Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Oral Cavity Reconstruction
Anatomy of the Oral Cavity
The oral cavity consists of the lips, buccal mucosa, maxillary and mandibular alveolar ridges, retromolar
trigone, floor of mouth, hard palate, and the anterior (oral or mobile) tongue (Figure 44.1).
FIGURE 44.1 Graphical depiction of the structures of the oral cavity.
The tongue plays the foremost role in speech, swallow, and airway protection. The anterior tongue in
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particular is critical for articulation, taste, and food manipulation. Intrinsic motor innervation is provided
by the hypoglossal nerve. The lingual nerve supplies general sensation to the anterior two-thirds of the
tongue, whereas the chorda tympani (through cranial nerve VII while accompanying the lingual nerve) is
responsible for taste. The V2 and V3 divisions of the trigeminal nerve provide general sensation to the
remainder of the oral cavity. Stenson duct drains salivary production from the parotid duct into the oral
cavity via an orifice opposite the second maxillary molar.
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Common Defects
Typical oral cavity defects include the buccal mucosa, retromolar trigone, floor of mouth, and varying
extents of the tongue including partial, subtotal, and total glossectomy. Composite defects are common
with inclusion of multiple oral cavity components, and may also involve the palate, oropharynx,
mandible, and lips. Reconstruction of these more complex defects requires additional functional and
aesthetic considerations, but the basic reconstructive principles of the oral cavity and pharyngeal
components are reviewed for this chapter.
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Buccal and Retromolar Trigone Reconstruction
Goals of Reconstruction
The buccal mucosa serves as a barrier of oral cavity contents from the facial musculature and nerves,
which are protected from mechanical trauma during mastication and speech. Its pliability allows for
unrestricted mouth opening during these functions. In addition to its functions related to vocalization,
suckling, and smile, the buccinator muscle and the buccal fat pad contribute to the contour and symmetry
of the cheek. Reconstructive goals for defects involving the buccal mucosa should address these
considerations.
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Flap Choices and Technique
Small buccal defects restricted to the mucosal layer may heal with secondary intention, or may be
reconstructed with skin grafts or skin-substitute matrices. Alternatively, locoregional options such as the
facial artery musculomucosal, buccal, tongue, submental, or supraclavicular flaps may be suitable. 1 As is
often the case, however, preoperative radiation exposure and/or concomitant neck dissection with
sacrifice of facial or lingual vessels may render locoregional options unavailable. A larger defect or one
that extends to include the floor of mouth or exposes the mandible or palate typically benefits from free
tissue transfer using a thin, pliable fasciocutaneous flap. Flaps with excessive bulk will protrude into the
oral cavity, thereby interfering with speech and swallow or potentially obstructing the airway. Forearm
free flaps based off of either the radial or ulnar pedicles are the classic donor sites for these defects.
However, depending on body habitus and pedicle length requirements, the anterolateral thigh, profunda
artery perforator, lateral arm, and medial sural artery perforator flaps represent suitable alternatives,
especially if the buccinator and/or the buccal fat are resected resulting in deficient cheek contour (Figure
44.2). 2,3 Radiation will result in further flap volume atrophy by up to 44%. 4 Occasionally, a full thickness
cheek defect that includes skin loss may require double-skin island reconstruction. These may be
thoughtfully designed using multi-perforator flaps such as the ALT or forearm flaps.
FIGURE 44.2 A. Buccal mucosal defect following excision of squamous cell carcinoma with loss of buccinator muscle and
exposure of buccal fat pad. B. Surface landmarks for harvest of the profunda artery perforator flap include the adductor longus
(red arrow) and gracilis (white arrow) muscles. The intramuscular pedicle is dissected through the fibers of the adductor
magnus (yellow arrow). C. Completed dissection of the musculocutaneous perforator pedicle of the profunda artery perforator
flap through the adductor magnus muscle. D. Completed inset and revascularization of flap for buccal mucosal defect.
The most commonly used recipient vessels are the facial artery and facial vein. The passage of the pedicle
for buccal defects should be carefully planned. In the absence of a floor-of-mouth component of the
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defect, the pedicle is passed through a subcutaneous tunnel and anteriorly over the intact mandibular
body into the neck. These pedicles may be more subject to compression with mouth opening and
animation, and adequate pedicle length should be harvested to avoid compromise. In the presence of a
floor-of-mouth defect component, which often requires marginal mandibulectomy and a neck dissection,
the vascular pedicle may be brought through the floor of mouth to the neck.
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Floor of Mouth Reconstruction
Analysis of Defect
The floor of mouth segregates the oral cavity from the sterile contents of the neck. Isolated floor-of-mouth
defects are relatively rare. More commonly, defects are also associated with glossectomy and/or
mandibulectomy. These larger defects lead to fistulous communication between the oral cavity and the
neck, and the reconstruction must prevent leakage of saliva and other oral cavity content into the neck,
where infection may threaten great vessel integrity or manifest as external cutaneous fistulae.
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Flap Choices
When a small floor of mouth defect exists that does not violate the suprahyoid musculature, skin graft or
skin substitute matrix application are suitable solutions. Alternatively, locoregional options such as the
facial artery musculomucosal flap or the submental flap may be considered. 1 However, concomitant neck
dissection typically sacrifices the facial artery, which serves as the pedicle for both of these flaps. The
supraclavicular flap has enjoyed increased recent popularity in both oral cavity and external neck skin
reconstruction, as its pedicle origin from the transverse cervical artery typically remains intact following
oncologic neck dissection.
For large full thickness defects of the floor of mouth, resections that include concurrent mandibulectomy
or partial glossectomy, or reconstruction in the setting of previous radiotherapy, free tissue transfer
remains the most definitive option. The amount of dead space requiring soft tissue obliteration should
dictate optimal flap selection. A radial forearm or ulnar artery perforator flap provides a thin and supple
lining that can be folded to provide coverage for the ventral tongue or to recreate the lingual sulcus
(Figure 44.3). 5 Recreation or maintenance of the sulcus is critical for tongue mobility and minimize
tethering. Other thicker fasciocutaneous flaps may be selected if greater bulk is desirable to fill the upper
neck; the lateral arm, anterolateral thigh, and profunda artery perforator flaps are reasonable choices
depending on individual body habitus. Chimeric muscle components may also be harvested with
fasciocutaneous flaps for dead space filling. The addition of vascularized muscle has the added benefit of
buttressing the flap skin island suture line to avoid salivary leakage. Pedicle length is not typically a
critical flap selection factor, because the proximity of floor of mouth defects to the neck allows for shorter
flap pedicle lengths in general.
FIGURE 44.3 A. Harvested radial forearm flap with inclusion of the cephalic vein. B. Radial forearm flap inset following
hemiglossectomy. Care is taken to preserve the lingual sulcus for tongue mobility.
The pedicled pectoralis major muscle or myocutaneous flap remains an alternative solution for floor of
mouth defects. With improved microsurgical capabilities, however, the donor site morbidity, propensity
for neck contracture, and poor aesthetic associated with the pectoralis flap limit its use in our practice to
high risk patients or to salvage scenarios of free flap failure or fistulae.
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Technical Details
Meticulous flap inset is of paramount importance, as small salivary leaks into the neck can result in
serious infection. If the remaining alveolar mucosal cuff is inadequate following the ablative procedure,
options include circumdental suturing (most common), continued elevation of a buccal mucosal edge
around the alveolus, or bony suture anchoring devices. Pedicle passage into the neck must be atraumatic,
tension-free, and accurately oriented. In most cases, the pedicle can be directly passed through the floor
of mouth.
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Glossectomy Reconstruction
Analysis of Defect and Goals of Reconstruction
The most common defects of the oral cavity requiring reconstruction are glossectomy defects.
Glossectomy compromises tongue function including speech, deglutition, and taste. The base of the
tongue is more important for swallowing function, whereas the oral tongue is critical for speech and food
manipulation. Restoration of these functions while preserving airway patency represents the main
objectives of tongue reconstruction.
The amount of remnant native tongue musculature is the foremost determinant of future tongue function.
6 The distinction among partial, hemi, subtotal, and total glossectomy types translates to disparate
reconstructive goals. Partial glossectomy typically implies resection of less than one-third of the tongue,
whereas hemiglossectomy describes loss of up to half of the tongue. Subtotal glossectomy removes up to
three-fourths of the tongue. Preservation of native tongue function is the primary goal after partial and
hemiglossectomy; reconstructive flaps need to be thin, supple, and pliable to avoid tethering or
displacement of the native tongue range of motion. By contrast, reconstruction after subtotal or total
glossectomy requires recreation of bulk for contact of the flap with the palate, thereby generating
acceptable speech and swallow while avoiding aspiration. The tissue bulk also serves to divert saliva and
food to the lateral gutters during swallowing to minimize aspiration.
Defect assessment should include the percentages of the anterior and base of tongue resected. The length
of the resection defect is measured from the tip of the remnant tongue to the tongue base. More extensive
posterior defects may extend to the epiglottis and/or the lateral pharyngeal wall. Contiguous loss of floor
of mouth and lingual alveolar mucosa should also be noted. Composite segmental mandibular resection
can mandate a second osseous or osteocutaneous flap reconstruction.
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Flap Choices for Partial and Hemiglossectomy With Technical Details
Partial glossectomy defects that preserve up to two-thirds of the tongue with minimal violation of the
floor of the mouth may be closed primarily or reconstructed with a skin graft. However, resection of the
floor of the mouth combined with a neck dissection often creates a wide communication between the oral
cavity and the neck. These defects, even if they involve less than one third of the tongue, are best
reconstructed with a flap to minimize the risk of fistula, which can in turn delay adjuvant therapies.
Thin, pliable fasciocutaneous flaps that fold easily are optimal for partial or hemiglossectomy
reconstruction. Folding creates the ventral and dorsal tongue surfaces, as well as formation of the lingual
sulcus extending onto the floor of mouth. Reproduction of this anatomy at the time of the initial
reconstruction is important for uninhibited tongue function; delayed revision to produce the sulcus is
challenging. For a hemiglossectomy, flap width of 6 to 8 cm usually provides adequate surface area,
though recreation of the lingual sulcus should be included in the three-dimensional defect measurement.
Radial and ulnar artery free flaps are most suitable for this purpose. The ulnar artery perforator flap has
been demonstrated to be a reliable alternative to its radial counterpart. 5 Flap dissection requires
meticulous attention to the safety of the ulnar nerve and generates a shorter length pedicle. However, the
ulnar forearm provides a more cosmetically-favorable donor site, and long-term hand function is
uncompromised.
For hemiglossectomy in thin patients, thigh-based options such as the anterolateral thigh (ALT) and
profunda artery perforator (PAP) flaps are viable alternatives (Figure 44.4). Pedicle length and flap width
for the two flaps are generally comparable, and some published evidence shows greater pliability of the
medial thigh tissue of the profunda artery perforator (PAP) flap that may be more amenable to folding.
3,7,8 The lateral arm is another fasciocutaneous option that often yields a pliable and relatively thin
subcutaneous adipose layer suitable for hemiglossectomy reconstruction. 2,9 With facile perforator
dissection techniques and improved knowledge of angiosome anatomy, microsurgeons have a large flap
armamentarium from which tailored flap selection can be individualized based on defect features, pedicle
length, and regional body habitus.
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FIGURE 44.4 A. A thin anterolateral thigh flap is also suitable for hemiglossectomy defects. Flap dimensions may be more
suitable for creation of larger skin islands for reconstruction of defects that extend into the lateral pharyngeal wall posteriorly.
Chimeric muscle components may also be useful to buttress friable suture lines or provide additional tongue base bulk as
necessary. B–D. A posterior partial glossectomy defect with contiguous lateral pharyngeal defect is reconstructed with an
anterolateral thigh flap.
Flap inset, in particular where the defect is posterior and includes the lateral pharyngeal wall, can be
challenging. Posterior inset should be performed first, preferably preceding flap reperfusion, in order to
maximize visualization. This can be accomplished through the neck exposure until the inset reaches the
mandible. Parachuting suture techniques are often helpful. The rest of the flap inset is completed through
the intraoral approach. It is essential to obliterate the submandibular dead space either with a small
amount of muscle (with ALT flap) or adipofascial tissue from the proximal forearm to minimize the risk
of infection.
In salvage scenarios following free flap failure or other high-risk settings where free flaps are
contraindicated, the pectoralis major muscle or myocutaneous flap may provide basic coverage. 10
Sufficient mobilization of the flap to ensure adequate cephalad reach requires at times division of the
clavicle. The flap can be islanded to avoid bulk in the lower neck. In some cases, muscle only may be used
to obliterate the floor-of-mouth defect, leaving the mucosal defect to heal secondarily or to be skin
grafted. This method obviates the need of a bulky skin island, and minimizes tethering of the tongue
remnant.
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Flap Choices for Subtotal and Total Glossectomy With Technical Details
The amount of flap bulk necessary for contact with the palate after a subtotal or total glossectomy can be
substantial, because the floor-of-mouth musculature is often included in the resection. A thick
fasciocutaneous or myocutaneous flap is desirable. The anterolateral thigh flap with some vastus lateralis
muscle is a versatile option. 11–13 Again, the muscle can be helpful for obliteration of the dead space. In the
morbidly obese population, muscle-only free flaps with skin grafting remain a reasonable alternative, but
such options are subject to atrophy with time and radiation, and speech and swallow functions may
decline as a result. The forearm flaps are quite thick in these patients and may be a better choice. A
summary of common free flaps used for oral cavity reconstruction is listed in Table 44.1 with a summary
of advantages and disadvantages. The pedicled pectoralis major flap may be used in poor candidates for
free tissue transfer or in cases of free flap failure.
TABLE 44.1
Common Free Flaps for Oral Cavity Reconstruction
Flap Type
Pedicle
Innervation Potential
Advantages
Disadvantages
Radial
forearm
Radial artery and venae
comitantes, cephalic vein
Sensory (lateral
antebrachial cutaneous)
Long pedicle length
Large arterial vessel caliber
Thin
pliable
skin
island
amenable to folding
No
need
for
perforator
dissection
Rapid harvest time
Venae comitantes can be
small in diameter, and
may need to include
cephalic vein
Unaesthetic donor site
Typically require skin
graft reconstruction of
donor site
Ulnar artery
perforator
Ulnar artery and venae
comitantes, basilica vein
Sensory (medial
antebrachial cutaneous)
Shorter
pedicle
length
compared
with
radial
forearm flap
Thin
pliable
skin
island
amenable to folding
Venae
comitantes
often
larger than radial venae
comitantes.
Better hidden donor site
than radial forearm
Close
proximity
and
potential injury to ulnar
nerve
Perforator vessels more
subject to shear than
radial forearm.
Typically require skin
graft reconstruction of
donor site
Anterolateral
thigh
Descending branch of
the lateral femoral
circumflex artery and
venae comitantes
Sensory (lateral femoral
cutaneous) and motor
(motor branch to vastus
lateralis)
Relatively
long
pedicle
length
Versatile
flap
design
including skin island size,
possible
chimeric
design
(muscle,
multiple
skin
islands)
Primary donor site closure
usually feasible
Variable septocutaneous
and
musculocutaneous
perforator course
Proximal perforator may
arise from the transverse
branch of the lateral
femoral circumflex.
Variable
thickness
depending
on
body
habitus
Profunda
artery
perforator
Perforating vessels off of
the profunda femoral
artery and venae
comitantes
None
Relatively
long
pedicle
length
Versatile
transverse
or
longitudinal
design
depending on laxity
Consistent anatomy
Primary donor site closure
usually feasible
Positioning difficulty for
dissection and closure
Extended intramuscular
dissection of perforator
Variable
thickness
depending
on
body
habitus
Less versatile than ALT
flap when chimeric flap
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is needed.
Lateral arm
Posterior radial
collateral and venae
comitantes
Sensory (posterior
cutaneous nerve of
forearm)
Aesthetic donor site with
primary
closure
usually
feasible
Short pedicle length and
small artery
Flap size limitation for
primary
donor
site
closure.
Potential injury to radial
nerve.
Variable
thickness
depending
on
body
habitus
Flap inset may present challenges due to paucity of remaining mandibular gingiva of suitable substance.
Interdental fixation or suturing the lower buccal mucosa may be necessary, rendering impossible the
recreation of any lingual sulcus. Trismus related to previous radiation may also limit visualization and
access. Proper flap planning to optimize muscle inclusion during harvest can limit risk of fistula or
infection into the neck by buttressing skin island suture lines. At the completion of flap inset, the bulk of
the flap should come into contact with the palate with the mouth closed (Figure 44.5).
FIGURE 44.5 Flap inset following total glossectomy should allow for contact with the palate during mouth closure to ensure
adequate bulk.
Because the suprahyoid musculature is removed during total and subtotal glossectomy, hyoid bone
resuspension is necessary to minimize aspiration risk. Circumhyoid sutures (0-Prolene) may be placed
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through drill holes in the mentum on the mandible on both sides of the midline. The distance between the
hyoid bone and the mentum is approximately 4.5 to 5 cm. Care should be taken to avoid compression of
the vascular pedicle by these suspension sutures.
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Recipient Vessel Selection
A virgin neck presents numerous recipient vessel options (Figure 44.6). The facial artery and common
facial vein are typically the primary candidates. Facial arterial lie may benefit from proximal dissection
and vessel transposition around the posterior digastric muscle belly, or the muscle may require division
to ensure absence of pedicle compression. The common facial vein is typically of excellent diameter to
serve as outflow. Secondary inflow options include the lingual and the superior thyroid arteries. The
middle thyroid vein and any other internal jugular venous branches are also outflow alternatives. In the
absence of venous branches off the internal jugular, an end-to-side anastomosis may be performed. The
external jugular may be used if the deep system is unavailable, but it is prone to twisting and kinking. It
should be carefully positioned before closing the incision and care should be taken postoperatively to
avoid extrinsic compression from neck malposition or devices such as tracheostomy collars.
FIGURE 44.6 Common recipient arteries include the facial, lingual, and superior thyroid arteries, which are all branches off the
external carotid artery (red vessel loop). The common facial (blue vessel loop) and middle thyroid (yellow arrow) veins provide
suitable venous outflow. Note the location of the hypoglossal nerve (white arrow).
The radiated or reoperative neck presents increased challenges due to vessel depletion. 14 Arterial walls
become notoriously friable. The transverse cervical artery which lies posterior to the sternocleidomastoid
at the base of the neck is usually spared after neck dissection, and in the majority of cases can provide
reliable inflow in an otherwise vessel-
 depleted neck (Figure 44.7). 15 Its transverse course rests just deep
to the posterior belly of the omohyoid muscle, which may be divided for exposure. The adjacent vena
comitans may or may not be of suitable caliber for outflow, but the external jugular vein at this level near
its convergence with the subclavian vein is another corresponding option, as compression is unlikely at
this depth. Further choices for the artery include end-to-end or end-to-side anastomoses to the external
carotid artery. The contralateral neck may yield vessel options, although a vein graft is often necessary for
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reach. As a last resort, the internal mammary vessels have been used in head and neck surgery in
conjunction with vein grafts. 16 The cephalic vein may also be fully mobilized along the length of the
upper extremity and turned up into the neck for venous outflow. The need for and use of vein grafts
alone are not necessarily predictive of increased risk of flap compromise; studies that do demonstrate an
association may merely reflect the overall increased complexity of such cases. 17
FIGURE 44.7 The transverse cervical artery and external jugular are good recipient vessel alternatives in the vessel-depleted
neck.
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Sensory and Motor Innervation
As a branch of the mandibular division of the trigeminal nerve, the paired lingual nerves supply sensory
innervation to the anterior two-thirds of the tongue. Fibers from the facial nerve via the chorda tympani
also course along the lingual nerve to generate taste from the anterior two thirds of the tongue. The
lingual nerve is typically cut during hemiglossectomy, and provides a potential target for sensory
reinnervation. Typically 2 mm in diameter, the nerve stump is located adjacent to the lingual cortex of the
mandible anterior to the angle. Some of the aforementioned common flap choices may be readily
harvested with inclusion of a sensory branch for reinnervation. 18 The anterolateral thigh flap has the
lateral femoral cutaneous nerve, the radial forearm or ulnar artery perforator flap may include an
antebrachial cutaneous nerve, and the rectus abdominis myocutaneous flap may be harvested with an
intercostal sensory nerve branch. Although spontaneous sensory recovery has been described without
nerve reconstruction, recovery is typically incomplete. A study of 21 patients who underwent
glossectomy reconstruction with the anterolateral thigh flap including 11 that had reinnervation using the
lateral femoral cutaneous nerve showed not only meaningful recovery of two-point discrimination, pain
and temperature sensation by 1 year after surgery, but also improved speech function in the sensory
reinnervated group. Although radiation delayed regaining of sensory function, differences were not
observed following 1 year. 18
Although sensory reinnervation is achievable, 19 dynamic reanimation of the reconstructed tongue is
much more unpredictable. The complexity of the interactive functions among the intrinsic and extrinsic
tongue musculature is technically impossible to fully reproduce. For speech, contact of the tongue tip
with the roof of the mouth is critical but achievable with passive movement of the reconstruction by the
native remnant tongue. For swallow and prevention of aspiration, intricate tongue motor actions are hard
to mimic with a single piece of muscle with linear contractility. Attempts at neurotized muscle flap
reconstruction with use of the hypoglossal nerve, in particular in the setting of radiation, have been
generally unsuccessful. Muscle fibrosis typically develops prior to reinnervation. Although innervation
may in some cases prevent muscle flap atrophy, there is no existing evidence that functional muscle
transfer for glossectomy leads to meaningfully improved function. In general, functional muscle transfer
is not indicated for partial glossectomy reconstruction. In total glossectomy cases, consideration may be
given to use of the anterolateral thigh flap, as this chimeric flap is unique in that concurrent motor and
sensory reinnervation is anatomically feasible using the motor branch to the vastus lateralis and the
lateral femoral cutaneous nerve.
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Postoperative Care and Complication Management
Patients typically undergo concurrent tracheostomy for airway protection. Nasogastric feeding tubes are
inserted for enteral nutrition while allowing for intraoral suture line healing. In the absence of medical
risk factors or other mitigating circumstances, spontaneous respiration is preferable with hourly flap
monitoring by nursing. With appropriate staff training, intensive care monitoring can be obviated.
Enhanced recovery protocols include minimization of narcotic use and early ambulation, including in
cases of lower extremity flap harvest. Care is taken to maintain neutral neck positioning to avoid pedicle
compression. By postoperative day one, tube feeding may be initiated along with pharmacologic
thromboembolic prophylaxis. A low threshold should be maintained for treatment of delirium tremens or
other symptoms of alcohol withdrawal, which is prevalent in this patient population. Though vascular
compromise of the flap is of utmost concern during the first 72 hours, vigilant monitoring for signs or
symptoms of infection should take place thereafter, as late flap loss is typically associated with infection.
Perioperative antibiotic prophylaxis beyond the initial 24 hours after surgery has not been shown to
reduce infectious complications, although the use of extended antibiotics remains common but varied. 20,21
Oral hygiene with gentle suture line cleansing and oral rinses should be diligently performed.
Swallow assessment with a modified barium test may be performed at 7 to 14 days after surgery, but a
more conservative 6-week waiting period of nothing by mouth may be more appropriate for radiated
defects extending to the hyoid bone. If a clinically-silent leak is detected, oral intake should be delayed for
1 to 2 weeks before radiographic reassessment.
The overall complication rate following glossectomy reconstruction is 15% to 25%. 22 Respiratory
complications including pneumonia and respiratory failure are the most common, highlighting the
importance of appropriate pulmonary toilet and avoidance of prolonged ventilatory support where
possible. Surgery-specific complications include neck infection, which should be treated early and
aggressively with operative washout, debridement, and drain placement. Neglected infection not only
threatens flap viability, but also poses risk to radiated great vessels of the neck that are susceptible to
catastrophic blowout. Persistent infection may also delay adjuvant therapies that need to be delivered
within a critical postoperative window. Any dead space or communication with the carotid or internal
jugular may be obliterated or covered with a pedicled pectoralis muscle flap; reservation of this flap for
secondary salvage is therefore beneficial.
When faced with a neck infection, careful intraoral examination must be performed for leak, dehiscence,
or fistula as the source of infection. Suture error, compromised tissue quality due to smoking or radiation,
and wound infection may all lead to dehiscence and leak. Proper flap inset is an exercise in balance
between appropriate suture spacing to allow for watertight closure and avoidance of tissue edge ischemia
with excessive numbers of small stitches. Pectoralis major muscle flaps are similarly useful for early
postsurgical and postradiation fistulae.
Flap failure due to arterial or venous thrombotic complications are reported at 1% to 2% in high-volume
centers. 17,23 Root cause analysis should be performed to determine the corrective course of action. If a
technical error can be identified, a second free flap reconstruction may be undertaken. Suspicion for
underlying hypercoagulability often may not be confirmed immediately, as these results may be delayed
or confounded by therapeutic anticoagulation. Judicious use of systemic anticoagulation is appropriate in
reoperative free flap cases, but there is a paucity of evidence for effective algorithmic anticoagulation use
in free flap surgery. 24
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Functional Outcome
Functional outcome following glossectomy directly correlates with the amount of preserved native
tongue tissue. Partial and hemiglossectomy reconstructive results are quite satisfactory in both speech
and swallow. Over 90% of patients are able to resume an oral diet without supplementary tube feeding.
Close follow-up with speech pathology and compliance with a dedicated training program can optimize
outcomes. On a standardized speech intelligibility and deglutition scale, all hemiglossectomy patients
should be able to achieve scores of 4 or 5 following rehabilitation. 25
Speech intelligibility scale:
1. Gross errors, unintelligible speech
2. Multiple errors, intelligible speech if the subject is known to the listener
3. Multiple errors, intelligible speech if the subject is unknown to the listener
4. Minor errors, acceptably intelligible speech
5. No errors, normal intelligible speech
Deglutition scale:
1. Severe dysphagia, nonoral feeding only
2. Partial oral, partial nonoral feeding
3. Liquid diet only
4. Pureed or soft mechanical diet
5. Regular diet
By contrast, outcomes following total glossectomy are much less favorable. 6 Over half of these patients in
long term are unable to rely solely on oral intake for nutrition and require tube feed supplementation.
Speech intelligibility is often poor; most patients achieve 2 or 3 on the intelligibility scale at best.
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Pharyngoesophageal Reconstruction
Anatomy of the Pharynx
The pharynx is the anatomic region that provides aerodigestive continuity between the oral and nasal
cavities and the esophagus (Figure 44.8). The pharynx is subdivided into the nasopharynx, oropharynx,
and hypopharynx. Posterior to the nasal cavity, the nasopharynx is superiorly bordered by the skull base
and inferiorly by the nasal surface of the soft palate. The pharyngeal tonsils are located on the posterior
wall of the nasopharynx. Posterior to the oral cavity lies the oropharynx, which begins at the uvula. The
base of the tongue serves as the anterior wall of the oropharynx. The hyoid bone represents the inferior
limit of the oropharynx. At this level, the epiglottis is an anterior-based connective tissue flap that seals
the entrance into the larynx during swallow, thus preventing aspiration. The hypopharynx (or
laryngopharynx) provides the final route of passage of food into the cervical esophagus. The
hypopharynx lies posterior to the larynx, the musculo-cartilaginous organ that transmits air from the
hypopharynx to the trachea for phonation. Extending from the level of the hyoid bone to the lower
border of the cricoid cartilage, the hypopharynx is a critical area responsible for airway protection,
swallow, and speech.
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FIGURE 44.8 Sagittal cross section anatomy of the nasopharynx, oropharynx, hypopharynx, and larynx.
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Laryngopharyngeal Reconstruction
Defect Analysis and Goals of Reconstruction
Most pharyngeal defects are created following total laryngectomy, which violates the anterior wall of the
hypopharynx to varying degrees. 10,26 Indications for total laryngectomy have narrowed as trends have
favored chemoradiation therapy with partial organ preservation for early-stage disease. These indications
include advanced primary laryngeal tumors with aggressive local spread, advanced hypopharyngeal
cancer, cancer recurrence or persistence after chemoradiation, and laryngeal failure with severe aspiration
following radiation. Although the frequency of total laryngectomies has decreased with time, the
difficulty of the cases encountered has increased with previous radiation exposure, reoperation, and other
high-risk factors. At the conclusion of the resection, assessment of the extent and viability of any
pharyngeal remnant should be made. Any devitalized edges should be sharply trimmed to avoid partial
necrosis resulting in a leak. The reconstructive goals following total laryngectomy include restoration of
digestive tract continuity from the tongue base to the cervical or thoracic esophagus without leak,
stabilization of airway with a secure tracheostoma, protection of the great vessels of the neck, dead space
obliteration, and possible external neck resurfacing.
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Flap Choice for Partial Defects
Partial pharyngectomy defects are characterized by preservation of a posterior strip of viable pharyngeal
mucosa (Figure 44.9). The width of the mucosal strip should be measured; the flap should be designed
such that the flap width plus the mucosal strip width equals approximately 9.4 cm. 27 A radial forearm
flap skin island provides an excellent anterior patch that replaces the anterior pharyngeal wall. However,
the flap provides little soft tissue excess for reinforcement of the suture line against leak, and dead space
obliteration is challenging. The anterolateral thigh flap may be similarly used as an anterior patch. 28 The
versatility of this flap is fully demonstrated with pharyngoesophageal reconstruction. The fascial
dimensions may be designed slightly larger than the skin island so that a second layer of coverage can be
created to protect the inset suture line, limiting the risk of salivary leak. Portions of the vastus lateralis
muscle may be harvested to fill dead space, buttress suture lines, and to provide coverage over the great
vessels of the neck. If perforator anatomy is suitable, a second skin island may be used to resurface the
peristomal skin (Figure 44.10). The pedicled pectoralis major muscle or myocutaneous flap remains an
option for partial pharyngoesophageal reconstruction. Its disadvantages include neck contracture and
poor appearance, and its primary use eliminates it as a potential source of salvage in the event of leak,
fistula, or infection.
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FIGURE 44.9 Partial pharyngectomy defects following laryngectomy preserve a posterior strip of viable pharyngeal mucosa.
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FIGURE 44.10 A. Anterolateral thigh flaps often have multiple perforators to allow for a second, distal skin island that can be
used to resurface neck skin around the tracheostoma. The proximal skin island is used for pharyngeal reconstruction. The V-
shape addition allows for spatulation of the distal neopharynx reconstruction. B. The distal skin island of the anterolateral thigh
flap is used for neck resurfacing.
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Flap Choice for Circumferential Defects
Traditionally, the jejunum free flap was the primary choice for circumferential defects of the
pharyngoesophagus. The anterolateral thigh has since supplanted the free jejunum flap as the optimal
donor site for this indication. 29 Table 44.2 is a comparison of free anterolateral thigh and jejunal flaps for
hypopharyngeal reconstruction. In most patients, the fasciocutaneous flap can be sutured into a
cylindrical tube using a 9.4 cm wide flap (Figure 44.11). In morbidly obese patients in whom tubular
fasciocutaneous flaps are prohibitive, 30 the jejunum flap may be the preferred option.
TABLE 44.2
Comparison of Free Anterolateral Thigh and Jejunal Flaps for Hypopharyngeal Reconstruction
Jejunal Flap
Anterolateral Thigh Flap
Defect type
Circumferential defects only
Circumferential or noncircumferential
Allows preservation of posterior pharyngeal cuff
Flap harvest difficulty level
High
Moderate; requires perforator dissection
Donor site morbidity
Requires laparotomy with enteral
reconstruction
Primary closure typically feasible
Ischemia time tolerance
60 min
4 or more hours
Potential for external neck
resurfacing
None; requires second flap
High; may use second perforator for additional skin island or
chimeric muscle with skin graft
Leak
Prone to leak at proximal
anastomosis, 2%
Distal anastomosis most prone to leak, 1%
Fistula
3% a
7% a
Stricture
2% a
4% a
Speech fluency
50%–75%
80%–100%
Use of tracheoesophageal
speech
25%
60%–100%
Return to oral diet
73%
91%
Tube feeding dependence
27%
9%
a Not statistically significant.
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FIGURE 44.11 Anterolateral thigh flap sutured as a cylindrical tube for circumferential pharyngeal reconstruction.
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Reconstruction of Simultaneous Pharyngoesophageal and Tracheostomal Defects
The upper neck skin flap on an apron incision typically used for laryngopharyngectomy is often
compromised by radiation exposure or even direct tumor invasion. The radiated skin lacks normal
compliance, and the neck may be contracted at baseline. Once the skin is elevated and the neck opened,
skin deficiency may present a challenge. Even without skin loss, direct closure of the upper skin flap to
the superior half of the tracheostoma may result in excess tension and delayed healing of the site. There
are four main methods to address the skin resurfacing needs. First, if the flap perforator anatomy is
amenable to creation of a second skin island, the latter may be used to secure the tracheostoma from 3 to 9
o’clock. If no second perforator is available, muscle may be harvested as a chimeric flap component and
covered with skin graft. These two techniques provide an externalized flap portion for monitoring of an
otherwise buried flap. 10 Finally, if the skin loss is extensive, or if a jejunal flap reconstruction is
completed, a second fasciocutaneous free flap or a pectoralis flap may be used.
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Pharyngoesophageal Reconstruction in a Vessel-Depleted Neck
Typical recipient vessel choices in head and neck reconstruction are often unavailable following
laryngectomy performed in the setting of reoperation and radiotherapy. Dissection and control of the
external carotid and internal jugular for end-to-side anastomoses is technically feasible but fraught with
risk of catastrophic hemorrhage. The transverse cervical vessels become critically useful under such
circumstances, because they are available in at least 92% of patients and are typically spared during most
neck dissections and radiation fields. 15 Located within the supraclavicular fossa posterolateral to the base
of the sternocleidomastoid muscle, exposure is relatively straightforward. The phrenic nerve should be
preserved, and the thoracic duct should be avoided in the vicinity on the left. The transverse cervical,
external jugular, or even stump of a ligated internal jugular vein may provide outflow options. The
external jugular near its confluence with the subclavian at this level is resistant to compression and
typically provides excellent vessel caliber. With proper flap planning, skin island orientation, and
adequate pedicle harvest, avoidance of vein graft even in the common setting of vessel depletion can be
achieved.
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Flap Inset and Technical Details
The authors use a single-layer flap inset with interrupted 3-0 Vicryl. Precise flap inset with edge eversion
is key. Optimal suture placement and spacing balances water-tight closure with marginal ischemia. In
tube-flap reconstructions, the T-junctions and proximal and distal anastomoses deserve special attention
as potential sites of leak. The authors prefer posterior orientation of the longitudinal suture line over the
prevertebral fascia to avoid any direct salivary leakage into the neck. Where possible, a second layer of
fascial wrap secured to the prevertebral fascia can serve to confine and limit any small dehiscence.
Further comprehensive detailing of the steps of completion of the individual flaps is beyond the scope of
this chapter, but is described in published journal articles. 27
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Minimizing Fistula and Stricture
Although older data demonstrate high complication profiles associated with laryngopharyngectomy
reconstruction, fistula and stricture rates can be as low as 6% and 19%, respectively, with appropriate
technical considerations and maneuvers. 10,26,27 Pharyngocutaneous fistula tends to manifest the first and
fourth weeks after surgery, but may also present in late stages following radiation. Smoking and
radiation increase fistula risk, but modifiable risk factors including technical error and inadequate
debridement of devitalized mucosal edges should be minimized. Proper eversion of tissue edges into the
lumen of the neopharynx with simple interrupted absorbable suture spaced 5 to 7 mm apart is optimal.
Suture line coverage with a wider fascial cuff or muscle offer added protection.
Any pharyngeal reconstruction is subject to postoperative scarring that may lead to long-term stricture
formation. Radiation is an exacerbating factor. The distal suture line near the cervical esophageal inlet is
particularly susceptible, as a natural funnel shape occurs at the normal pharyngoesophageal transition.
The upper esophageal sphincter, or the cricopharyngeus muscle, may be divided anteriorly with a
longitudinal myotomy. 10 This spatulating effect will then accommodate flap inset with a built-in V shape
to maintain width of the distal reconstruction. In extremely high-risk cases such as a low distal
anastomosis to the upper limit of the thoracic esophagus, an area that is particularly prone to stricture,
placement of a Montgomery salivary bypass tube with a 14 mm diameter within the tubed neopharynx
extending across the distal anastomosis may be helpful to reduce fistula and stricture. The tube may be
left in place while secured to the cheek for 2 to 4 weeks depending on patient tolerance.
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Postoperative Care and Management of Complications
Prolonged mechanical ventilation following laryngopharyngectomy reconstruction is not necessary.
Spontaneous breathing via the newly secured tracheostomy is desirable. Flap monitoring protocols will
depend on availability of external monitoring segments or placement of internal flow monitors for buried
flaps. Nasogastric or percutaneous gastrostomy feeding can be started on postoperative day one. Mean
length of stay based on our experience is 8 days. Modified barium swallow is performed at 2 weeks
postoperatively, or 6 weeks for radiated patients.
Infections of the neck should be aggressively treated with washout and antibiotics, and a low suspicion
for leak or fistula should be maintained. Infection can compromise flap viability leading to flap loss.
Small subclinical fistulae noted on swallow evaluation will typically heal within 2 weeks with continued
avoidance of oral intake. The swallow evaluation can be repeated to confirm resolution. Larger fistulas
usually require reoperation. The infection should be thoroughly debrided. The site of leak should be
identified. Upper endoscopy may facilitate intraoperative identification of the fistula if it is not
immediately apparent within the inflamed neck. Although attempt at debridement and reclosure of edges
may be possible, the tissue friability, dead space, and threat to great vessels associated with these cases
often mandates use of a pectoralis muscle flap. Persistent nonhealing fistulae should raise suspicion for
disease recurrence and/or distal obstruction due to stricture.
New onset dysphagia or regurgitation during long-term follow-up warrants work up for stricture or
recurrence. Modified barium swallow can localize the stricture, and endoscopic biopsy or balloon dilation
may be performed as indicated. Severe strictures that do not respond to dilation may ultimately require
excision and free fasciocutaneous flap reconstruction. Cases of reconstructive failure may rarely be
palliated with salivary diversion using a spit fistula at the neck, esophageal ligation, and gastrostomy or
jejunostomy feeding.
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Tracheoesophageal Speech
Following removal of the larynx, the patient becomes aphonic. Esophageal speech is where patients use
swallowed air to create esophageal oscillation that is typically softer and less precise than vocal cord
phonation. An electrolarynx is a device that can be used to transmit esophageal vibrations through neck
skin to generate speech. Use of the electrolarynx may be introduced during the early postoperative
period, but a period of rehabilitation to achieve familiarity and efficiency with the device is typically
necessary. A better alternative, the tracheoesophageal puncture, is a surgical procedure that may be
performed primarily at the time of laryngectomy with flap reconstruction or as a secondary operation. A
controlled communication is created by puncture through the trachea into the esophagus. Once the tract
size stabilizes and becomes optimized, an indwelling prosthetic device may be applied by speech
pathology. Fluent intelligible speech is achieved in 63% to 89% of patients. 31 Use of a fasciocutaneous flap
provides some advantages for postoperative speech intelligibility; speech after jejunal reconstruction is
typically characterized as sounding “wet” with diminished clarity.
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Total Esophageal Reconstruction
Indications
Indications for total esophagectomy include extensive tumor, radiation-related stricture or other injury,
ingestion injuries, direct trauma, or congenital and autoimmune disease. Restoration of digestive tract
continuity while limiting reflux and aspiration is the primary reconstructive goal, but such should be
accomplished while diminishing risk to the numerous vital structures of the mediastinum and neck and
minimizing donor site morbidity. The primary reconstructive option is the gastric pull-up procedure
where the stomach is mobilized based on its blood supply from the right gastric and right gastroepiploic
pedicles. The stomach is then advanced into the thoracic cavity to achieve anastomosis to the proximal
esophageal remnant. The reach of the stomach is limited by its pedicled blood supply; the cephalad
position of the cervical esophagus and hypopharynx exceed the advancement capacity of the gastric pull-
up procedure.
In this scenario and in other cases in which the stomach is unavailable (gastric or lower esophageal
radiation, previous gastrectomy, tumor invasion of the stomach, or other contraindicating abdominal
surgical history), the colonic interposition and the supercharged jejunum flap are viable alternatives. The
colonic interposition flap typically makes use of the descending colon, which is segmentally discontinued
from the remaining colon and transposed to the esophagectomy defect while vascularized by the left colic
vessels. Proximal and distal anastomoses are then required for colonic interposition inset, in addition to a
third anastomosis for colon continuity. The main cited advantage of the colonic interposition over the
supercharged jejunum flap is the lack of need for a microsurgical anastomosis. Many thoracic surgeons
therefore favor colonic interposition when the gastric conduit is unavailable. However, adequate colonic
mobilization sometimes compromises anastomotic perfusion at the proximal and distal limits of the
segment. Over time, colonic interposition flaps are prone to dilation and redundancy, leaving a
defunctionalized conduit that may compromise dietary intake. The colon is also a common site for
diverticula, cancer, and polyps, whereas the jejunum is typically disease-free.
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Technique of the Supercharged Jejunum Flap
The supercharged jejunum flap is a long-segment jejunal flap (Figure 44.12). 32 Via an open laparotomy,
the ligament of Treitz is identified. The small bowel mesentery is transilluminated for identification of the
second vascular arcade off of the superior mesenteric artery. The first arcade is preserved for perfusion of
the proximal jejunum for eventual Roux-en-Y reconstruction. The second arcade is completely dissected
toward its superior mesenteric artery origin and divided. The bowel is mobilized along the marginal
vessels along the length of the flap. The third arcade is usually divided to achieve further length. The
fourth arcade is typically preserved, serving as the actual pedicle to the flap. The bowel is then divided at
the proximal limit of perfusion of the second arcade, which will be used for microvascular supercharging.
This location typically measures between 30 and 40 cm from the ligament of Treitz. The jejunal flap is
then passed either retrocolic along the posterior mediastinum or antecolic through the retrosternal space.
Working space and visualization are typically enhanced with manubriectomy and resection of the medial
clavicular head and the first rib at the costosternal junction which also exposes the internal mammary
vessels to serve as excellent recipient vessels. The transverse cervical vessels are within easy reach and are
the authors’ second choice. Using branches of the external carotid artery mandates vein grafting. The
jejunum is notoriously intolerant of prolonged ischemia, and facile and expedient technique is paramount
to success.
FIGURE 44.12 Supercharged jejunum flap harvested for total esophagectomy reconstruction.
After the anastomoses are completed, the requisite length for the jejunal segment to achieve tension-free
proximal anastomosis while providing a straight, nonredundant conduit is determined. A short segment
of the most proximal portion of the flap is divided and externalized as a monitoring segment. A healthy
jejunal segment is light pink without congestion or edema, and maintains briskly peristaltic to mechanical
stimulation. A Doppler signal should be detectable both intrinsically and within its mesentery. The
remaining jejunal stump may then be anastomosed to the tongue base or hypopharynx, typically using a
hand-sewn two-layer technique. The distal aspect of the isoperistaltic flap is anastomosed to the stomach
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or another small bowel segment to restore alimentary continuity. The biliary limb is also reconstructed,
typically in Roux-en-Y fashion. A feeding jejunostomy is placed. Cautious neck drain placement is
performed to avoid direct contact against vascular and enteric anastomoses.
Postoperatively, the externalized segment is monitored using free flap protocols. Meticulous pulmonary
toilet should be instituted to avoid prevalent pulmonary complications. Signs of early leak may manifest
as tachycardia or other cardiac arrhythmia. Barring unexpected deviation from the recovery course, the
monitoring segment may be ligated and excised at bedside before discharge. Swallow evaluation may
take place at 2 to 6 weeks.
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Outcomes
In the largest published experience of supercharged jejunal flaps for total esophagectomy reconstruction,
51 patients underwent the procedure with 94% flap success rate. 32,33 Overall complication rate was 65%,
with intraabdominal and respiratory morbidity being most prevalent. Twelve percent of patients
experienced subclinical leaks that healed spontaneously. More clinically significant esophagocutaneous
fistulae occurred in 14% of patients, of which almost half healed spontaneously. Anastomotic stricture
rate was 10%. Two patients died during their prolonged hospitalizations, reflecting the complexity of the
procedure and the severity of complicating comorbid conditions. Overall, 90% were able to achieve a
regular diet, while 80% were able to discontinue enteral tube feeding.
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Combined Esophageal and Tracheal Resections
Combined esophageal and tracheal resections for locally aggressive cancers complicated by
tracheoesophageal fistula presents a tremendous reconstructive challenge. 34 Though convention suggests
that such advanced disease contraindicates resection, successful reconstruction may provide good quality
of life and palliation. The esophagectomy component may be reconstructed using a supercharged
jejunum, and the tracheal resection may be reconstructed with a tubed fasciocutaneous flap, such as the
anterolateral thigh flap. The fasciocutaneous flap may also be extended to help create the tracheostoma as
previously described, as the neck skin is often deficient. The primary surgical goals in these cases include
provision of airway safety and stability as well as infection control. Consideration may be given to delay
of the esophageal component of the reconstruction with temporary diversion in order to limit operative
time and to allow for improved nutritional and functional status prior to staged reconstruction.
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Summary
Oral cavity, pharyngeal, and esophageal reconstruction present challenges to the reconstructive surgeon.
35 Free tissue transfer remains the most predictable means of reconstruction for these complex defects that
are often further complicated by risk factors such as radiation injury and patient comorbidities. Optimal
flap selection with a clear knowledge of reconstructive goals along with preemptive measures to avoid
common complications can increase the likelihood of success. With knowledge expertise and meticulous
execution, good functional outcomes are achievable while minimizing morbidity and maximizing quality
of life. 36
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Questions
1. A 59-year-old woman initially presented with a squamous cell carcinoma in the right oral tongue
and underwent partial glossectomy with skin grafting, right neck dissection, and postoperative
radiotherapy 2 years ago. Approximately 3 months ago, she developed an ulcer in the remaining
tongue that grew quickly to involve much of the remaining tongue including the tongue base. CT of
head and neck suggested recurrence of tongue cancer. Subsequent biopsy confirmed squamous cell
carcinoma. There was no evidence of bone involvement. Her BMI is 28. On physical examination, she
has severe scarring in the right neck. All extremities are well perfused. She has very thin forearms
and moderate thickness in the thighs, estimated 2 cm thickness of subcutaneous fat. There are no
surgical scars in the abdomen. Which of the following is the most appropriate treatment option?
a. A partial glossectomy with split thickness skin grafts
b. A total glossectomy with a thin radial forearm flap
c. A total glossectomy with an anterolateral thigh flap
d. A subtotal glossectomy with a free jejunal flap
e. A subtotal glossectomy with a submental flap
2. A 65-year-old man status post laryngopharynectomy with tubed anterolateral thigh flap
reconstruction 4 weeks ago presents to the emergency department with persistent drainage from a
small opening on the neck skin. He has a history of preoperative radiation. CT scan is pending. He
also reports that earlier that day, he noticed a small amount of bloody drainage around his
tracheostoma that spontaneously subsided in a few minutes. His vital signs are normal, and he feels
overall well. There is no ongoing bleeding on exam. What is the most appropriate course of action
next?
a. Perform bedside incision and drainage of suspected neck abscess under local anesthesia
b. Obtain a complete blood count and coagulation panel to quantify amount of bleeding
c. Occlude the tracheostoma with a finger to prevent hemorrhage
d. Prepare for emergent operative treatment with or without angiography
e. Obtain a modified barium swallow evaluation to look for leak or fistula
3. A 48-year-old woman previously underwent a partial glossectomy and bilateral neck dissection for
squamous cell cancer. Reconstruction was performed with skin graft only. Postoperatively, she
received adjuvant radiation treatment. One year later, she presents with a local recurrence. During
free flap reconstruction for the defect after subtotal glossectomy, the right neck is explored for
vessels. The external carotid artery was injured during exploration and required ligation at the
carotid bifurcation. The left neck has not been opened, but the skin is densely scarred. Which blood
vessel should be explored next as a microsurgical recipient artery for free flap reconstruction?
a. Right internal carotid artery
b. Left facial artery
c. Right facial artery
d. Left transverse cervical artery
e. Right transverse cervical artery
4. During exploration of the neck for possible recipient vessels for free flap reconstruction of a floor-
of-mouth defect, a linear structure is encountered emerging from behind the posterior belly of the
digastric muscle inferior to the border of the mandible. The structure may be followed proximally
between the internal carotid artery and the internal jugular vein, and more distally crosses anterior to
the lingual artery. What is this structure?
a. Hypoglossal nerve
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b. Lingual nerve
c. Facial artery
d. Spinal accessory nerve
e. Great auricular nerve
5. A 71-year-old man has a history of perforated colonic diverticulitis requiring segmental colectomy.
He now presents with cervicothoracic esophageal carcinoma requiring transhiatal esophagectomy of
the proximal two-thirds of the esophagus with resection of the pharynx to the base of tongue. What
is the best option for reconstruction?
a. Tubed anterolateral thigh flap
b. Free jejunal interposition flap
c. Supecharged jejunal flap
d. Colonic interposition
e. Gastric pull-up
1. Answer: c. In this patient with massive recurrence, a total glossectomy is required to remove the
cancer. The goal of total glossectomy reconstruction is to provide enough bulk with a rather thick
flap so that the reconstructed neotongue can touch the palate to improve speech quality. The bulk is
also necessary to divert the food and saliva to the lateral gutters to avoid “dumping” of food and
liquid into the airway causing aspiration. A partial glossectomy would not be able to remove all the
cancer. Skin grafting in a previously radiated area, especially in the oral cavity will likely to fail,
resulting a massive orocutaneous fistula. A thin radial forearm flap would not provide enough bulk
for the neotongue. In fact, it will only provide lining with no bulk at all. Such a reconstruction will
create a “funnel” in the oral cavity causing massive aspiration and unintelligent speech. Frequent
aspiration pneumonias can be fatal and often require a total laryngectomy. A free jejunal flap is not
indicated for tongue reconstruction. The jejunal flap is often used to reconstruct a circumferential
pharyngoesophageal defect from a total laryngopharyngectomy. The submental flap is often
unavailable in a radiated and previously operated neck. The vascular supply of the submental flap is
a branch of the facial artery. During a neck dissection, the facial artery is often ligated and divided.
Even with the contralateral facial artery intact, previous radiotherapy will significantly compromise
the flap viability. In addition, the radiated and operated neck is firm and tight, and will not have
enough skin laxity. The flap is also not bulky enough for subtotal glossectomy reconstruction.
2. Answer: d. The patient reports symptoms consistent with a sentinel bleed, a possible innocuous
sign of impending catastrophic hemorrhage from carotid blowout. Risk factors include radiation,
reoperation of the neck, and concomitant infection. The additional presenting symptoms are also
concerning for fistula and infection. Assessment and preparation for either angiographic and/or open
surgical treatment of arterial hemorrhage should immediately be initiated. This patient has ongoing
infection that will also require operative washout, and adequate vascular control of the great vessels
of the neck need to be obtained given the likelihood of carotid blowout. Bedsides, incision and
drainage of the infection may result in uncontrolled hemorrhage compromising airway and
circulation leading to a potentially fatal outcome. The likely cause of bleeding is not coagulopathy,
and a normal complete blood count does not rule out the possibility of impending massive
hemorrhage. There is no ongoing bleeding site that requires direct digital pressure. Empiric occlusion
of the tracheostoma obstructs the permanent airway after total laryngectomy, and leads to
asphyxiation. A modified barium swallow evaluation does not adequately address the sentinel bleed
and probable impending hemorrhage.
3. Answer: e. The transverse cervical artery is located within level Vb of the neck, which is not
typically routinely dissected during cervical lymphadenectomy for cancers of the anterior tongue.
Experience shows that, despite previous surgery and radiation the transverse cervical artery is
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available in over 90% of patients, making the vessel suitable to serve as a microsurgical recipient
target. The internal carotid artery perfuses the brain and should not be used as an inflow vessel for
free flap reconstruction of the head and neck. The transverse cervical artery should be explored in the
open neck prior to attempted opening and investigation of the contralateral neck. In the setting of
previous neck dissection and radiation, the left neck may be similarly hostile, and another vascular
or nerve injury is possible. The facial artery is a branch of the external carotid artery, which has
already been ligated.
4. Answer: a. The anatomic description corresponds with the extracranial course of the hypoglossal
nerve. This structure is divided during hemiglossectomy on the ipsilateral side, but should be
preserved for motor function of the tongue (deviation to the ipsilateral side) during vessel
exploration for a floor-of-mouth reconstruction. The lingual nerve is encountered higher in the neck,
typically posterior to the lingual surface of the mandible. Knowledge of the lingual nerve anatomy is
useful for sensory reinnervation of glossectomy reconstructions. Although the facial nerve courses
deep to the posterior belly of the digastric, it originates from the external carotid artery and does not
course between the external and internal carotid arteries. The spinal accessory nerve crosses the
internal jugular vein around the level of the posterior belly of the digastric, crosses posteriorly over
the spinal accessory muscle, and continues into the posterior neck to reach the trapezius muscle. The
great auricular nerve is located in the posterior neck, coursing around the posterior border of the
sternocleidomastoid and running on its anterior surface to provide sensation to the skin over the
mastoid and parotid region.
5. Answer: c. The procedure allows for diversion of the oropharyngeal lumen into a limb of
mobilized jejunum that remains in continuity distally. While the more distal jejunum remains
vascularized via the intact superior mesenteric blood supply and marginal arcade, the more proximal
stump that is pulled into the neck is revascularized with microsurgical supercharging of the second
mesenteric arcade stump which requires division to gain adequate mobilization into the neck. When
the gastric pull-up procedure is unavailable or insufficient for superior reach, an alternate means of
reconstruction needs to be selected. A tubed anterolateral thigh flap is unlikely to be of sufficient
length to allow for complete replacement of the long segment of resected esophagus. Inset would
also require an intrathoracic anastomosis that is challenging during a transhiatal approach and
subject to intrathoracic leak. An intrathoracic anastomosis would also be required for a free jejunum
interposition. This anastomosis can be avoided with other options. The jejunum is poorly tolerant of
ischemia, but complete ischemic rendering of this flap is necessary. The supercharged jejunum flap
avoids total flap ischemia, and only requires revascularization of the most proximal aspect of the
mobilized stump. The patient has a history of perforated colonic diverticulitis that required
segmental colectomy. Use of the colon would be inappropriate in this scenario. Absent this
circumstance, some centers favor the colonic interposition procedure over the supercharged jejunum
flap when the gastric pull-up procedure is not feasible. While the gastric pull-up procedure is the
primary reconstructive option following esophagectomy, the stomach typically cannot be mobilized
to reach the base of tongue without devascularization.
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Namin, AW, Varvares, MA. Functional outcomes of sensate versus insensate free flap reconstruction in oral and oropharyngeal
reconstruction: a systematic review. Head Neck. 2016;38(11):1717-1721.
Dort, JC, Farwell, DG, Findlay, M, et al. Optimal perioperative care in major head and neck cancer surgery with free flap reconstruction: a
consensus review and recommendations from the Enhanced Recovery After Surgery Society. JAMA Otolaryngol Head Neck Surg.
2017;143(3):292-303.
Haidar, YM, Tripathi, PB, Tjoa, T, et al. Antibiotic prophylaxis in clean-contaminated head and neck cases with microvascular free flap
reconstruction: a systematic review and meta-analysis. Head Neck. 2018;40(2):417-427.
Chang, EI, Yu, P, Skoracki, RJ, et al. Comprehensive analysis of functional outcomes and survival after microvascular reconstruction of
glossectomy defects. Ann Surg Oncol. 2015;22(9):3061-3069.A large single-institution experience examining long term outcomes of free flap
reconstruction after glossectomy.
Chang, EI, Zhang, H, Liu, J, et al. Analysis of risk factors for flap loss and salvage in free flap head and neck reconstruction. Head Neck.
2016;38(suppl 1):E771-E775.
Wang, TY, Serletti, JM, Cuker, A, et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg.
2012;129(2):443-453.A frequently cited article describing the use of free tissue transfer in patients with hypercoagulable conditions.
Dzioba, A, Aalto, D, Papadopoulos-Nydam, G, et al. Functional and quality of life outcomes after partial glossectomy: a multi-institutional
longitudinal study of the head and neck research network. J Otolaryngol Head Neck Surg. 2017;46(1):56.
Selber, JC, Xue, A, Liu, J, et al. Pharyngoesophageal reconstruction outcomes following 349 cases. J Reconstr Microsurg. 2014;30(9):641-654.
Yu, P, Hanasono, MM, Skoracki, RJ, et al. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total
laryngopharyngectomy. Cancer. 2010;116(7):1718-1724.With its proposal of the anterolateral thigh flap for laryngopharyngectomy reconstruction,
this study was key in the popularization of the reconstructive technique as potentially advantageous over the more conventional use of jejunal flaps
previously.
Yu, P, Robb, GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study. Plast
Reconstr Surg. 2005;116(7):1845-1855.
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Yu, P, Lewin, JS, Reece, GP, Robb, GL. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal
reconstruction with the anterolateral thigh free flap versus the jejunal flap. Plast Reconstr Surg. 2006;117(3):968-974.This study was key in
direct comparison of speech and swallow outcomes after anterolateral thigh and jejunal free flap reconstruction after pharyngoesophageal
reconstruction, demonstrating several advantages of the anterolateral thigh option.
Yu, P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck.
2004;26(9):759-769.
Lewin, JS, Barringer, DA, May, AH, et al. Functional outcomes after circumferential pharyngoesophageal reconstruction. Laryngoscope.
2005;115(7):1266-1271.
Poh, M, Selber, JC, Skoracki, R, et al. Technical challenges of total esophageal reconstruction using a supercharged jejunal flap. Ann Surg.
2011;253(6):1122-1129.A high-impact article that describes use of the supercharged jejunal flap as an alternative for esophageal reconstruction.
Blackmon, SH, Correa, AM, Skoracki, R, et al. Supercharged pedicled jejunal interposition for esophageal replacement: a 10-year experience.
Ann Thorac Surg. 2012;94(4):1104-1111.
Ghali, S, Chang, EI, Rice, DC, et al. Microsurgical reconstruction of combined tracheal and total esophageal defects. J Thorac Cardiovasc Surg.
2015;150(5):1261-1266.
Vosler, PS, Orsini, M, Enepekides, DJ, Higgins, KM. Predicting complications of major head and neck oncological surgery: an evaluation of
the ACS NSQIP surgical risk calculator. J Otolaryngol Head Neck Surg. 2018;47(1):21.
Cohen, WA, Albornoz, CR, Cordeiro, PG, et al. Health-related quality of life following reconstruction for common head and neck surgical
defects. Plast Reconstr Surg. 2016;138(6):1312-1320.
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PA R T V
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Aesthetic Surgery
45. Nonsurgical Facial Rejuvenation and Skin Resurfacing
46. Dermal and Soft-Tissue Fillers: Principles, Materials, and Techniques
47. Botulinum Toxin
48. Fat Grafting in Plastic Surgery
49. Forehead and Brow Rejuvenation
50. Blepharoplasty
51. Facelift and Necklift
52. Rhinoplasty
53. Otoplasty
54. Facial Skeletal Augmentation With Implants and Osseous Genioplasty
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C H A P T E R 4 5
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Nonsurgical Facial Rejuvenation and Skin
Resurfacing
Deniz Basci and Jeffrey Kenkel
Key Points
Ablative resurfacing techniques rely on controlled injury to targeted layers of the epidermis and
dermis, followed by healing and replacement of the ablated tissue with normal tissue.
Various resurfacing modalities produce similar injuries; the appropriate treatment should be chosen
based on patient evaluation, their specific goals, and physician comfort with the procedure.
Aesthetic benefit, complication risk, prolonged erythema, and hypopigmentation are directly related
to depth of injury and target tissue specificity.
Treatment of skin wrinkles requires ablative therapy through the dermal-epidermal junction into a
variable depth of the papillary dermis.
The precision and outcomes of chemical peeling and dermabrasion are more technique dependent
than their laser counterparts.
Pretreatment with tretinoin or hydroquinone is recommended prior to chemical resurfacing, for even
depth of penetration and a reduction in associated morbidity.
Protection from the sun before and after treatment is mandatory for all resurfacing modalities,
especially when light amplification is being used to prevent burns, hyperpigmentation, and
recurrence.
Selective photothermolysis targets chromophores melanin, hemoglobin, or water in the skin to
deliver targeted thermal injury. The ideal treatment parameters remain controversial.
Fractionated lasers are designed to keep the stratum corneum largely intact while ablating a variable
amount of dermis depending on the physicians’ preferred density.
Nonsurgical treatments to reverse the signs of aging are in increasingly high demand and continue to
evolve rapidly as new technology develops. The American Society of Aesthetic Plastic Surgery 2017
survey data show that noninvasive procedures have risen 38% since 2012 and have increased 4.4-fold
since 1997. 1
Irregularities in surface texture, pigmentation, and wrinkling are hallmarks of aged skin. Classically,
mechanical, chemical, and photodynamic injuries to the skin have been used in a controlled fashion to
elicit desired changes. Cutaneous resurfacing targets abnormal skin structures at specific depths causing
the body to replace the desired areas with normal healthy tissue to achieve aesthetic goal. The face, neck,
décolletage, and hands are subject to the most sun exposure over a lifetime and are the most frequent
sites of skin resurfacing.
Although multiple modalities exist to achieve similar injury patterns, patients present different challenges
to achieving the desired aesthetic result. To minimize the risk of complications, an understanding of skin
anatomy as it relates to aging and a logical approach to selecting an intervention are of the utmost
importance.
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