happy microvascular reconstruction ...

happy microvascular reconstruction of the head and neck in cancer patients requires a well-coordinated team approach, including plastic and reconstructive surgeon head and neck surgical oncologists, medical and radiation oncologists, perioperative festers speech and physical therapists, dental oncologists, and prosthodontists as well as ancillary personnel Rehabilitation of patients with cancer of the head and neck can be an emotionally and technically challenging endeavor. Traditionally, local and regional flaps have been the mainstay of reconstruction for surgical deficiencys after ablation of malignancies; however, microsurgical techniques and unrestrained tissue transfer have ushered in a recently made known era for reconstruction of these patients. Since 1991 at the University of Nebraska Medical Center Omaha, we have performed more than 150 microvascular tissue transfers for reconstruction after head and neck cancer ablative surgery We review our team approach and experience with microvascular head and neck reconstruction.

RECONSTRUCTIVE OPTIONS

Reconstruction of the head and neck is sustained by on the type and amount of tissue resect Four major signs of reconstruction include mandibular, intraoral, pharyngeal, and plastic tissue defects. Although local and regional flaps occasionally are used to re-establish these defects, this article reviews any of the more common microvascular flaps employed

Mandibular resection creates a large cosmetic and functional deformity, especially anterior mandibular resection (Figure 1) The want resulting from resection of the anterior mandible is also known as the "Andy Gump" deformity, after the cartoon character created from Sidney Smith. Reportedly, Smith based his character in succession a local man who had undergone mandibular resection for cancer of the mouth(1) The man attempted to entreat the cartoonist, a reflection of the psychological impact this imperfection had on his self-image.

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Reconstruction of the mandible traditionally has been accomplished with bone grafts, trays, and local flaps. As these tissues oftentimes are poorly vascularized secondary to previous surgery and/or radiation, complications have been public In 1989, however, a operation was described in which a microvascular fibula flap was used to construct again the mandible.(2) The fibula is a lengthy oval-shaped bone nourished by the peroneal artery. The fibula provides up to 25 cm of bone for reconstruction. The periosteal offspring supply permits multiple osteotomies for exact contouring of the bone Osseointegrated dental implants can be inserted to restore dentition (Figure 2) frequently a cutaneous paddle is harvested with the bone (Figure 3) to construct again intraoral soft tissue defects. This flap has have fruition ofed widespread popularity, especially for immediate reconstruction of the mandible.

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Tumors of the oral cavity at short intervals involve portions of the tongue, floor of jaws and oropharynx. Soft tissue reconstruction of these areas attempts to keep sound speech and swallowing. The microvascular fasciocutaneous radial forearm flap (Figure 4) provides well-vascularized, relatively thin and pliable smooth tissue ideally suited for reconstruction of the anterior floor of jaws retromolar trigone, tonsil, and lateral and posterior pharynx (Figure 5) The flap is based upon the radial artery and veins and is harvested from the relatively hairless portion of the volar forearm. The flap is well vascularized and has tremendous versatility.(3)

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Large tumors of the larynx and pharynx sometimes require total or near total removal of the pharynx. Circumferential wants of the pharynx traditionally have been undivided of the most difficult reconstructive challenges for the plastic and reconstructive surgeon(4) Microvascular techniques now allow the transfer of a portion of jejunum based most commonly forward the second jejunal branch and its arcade. Before microvascular tissue transfer, many of these patients meet withed from salivary fistulas, were unable to sustain themselves orally, and required gastrostomy tubes.

frequently resection of malignancies of the head and neck particularly craniofacial resections, comes in massive soft tissue defaults Microvascular soft tissue transfers fill these lacks providing critical coverage of vascular conformations and the meninges when local and regional flaps are insufficient. The more commonly used independent flaps are the latissimus dorsi muscle, based forward the thoracodorsal artery, and the rectus abdominis muscle, based upon the deep inferior epigastric artery.(5)

PREOPERATIVE PHASE

Preoperative communication between surgeon surgical staff members, and anesthesia personnel is essential. Communication includes the planned conducts and order of succession, as well as the site for flap harvest. Donor site information is important for planning of line placement and patient positioning. In the preoperative holding area, the circulating pamper introduces herself or himself to the patient and family members. The foster explains the perioperatire routine, including placement of monitors, IV lines, arterial lines, urinary catheter, and compression stockings. The family is assured of of common occurrence communication with the circulating nourish during the procedure.