear is a difficult structure to drawor sculpt, let alone surgicallyreproduce.

• the plastic surgeon’s aim is to achieveaccurate representation —that beingto create an acceptable facsimile of anear that is the proper size, in theproper position, and properly orientedto other facial features.

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Prominent ears

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Otoplasty for the prominent ear

• Most common causes are:– Concha – overdeveloped, or excessively

deep conchal cup.– Antihelix fold – underdeveloped, effaced or

absent fold.– Concha and antihelix fold combined.

• Height and width of the ear remainnormal

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Operative maneuvers• Alteration of the depth of the concha

– Suturing to the mastoid fascia.– Excision of cartilage.– Scoring of cartilage(Gibson’s principle)

• Alteration of antihelix folds– Suturing of cartilage.– Scoring of cartilage.– Thinning or grooving the posterior surface of the

antihelix + Mustarde sutures.– Through incision of cartilage(luckett procedure) or

tubing method.• Alteration of the position of the upper auricular pole

– fossa – fascia stitches– Scoring of cartilage.

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• Alteration of soft tissues– Earlobe – suturing earlobe to concha.

»Cauda helicis to posterior wall ofconcha.

– Excision of auricularis posterior muscle andadjacent soft tissue for concha to “sit” into(Elliot maneuver).

• Ear molding with tapes and dental compound issufficient in neonates

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Operative maneuvers

Complications of Otoplasty• Hematoma

• Malposition of the ear – headband, tapeand soft dental wax,post-auricular prop.

• Pressure deformation.

• Wound infection06/09/13 Reconstructive surgery 47

Reconstruction of the microtic ear

• First Stage of Reconstruction• Obtaining Rib Cartilage• Framework Fabrication• Framework Implantation• Postoperative Management• Other Stages of Auricular Construction

Rotation of the LobuleTragal Construction and Conchal DefinitionDetaching the Posterior Auricular RegionManaging the Hairline

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Ear framework

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Fabricating an ear framework

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Donor site iscontralateralthorax. Helical rimis obtained fromfloating ribcartilage.

INDICATIONS FOR EARRECONSTRUCTION

• Congenital auricular deformities

• Partial ear loss

• Total ear loss

• Other acquired eardeformities,such as burns

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AIM OF RECONSTRUCTION

• To restore the form and function of theear to as close to the normal as possible

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RECONSTRUCTION FOR ACQUIREDDEFORMITIES

• CAUSES- trauma, tumour excision,burns

• Defect may be partial thickness or fullthickness(composite loss)

• Partial composite ear loss• Upper third• Middle third• Lower third

• Total ear loss06/09/13 Reconstructive surgery 53

Acquired Partial Defects

• The most commonly encountered• Reconstruction influenced by aetiology,

location and nature of the residual deformity.• Skin loss without cartilage exposure – STSG

or FTSG• Cartilage exposure – excision+ primary

suturing; local flap closure• Composite loss – options vary

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Specific Regional Defects• External auditory canal

• Prevent stenosis by careful realignmentof tissues and insertion of an acrylicmold;retain for 6months

• If stenosed – Meatoplasty +FTSG over anacrylic mold applied to suitable recipient bed

- multiple Z-plasties- local flap

• Helical rim• Helical advancement• Chondrocutaneous graft• Local advancement flap+ rim of cartilage• Use of thin-calibered tubes06/09/13 Reconstructive surgery 55

Upper Third Defects

• Rim loss –Helical advancement (Antia-Buch)-pre-auricular flap cover

• Intermediate loss – Banner flap+ cartilagegraft (Crikelair)

• Major loss – contralateral conchal cartilagegraft(Adams,1955)

- chondrocutaneous compositeconchal flap

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Antia-Buch’s helical rim advancement

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Middle Third Defects

• Rim: Helical advancement

• Post-tumor excision: wedge excision withaccessory triangles

• Major loss: Conchal rotation (Orticochea)cartilage graft inserted viaConverse’s tunnel procedure orcovered by adjacent skin flap

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• Ortichochea’s conchal rotation.

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FACIAL PALSY

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Main divisions of facial nerve

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Tissueexpansion

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• Selected readings in Plastic Surgery.• Baylor University Medical centre.

• Hackney FL. Plastic Surgery of theear

• Anderson RG. Facial palsy.• Muzaffar AR and English JF. Nasal

reconstruction

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