Reconstruction of the Head and Neck

PLASTIC SURGICAL RECONSTRUCTION: POSSIBILITIES IN SURGICAL ONCOLOGY I1

1055-32O7/97 $0.00

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RECONSTRUCTION OF THE HEAD AND NECK Stephan Ariyan, MD, MBA, Douglas A. Ross, MD, and Clarence T. Sasaki, MD

HISTORY

Over the last three decades, society has taken a broad approach in an attempt to decrease the incidence of head and neck cancer and to improve survival after the treatment for this disease. Through the efforts of a variety of groups such as The American Cancer Society, the Commission on Cancer of the American College of Surgeons, and various public advocate groups, legislation has been passed to safeguard the working place from environmental hazards and occupational hazards. There have been a number of public education programs instituted to warn the public about the risks of the development of cancer through many of the lifestyle changes. The medical profession has attempted to manage head and neck cancer by working with interdisciplinary cancer teams composed of surgeons, radiotherapists, chemotherapists, dentists, prosthodontists, speech therapists, and social workers, all of whom work together and are dedicated to the treatment of this disease. These team efforts have worked together to provide optimal clinical care and an environment for clinical and basic science research of the cancers within this area. This has been through an attempt at consolidating the experiences and -

From the Department of Surgery (SA, CTS), and the Sections of Plastic Surgery (SA) and Otolaryngology (SA, DAR, CTS), Yale University School of Medicine, New Haven, Connecticut

SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA VOLUME 6 NUMBER 1. JANUARY 1997

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expertise of these various specialties. In spite of these attempts, only modest improvements have been documented over the last 50 years. Although statistics on the incidence and cure of cancers of the oropharyngeal area have not shown significant improvement during this period, nevertheless, there have been major advances in the early reconstruction to decrease the disability of these patients after their treatment. These developments have made major changes by shortening the length of hospital stay for most of these patients and improving their overall quality of life after treatment.

CLINICAL DIAGNOSTIC STAGING

Clinical staging is used to represent the increasing extent of disease and, as such, the effect that this has on the likelihood of curability. The accepted standard by the American Joint Commission (AJC) of cancer staging and end results reporting is the use of the TNM system (Table 1).Because there are a large number of combinations within each stage, this classification for stage is not always as meaningful. For example, a

Table 1. AJC STAGING TNM Classification Tumor (T) oral cavity Tis Carcinoma in situ T I Tumor 2 cm or less T2 Tumor more than 2 cm, less than 4 cm T3 Tumor more than 4 cm T4 Tumor with deep invasion of antrum, base of tongue, mandible, or skin Nodal involvement (N) NO No palpable nodes N1 Single, ipsilateral node 3 cm or less N2 Single node more than 3 cm, less than 6 cm, or multiple nodes none more than 6 cm N3 lpsilateral nodes more than 6 cm, any contralateral nodes, or bilateral nodes Stage l

T,

T2

I

II

T,

T4

T l NO MO

Stage ll T2 NO MO Stage Ill T3 NO MO T I or T2 or T3, N1

N,

111

N2 Stage IV T4, NO, or N1, MO Any T, N2 or N3, MO Any T, any N with M I

IV N3

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T4N3bM1 tumor and a TlN2MO tumor are both stage IV disease, yet the former probably represents an unresectable tumor, whereas the latter represents a tumor that may be controlled with surgical resection and radiation therapy if it were in the larynx. As a general rule, however, the treating physician can predict a 5-year cure rate with no evidence of disease within the following general ranges: stage I: > 75%; stage 11: 50% to 75%; stage 111: 25% to 50%; stage 1V: 25% or less.

MANAGEMENT OF THE NECK

The goal of treatment of the neck nodes in a patient with cancer of the head and neck is to remove the tumor and the likelihood of recurrence. Although the prophylactic treatment of cervical lymph nodes when they are not palpable may be successful with either surgical resection or radiation therapy, the management of clinically palpable lymph nodes suggestive of metastases is generally surgical. In 1906, CrilelS advocated the removal of the lymphatic contents of the neck because he realized that the tumors of the oropharyngeal area spread primarily to the lymph nodes. The advantage of this therapeutic approach was further emphasized by the work of Martin et More recently, however, the decision regarding the management of cervical lymph nodes has centered around the method of treatment, with an effort to remove all of the cancer while preserving the function of the neck. In addition, the decision to be made is whether to add radiation therapy and whether to add it preoperatively or postoperatively. Indeed, Martin et a1 advocated the radical resection of not only the lymph nodes in the neck but all nonessential structures, including the jugular vein and sternocleidomastoid muscle as well as the spinal accessory nerve. It is interesting to note, however, that when Crilels advocated the radical resection of all of the cervical lymph nodes for squamous carcinoma, he did not remove the spinal accessory nerve. Furthermore, he resected the sternocleidomastoid muscle only to provide better exposure to the anatomy during the dissection to get access to the jugular vein. More than five decades later, S u a r e ~demonstrated ~~ that the cervical lymph nodes lie within a space enveloped by the superficial and deep layers of the cervical fascia and that lymphatic vessels are not found in the walls of the major vessels or on the muscles overlying these vessels. Because the internal jugular vein and the sternocleidomastoid muscle are outside of these fascia1 envelopes, there is little rationale for their removal unless there is extranodal spread of the tumor to invade these structures. Therefore, the decision to include the spinal accessory nerve, internal jugular vein, or the sternocleidomastoid muscle should be determined not in terms of facilitation of the surgical dissection but by the

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potential risk of invasion of these structures by virtue of adherence of the tumor. Although few would argue against the use of the classical radical neck dissection in patients in whom the tumor is adherent to the surrounding soft tissues, there is little justification for such surgical procedure in every case. Bocca et a18, reported their experiences with several hundred cases of neck dissections in which they spared some or all of these structures without altering the disease-free rates. Whereas the classical radical neck dissection is indicated for tumor of cervical nodes extending beyond the capsule and into adjacent tissue, a more difficult decision is raised when tumor invades the carotid artery, brachial plexus, or vagus nerve. In these cases, the value of resection must be weighed against the complications and disability in such cases, which are generally high. Martinez et a141 reported a 14% mortality rate with resection of the carotid artery; Kennedy et aP0 documented no difference in survival rate but a 50% complication rate when the carotid artery is resected, as opposed to dissection of the tumor from the carotid artery wall with preservation of the vessel. Radiation therapy also plays a role in the management of clinically Meoz-Mendez et positive neck nodes. Million et a1,46Fletcher,2l a1,44 and Lindberg and F l e t ~ h e rhave ~ ~ reported the use of radiation therapy for selected patients with N1 or N2 lymph node involvement, particularly when radiation has been chosen for the definitive treatment of the primary tumor site. However, it is difficult to ascertain the true successful control rates in these reports of clinical cases because there was no histologic documentation of the involvement of the lymph nodes with tumor cells; some of these clinically palpable nodes may have been reactive nodes. Because 20% to 25% of clinically palpable nodes have been found not to harbor any tumor cells after elective lymphadenectomy, it is expected that a similar percentage of these patients who were treated with radiation were also treated for microscopically uninvolved nodes. One argument in favor of the prophylactic treatment of the NO neck relates to the early detection of metastases to the neck (e.g., N1 as opposed to N2 or N3). The actual selection of surgery or radiation for the treatment of these necks should take into the consideration the patient's general health, the risk of surgical morbidity, the patient's compliance and reliability, and the choice of treatment based on the site of the primary tumor. Classical Radical Neck Dissection

We do not go into significant detail of the management of the classical radical neck dissection. This is available in the standard surgical

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atlases and textbooks for the treatment of head and neck cancer. There are a number of incisions that have been advocated for exposure, and it is important to bear in mind that exposure is the most important factor in determining the facility with which this operation can be performed. The most commonly used neck incisions are illustrated in Figure 1, of which the Y incision in its many variations has been the most popular because of the excellent exposure that it permits. It must be kept in mind, however, that the variations of this incision are also the most likely to result in flap necrosis of the distal ends, particularly if the neck has been previously radiated. The M a ~ F e ebipedicle ~~ flap incision is more reliable because it provides blood supply to the skin from both the anterior and posterior bases, but it is a much more tedious dissection. The posterior cervicopectoral incision reported by Ariyan2provides excellent exposure with a reliable blood supply. This incision is made from the mastoid region to the shoulder, running approximately 2 cm behind the anterior border of the trapezius muscle, before extending medially below the clavicle onto the pectoral chest wall. This flap is elevated with the underlying platysma muscle and provides complete and full access to the neck structures for either the classical radical dissection or the more functional selective neck dissection. Regardless of the individual flap that is selected, the flap should be elevated to the limits of the proposed neck dissection: anteriorly to the sternohyoid muscle, inferiorly to the clavicle, posteriorly to the trapezius muscle, and superiorly to the mandible (Fig. 2). During the elevation of the flap to the superior margin, care must be taken to identify and avoid injury to the marginal mandibular branch of the facial nerve, which curves as much as 2 to 4 cm below the mandible at the level of the antegonial notch as it crosses the facial artery and vein.

Functional Radical Neck Dissection

The investing layer of the superficial cervical fascia extends across the posterior triangle, splits around the sternocleidomastoid muscle with its two layers, and reforms as a single layer to extend across the anterior cervical triangle (Fig. 3). If the sternocleidomastoid muscle is dissected and elevated from the neck, the deeper half of this split cervical fascia remains intact, with the remainder of the cervical fascia covering the anterior and posterior cervical triangles. This can be performed in one of two methods: (1) the anterior and posterior borders of the muscle may be incised, the muscle left attached at its superior mastoid attachment and its inferior sternoclavicular attachment, and elevated as a bipedicle flap; or (2) the sternoclavicular attachments may be transected and the muscle elevated up to the mastoid region on its superior blood

Figure 1. See legend on opposite page

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Figure 2. A, The classical neck dissection through the Ariyan incision. B, The dissection of the cervical contents begins with the posterior triangle to include the internal jugular vein and the sternocleidomastoid muscle (C). D,All of the neck contents have been removed while preserving the carotid artery, phrenic nerve, vagus nerve, hypoglossal nerve, and lingual nerve. (From Ariyan S: Radial neck dissection. Surg Clin North Am 66:133-148, 1986.)

supply from the occipital artery, providing full access to the neck. In the latter approach, the muscle is reinserted to its sternoclavicular origins by suturing the ligamentous ends at the completion of the neck dissection (Fig. 4). FLAP RECONSTRUCTION

In the past two decades alone, there have been significant improvements in the quality of life for these patients as a result of developments of one-stage reconstruction with myocutaneous flaps and microvascular free flaps. These advances in surgical techniques have provided well-

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Figure 1. Various incisions described over the last five decades for access to the neck for lymphadenectomy. (From Ariyan S: Radial neck dissection. Surg Clin North Am 66:133148, 1986.)

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Figure 3. The sternocleidomastoid muscle is located superficial to the cervical fascia which contains the lymphatics and lymph glands in the neck itself. (From Ariyan S: Radial neck dissection. Surg Clin North Am 66:133-148, 1986.)

vascularized composite tissue to improve the healing, decrease wound complications, and improve the overall functional result. These changes also led to the one-stage reconstructions of the mandible with wellvascularized composite tissues either by pedicle flaps or by microvascular free-flap techniques, as discussed later. Small defects of the tongue or the floor of the mouth may be covered with either local flaps, such as the tongue flap or nasolabial flap, whereas larger defects may require additional tissue, as provided by the sternocleidomastoid muscle flap. If bulk is necessary with the addition of skin, as in composite resection of the tongue and the floor of the mouth, the pectoralis major or trapezius myocutaneous flaps may be required. Composite resections with larger segments of the mandible may be reconstructed with the pectoralis major, trapezius, or latissimus dorsi osteocutaneous flaps. Finally, cutaneous or osteocutaneous free flaps may be used for major reconstructions of the mandible and soft tissues.

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Forehead Flap

The forehead flap described by M ~ G r e g o has r ~ ~been a reliable flap for intraoral cancer resections. The flap is best elevated by incising along the hairline superiorly and the upper limit of the eyebrow inferiorly to incorporate the entire forehead as one aesthetic unit. The flap can be removed of skin at its base as it is transferred through the cheek into the oral cavity. The donor site of the forehead is then grafted in one large sheet to provide the most aesthetic unit (Fig. 5). However, the disadvantage of this flap is that it does result in an aesthetic deformity of the forehead with a dry, shiny skin graft.

Nasolabial Flap

Nasolabial flaps are used effectively for intraoral reconstruction, particularly if the patient is edentulous. In such cases, the skin can be

Figure 4. The functional neck dissection. A, The sternocleidomastoid muscle (SCM) is elevated from the deeper cervical fascia. The spinal accessory nerve (SA) is identified as it enters the border of the trapezius (T) muscle. B, The neck contents are dissected from the posterior triangle up anteriorly and superiorly, while identifying and preserving the brachial plexus (BP). C, As the dissection is continued in cephalad direction, the common carotid artery (CC) and the internal jugular vein (IJ) are identified and preserved. D, After the completion of the neck dissection, the SCM muscle is returned to its sternal and clavicular origins and sutured in position. (From Ariyan S: Radial neck dissection. Surg Clin North Am 66:133-148, 1986.)

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Figure 5. The forehead flap is an axial cutaneous flap based on the superficial temporal vessels that cross the midline to communicate with the superficial temporal vessels of the opposite side. This flap then can be passed under the zygoma for intraoral reconstructions, and can be performed in one stage if the skin is dissected off the portion that passes through the cheek into the oral cavity.

removed from the base of the flap, tunneled through the full thickness of the cheek, and applied to the intraoral wound in the floor of the mouth or over the mandible. If the patient has teeth, the base needs to be divided and inset at 10 to 14 days.

Tongue Flap

This flap is used effectively for the resurfacing of the anterior and lateral floor of the mouth and over the mandibular crest. With the tongue retracted, the flap is elevated from the lateral aspect of the tongue, with equal amounts from the dorsum and ventral surfaces. The incision should be incised as a V-wedge toward the depth of the tongue to include a portion of the tongue musculature with the flap to provide bulk and adequate blood supply to the overlying mucosa.

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Apron Flap

The apron flap can provide an adequate size of thin tissue to resurface a significant defect in the floor of the mouth. This flap is elevated incorporating the platysma muscle from the anterior portion of the upper and mid portion of the neck. The base of the flap, which is tunneled under the root of the tongue toward the floor of the mouth, is removed of its overlying skin to provide one-stage reconstruction of the defect (Fig. 6).

Sternocleidomastoid Myocutaneous Flap

The sternocleidomastoid (SCM) muscle has three blood supplies3: the occipital artery superiorly, the thyrocervical trunk inferiorly, and branches from the superior thyroid artery in the midportion (Fig. 7). This muscle can serve as the vascular pedicle to a skin paddle that may be outlined on the lower portion of the neck and transported on the superior blood supply or alternatively as skin paddle on the mastoid region transferred on the inferior blood supply (Fig. 8). The skin paddle is outlined over the selected portion of the muscle, and after the incision is made, the skin paddle is sutured to the underlying muscle to prevent traction damage to the thin and delicate perforat-

Figure 6. The apron flap is located along the anterior neck skin, and is elevated together with the underlying platysma muscle. That portion that is turned into the neck through the root of the tongue to the oral cavity can be de-epithelialized to permit one-stage reconstruction. The donor site along the anterior neck is then covered with a split-thickness skin graft.

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Figure 7. The blood supply to the sternocleidomastoid is from the occipital artery above, superior thyroid in the midportion, and the thyrocervical trunk below. (From Ariyan S: Radial neck dissection. Surg Clin North Am 66:133-148, 1986.)

ing vessels. The muscle is elevated from the deep layers of the cervical investing fascia; the dissection of the pedicle should proceed only as far as is necessary to mobilize the flaps effectively to transfer the skin paddle to the defect in the oral cavity. Once the flap is transferred into the oral cavity, the pedicle must be anchored securely to the periphery of the intraoral wound to prevent traction on the suture line. The skin paddle then should lie in the wound without any tension whatsoever before the sutures are placed between the skin paddle and the mucosal margin of the wound. In this fashion, there is no traction on the skin paddle itself.

Pectoralis Major Myocutaneous Flap

The pectoralis major muscle can provide more significant amounts of skin and muscle bulk for larger defects of the oropharyngeal area.

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Figure 8. The SCM flap may be elevated on its superior blood supply to transport skin from the inferior portion of the neck (top) or may be transferred on the inferior blood supply to transport skin from the superior portion of the neck (bottom) to the intraoral cavity. (From Ariyan S: Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck reconstruction. Clin Plast Surg 739-1 09, 1980.)

This muscle is a flat, fan-shaped structure covering the anterior upper chest, with its dominant blood supply from the thoracoacromial artery, The vessel perforates which exits under the midportion of the ~lavicle.~ the clavipectoral fascia and travels along the undersurface of the muscle along an axis from the shoulder to the xiphoid (Fig. 9). The skin paddle is outlined along the inferomedial aspect of the muscle and elevated with a narrow pedicle of only that portion of the muscle that is necessary to include the underlying vascular pedicle.

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Figure 9. The blood supply to the pectoralis major myocutaneous flap is from the thoracoacromial vessels. These vessels lie along an axis from the shoulder to the xiphoid. The skin paddle is elevated with a narrow portion of the pectoralis major muscle sufficient to carry the underlying vascular pedicle. This flap may be elevated with an adjacent segment of rib if composite tissue also is required for a skeletal reconstruction. The donor site can invariably be closed with advancement flaps without the need of skin grafts. (From Ariyan S: Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck reconstruction. Clin Plast Surg 7:89-109, 1980.)

The muscle pedicle is dissected to the clavicle, at which point the infraclavicular portion of the muscle is removed from the vascular pedicle, leaving the entire flap attached only by its arteriovenous pedicle and its fascia. With this maneuver, the flap can be transposed over the clavicle and under the neck flaps, with only the vessels overlying the clavicle rather than a bulk of muscle at its base. If a segment of the mandible has been resected, it is possible to transfer a portion of the

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fourth or fifth rib along with the pectoralis major muscle for the reconstruction. Ariyan4,"as demonstrated that vascularized ribs can be transferred by microsurgery on the anterior blood supply from the intercostal vessels through the periosteum. With the documentation of this periosteal blood supply, Cuono and Ariyanl"hen demonstrated the successful transfer of vascularized rib with the pectoralis major muscle. The pectoralis major also can be used for reconstruction of large defects of the lateral skull, posterior and base of skull, and major reconstructions of the maxillofacial area after resections.

Trapezius Myocutaneous Flap

The trapezius muscle is another useful flap for intraoral and external reconstructions. In addition, this muscle can be transferred with a segment of attached bone from either the transverse spine of the scapula or the a c r o r n i ~ n .20~The ~ , trapezius is a flat, triangular muscle of the neck and back, with fibers originating from the occiput of the skull and the spinous processes of the thoracic vertebrae, inserting on the lateral third of the clavicle, the acromion, and the scapular spine (Fig. 10). The skin paddle can be placed inferiorly over the descending posterior portion of the transverse cervical artery, as described by Mathes and Nahai,"2 or transversely over the shoulder, as originally described by Demergasso and Piazza.18 In order to preserve the function of the trapezius muscle, the lower portion of the descending trapezius muscle may be harvested, dissecting out the vascular pedicle under the upper portion of the muscle while preserving the spinal accessory nerve to this upper portion, as described by Mathes and Nahai.42 If the acromion or the spine of the scapula is to be included in the flap for a composite reconstruction of bone, this segment of bone is cut with an oscillating saw. The flap can be elevated on a pedicle of muscle, or it can be completely freed on the vessels alone, as a true vascular island flap. In most cases, the donor site can be closed by advancement of the skin flaps without the need for additional skin grafts. The trapezius muscle can be used for reconstructions of the skull base, lateral neck, and temporal and posterior skull regions.

Latissimus Dorsi Myocutaneous Flap

If an even larger amount of tissue is required, the latissimus dorsi . ~ ~ is a triangular muscle that may be used, as described by Q ~ i l l e nThis arises from the broad aponeurosis of the spinous processes of the lower six thoracic, lumbar, sacral vertebrae, and the iliac crest and extends up

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Figure 10. See legend on opposite page

to and inserts on the humerus. The blood supply to the muscle is provided by the thoracodorsal artery and vein. A skin paddle can be outlined on the inferolateral portion of the muscle, and this segment can be elevated with its thoracodorsal vascular pedicle (Fig. 10). It can be tunneled through the axillary space and under the pectoralis major muscle and brought anteriorly into the neck or the pharyngeal regions for reconstruction. It also can be transferred directly to the posterior cervical region for skull base reconstruction or for lateral skull defects.

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Figure 10 (Continued). The trapezius muscle is supplied with the transverse cervical artery and vein. The muscle may be used in the transverse direction across the shoulder (right), or in a descending fashion along the paraspinous region for a longer flap (left). The latissimus dorsi flap is supplied by a thoracodorsal artery and vein and can incorporate a very large amount of tissue if necessary along the lateral and posterior chest (left). (From Ariyan S: Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck reconstruction. Clin Plast Surg 7:89-109, 1980.)

Microvascular Free Flaps

Microvascular free flaps have become versatile in reconstructions of the head and neck area, where these flaps are needed. The most versatile are either the jejunal free flap13,53 or the radial forearm free flap.I224, 58

The jejunal free flap is used for reconstruction of the cervical esophagus after laryngopharyngectomies (Fig. ll), but it also has been used as a "flat flap" to resurface intraoral lining after resections. Because an intraabdominal procedure is necessary to harvest the jejunum, the radial forearm free flap has become more popular recently for thin flap reconstructions for defects in the head and neck area. The skin paddle is outlined over the distal portion of the radial artery to incorporate the vessel and its accompanying veins (Fig. 12). The donor site is then covered with a split-thickness skin graft, and the flap can be transferred to the head and neck area to reconstruct the esophagus, provide lining in the intraoral cavity, or provide outer coverage for significant portions of the face and cranium.

Figure 11. A segment of the jejunum may be used as a cylindric tube for reconstruction of the cervical esophagus (A and B), anastomosing its vascular pedicle to an artery and vein in the neck (C and D). (From Stahl RS: Microvascular bowel transfer. In Ariyan S: Cancer of the Head and Neck, St. Louis, CV Mosby, 1987; with permission.)

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LARYNGOPHARYNGOESOPHAGECTOMY WITH GASTRIC PULL-UP

The 5-year survival rate for patients with hypopharyngeal squamous cell carcinoma invading the upper esophagus is less than 25% regardless of therapy. Because these patients, on average, have a limited time to live, surgical treatment should aim to maximize the quality of remaining life. Essential to this goal are complete tumor removal and rapid return to oral feeding. Furthermore, short hospital stay and low perioperative morbidity are especially important. We have found that an effective way to treat this cancer is with a laryngopharyngectomy and gastric pull-up.

Surgical Procedure

We do not go into the full details of the operation, because they have been described previously.', 2" 32, 33, 47, 55, 60, 66 The operation is started by the head and neck surgical team, who determines that the tumor is resectable. After the larynx is mobilized, the pharynx is entered above the vallecula and is circumferentially transected. A sleeve resection is performed that includes the hypopharynx, larynx, and esophagus. Care is taken to preserve the thyroid and parathyroid glands when oncologically feasible. Once resectability has been established, the abdominal surgical team opens the abdomen through a midline incision. The stomach is mobilized with omentum, preserving the right gastroepiploic artery and vein. Blunt dissection from the thoracic inlet above and esophageal hiatus below results in complete mobilization of the esophagus. The duodenum is mobilized, and a pyloroplasty is performed. By a combination of traction from above and advancement from below, the stomach is pulled up into the cervical area. The esophagogastric junction is then transected with a stapling device, and the greater curvature is anastomosed to the pharynx using redundent omentum to support the suture line. Abdominal and cervical drains are placed, and the wounds are closed.

Results

We performed total laryngopharyngoesophagectomy with gastric transposition in 34 patients with hypopharyngeal and cervical esophageal squamous cell carcinoma. There has been one perioperative death (3%) and one temporary fistula (3%). No major mediastinal or intrathoracic complication occurred. Patients began oral feeding by postopera-

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Figure 12. See legend on opposite page

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Figure 12 (Continued). The skin of the distal volar forearm is outlined over the radial artery (A), and can be elevated in the size and shape of the defect (B) for reconstruction. The flap is then sutured into a tube over a gastric drainage tube (C). Postoperative barium swallow shows a widely patent reconstruction (D).

tive day 10, with return to a full diet and discharge home within 16 days, maximizing both quality and quantity of time remaining outside the hospital. Our results in patients with squamous cell carcinoma of the hypopharynx and cervical esophagus compare favorably with results of other series of gastric transp~sitions~~ and with those of free jejunal transfer.'" 52 Gastric transposition has several advantages over other operations for hypopharyngeal-esophageal reconstruction: (1)the operation is done in a single stage by two teams working simultaneously; (2) the stomach has an excellent blood supply so that failure due to necrosis is almost unheard of; (3) only one suture line is required within the alimentary tract; (4) the alimentary tract remains lined exclusively by native mucosa; and (5) stricture, ulceration, and fistula are rare. Most

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patients are able to achieve full oral alimentation within 10 days, and the operative mortality rate is low. Gastric transposition is an excellent means of reconstruction after resection of the pharynx, larynx, and esophagus. It is well suited to the goal of palliation and in no way compromises the chance of cure in those few patients with more limited disease. Operative mortality is low, mean hospital stay is acceptably short, and there is rapid return to oral alimentation. Quality and quantity of remaining time outside the hospital are maximized.

SKULL BASE RESECTIONS

Advances in skull base surgery have depended heavily on recent technologic improvements. The capability of sophisticated diagnostic imaging, laser hemostasis, surgical illumination, and magnification collectively has exerted unprecedented impact on a form of regional surgery previously hampered by great anatomic complexity. Furthermore, improved understanding of brain protection and primary closure of wounds with well-vascularized skin flaps greatly diminishes the incidence of exposure-necrosis and life-threatening infection, further reducing the morbidity and mortality of surgical intervention. The recent growth of surgical procedures related to the cranial base rests on two major factors: recent technologic advances and the spirit of cooperative effort across surgical disciplines. The spectrum of modern skull base surgery safely includes transethmoid and transseptal exposures of the pituitary fossa, transmaxillary routes to the basisphenoid, infratemporal exposure of the clivus, and translabyrinthine or transcochlear routes to the cerebellopontine angle. This section is based on two procedures that best exemplify the impact of technologic advances and the spirit of cooperative effort among the subspecialties.

Tumors of the Anterior Skull Base

Malignancies involving the anterior skull base constitute a unique group of neoplasms posing one of the most formidable problems in oncologic management. Such cancers, biologically no different from other histologic types found in the head and neck, produce a significant therapeutic dilemma due to the proximity of the eye, brain, carotid artery, major dural sinuses, and cranial nerves. Any or all of these structures may be invaded by cancer, and their vital functions can be disturbed greatly either by the disease itself or by subsequent therapy.

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Whereas the same histologic tumor, arising elsewhere in the head and neck, is aggressively attacked and often successfully eradicated, tumor surgery of the cranial base is often compromised for technical reasons related to anatomic complexity. For this reason, malignancies involving the anterior skull base historically have carried a dismal, if not altogether hopeless, outlook. The recent use of combined craniofacial resection has irnproved curability for many patients once considered hopeless, effectively changing our therapeutic outlook for disease in this location. Dandy17 in 1941 first described a transcranial approach to resect orbital tumors. A decade later, others31,",h5 reported resecting frontoethmoid cancers by this technique. Although the benefits of this surgery were high, so were the initially reported complication rates of 7% mortality and 8O0I0morbidity. Since then, others have reported useful reconstructive techniques to minimize the expected morbidity of this ~urgery,5~, s7 resulting in further surgical acceptability. Nevertheless, potentially life-threatening complications continue to threaten otherwise successful oncologic resections with exposed bone and cerebrospinal fluid leaks. Such morbidity may be related to inadequate intracranial protection by split-thickness skin grafts that may not take completely in all areas of repair after curative radiation therapy. Furthermore, we may anticipate that the use of vascularized flaps would not only better seal against cerebrospinal fluid leaks but also afford improved protection against bacterial invasion at the operative site. Upon these anticipated benefits, the pectoralis major myocutaneous flaps,49 played a pivotal historical role in the reconstruction of anterior skull base defects after major oncologic resections, paving the way for the use of current free-flap reconstructions. Surgical Procedure

The combined intracranial-extracranial approach for en bloc resection is worth a brief description. In this case example, the tumor extends from the ethmoid sinus through the cribriform plate and into the medial orbit (Fig. 13). 1. Perioperative antibiotics, based on a recent nasal culture, are begun the night before surgery and are continued every 4 hours through surgery. Antibiotics are directed against the predominant bacterial organism obtained from the nose. If a cerebrospinal fluid leak occurs during surgery, antibiotics are continued for 5 days postoperatively. If no leakage has occurred, only two additional doses are administered postoperatively. 2. To prevent secondary injury to the brain after intraoperative

Figure 13. Computed tomography indicates tumor (T) has eroded the right ethmoids and extends into the right orbit.

3.

4.

5.

6.

7.

retraction, dexamethasone is administered the day before surgery at a dose of 4 mg/6 h. This dose is continued intravenously through surgery and is rapidly tapered in 3 to 4 days postoperatively. After the administration of general anesthesia, a lumbar subarachnoid catheter is inserted. Slow, gentle suction or gravity drainage is used to remove 100 to 120 mL of cerebrospinal fluid. Brain relaxation minimizes the need for prolonged brain retraction and compression, reducing direct injury to the frontal cortex. Controlled hyperventilation is used to lower the Pco, to approximately 25 mm Hg. This accomplishes an additional decrease in brain volume by cerebral vasoconstriction. To further minimize brain retraction, mannitol (500 mL) is administered as a 20% solution to dehydrate and shrink the brain. It is given intravenously when the scalp incision is made. A frontal craniotomy is performed through a large bicoronal flap. The dura of the frontal lobe is retracted to expose the floor of the anterior cranial fossa, and the degree of retraction depends on the extent of resection planned (Fig. 14). The tumor with its surgical margin is mobilized from below

RECONSTRUCTION OF THE HEAD AND NECK

25

through facial incisions using standard otolaryngologic techniques. 8. Anterior bone cuts at the cranial base are made transfacially with direct visualization of these cuts as the brain is retracted posteriorly from the cranial side. However, the posterior bone cuts into the sphenoid and along the optic nerves are made transcranially as the brain is sufficiently retracted for adequate exposure below, allowing the resected specimen to be removed from the surgical field (Fig. 15). 9. Bone margins are smoothed with bone rongeurs, and all remaining and exposed sinus mucosa is removed. 10. Because olfactory nerves must be transected in this operation, cerebrospinal fluid leaks are inevitable. Meticulous dural repair is mandatory, using pericranial or fascia1 grafting techniques. 11. For the closure, a posteriorly based mucoperichondrial flap is used from the nasal septum; the nasopharynx is partitioned from the operative cavity in preparation for further reconstruction using the pectoralis major myocutaneous flap. This is a key step in providing effective separation of the skull base defect from the nasal cavity (Fig. 16). 12. Bone grafts, used to support the brain, are rarely necessary in our experience. When used, however, wire sutures are avoided to prevent scatter of postoperative radiation therapy. Embedded

Figure 14. A frontal craniotomy provides wide exposure of the floor of the anterior cranial fossa.

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Figure 15. The frontal sinus, ethmoids, and orbit are exenterated en bloc.

hardware also may interfere with subsequent CT or MR imaging and is thus to be avoided. 13. A pectoralis major myocutaneous flap is elevated the full length across the chest and should be as wide as the diameter of the skull base defect (Fig. 17). 14. Skin is removed from the distal 4 to 6 cm of the flap. The distal muscle and subcutaneous tissue are used to fill the facial cavity. The edges of the skin flap are then sutured to the wound edges, and the chest donor site is closed by advancement of skin. 15. In these cases, the flap is brought up over the neck and face as an external pedicle to avoid tunneling the pedicle under the neck and facial skin. Because the undersurface of the pedicle is raw, care should be taken to prevent desiccation of the tissue that would result in thrombosis of vessels and necrosis of the flap. The topical application of antibacterial cream (such as silvadiazine) is used for this purpose. The pedicle also is covered by petrolatum gauze that is changed daily. 16. The pedicle can be divided and inset at the end of 2 weeks, at which time the excess pedicle may be discarded (Fig. 17C).

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27

17. Prior to the patient's hospital discharge, a baseline CT scan is obtained to which follow-up CT scans can be compared.

Tumors of the Posterior Skull Base

The histologic diagnosis of mastoid or middle ear carcinoma is made by biopsy in patients who exhibit changes in symptomatology previously considered to be inflammatory rather than neoplastic. Unremitting pain should raise the spectre of underlying malignancy rather than chronic infection. Bleeding, deafness, vertigo, and facial paralysis are usually late manifestations of this disease. Routine radiographs of the skull and petrous bone generally precede CT evaluation. Angiography and MR imaging also assist in delineating the precise extent of disease. We believe the most important role of imaging is to determine whether disease has extended into vital areas, which would render any operative intervention inadvisable. Our criteria of inoperability, therefore, include the invasion of the carotid artery, invasion of the temporal lobe dura medial to the entry of the middle meningeal artery,

Figure 16. The septa1 flap is transposed across the posterior concha.

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ARIYAN et a1

Figure 17. A, The facial incisions are closed after watertight dural repair has been accomplished. A large, common fronto-orbital defect remains. B, The pectoralis flap is positioned to fill the fronto-orbital defect. C, The flap has been divided and inset. The late postoperative result is quite satisfactory.

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29

and invasion of the posterior fossa dura medial to the internal auditory meatus, although individual exceptions are possible.50 Historically, both surgery and radiation have been advocated for cancer involving the temporal bone. Whereas radiation therapy alone effects a 5-year survival rate of 14% in the report of Sinha and A ~ i z , " ~ surgery alone produces a comparable 16% in the series of Conley and Novack.I4 Radical mastoidectomy and postoperative radiation are described by Boland and Paterson,Io who observed that an open mastoid cavity increases the incidence of painful osteoradionecrosis and lifethreatening meningitis. A 5-year survival rate of only 8% is reported from Memorial Hospital using this once prevalent treatment." Needless to say, treatment of temporal bone cancer was historically not good. Nevertheless, from these early experiences have emerged principles of management that nearly double curability and greatly improve functional preservation. Five-year cure rates for mastoid cancer currently approach 30°/0 in a report by Lewis" and more than 40% in a report by . ~the ~ past, principal causes of therapeutic failure Gacek and G o ~ d m a nIn and unacceptable morbidity have resulted from en bloc resection when possible, coverage of exposed bone by vascularized skin-muscle flaps, and postoperative rather than preoperative radiation. Surgical Procedure

A combined intracranial-extracranial approach for en bloc resection represents a rather massive if not heroic exercise and is worth a brief description of our surgical approach. A temporal craniectomy is first accomplished to evaluate the medial extent of tumor involvement (Fig. 18A). Recognizing that extradural extension of tumor is at best difficult to assess by noninvasive means, we have come to rely on wide craniotomy for this definitive decision. In general, the tumor is considered inoperable when dura is invaded medial to the foramen spinosum. If dura is necessarily resected medial to this foramen, watertight closure of the subarachnoid space is difficult to achieve using fascia1 grafting techniques. Because the probability of cerebrospinal fluid leak and subsequent meningitis represents too great a risk for resection of tumor located so medially, we generally terminate the operation at this point. On the other hand, if the tumor is considered to be resectable, the craniectomy is extended into the posterior fossa, allowing the sigmoid sinus and jugular bulb to be mobilized from their attachments to bone (Fig. 18B). In order to control the great vessels at the skull base, a total parotidectomy with facial nerve dissection is first accomplished. The mandibular condyle is resected for exposure of the internal carotid artery and jugular vein (Fig. 18C). Through the temperomandibular

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Figure 18. A temporal craniectomy is accomplished at cut A. A limited craniectomy is extended into the posterior cranial fossa at cut B. The mandibular condyle is resected at cut C in order to gain exposure of the carotid artery as it courses through the petrous bone.

joint, the intratemporal carotid is identified and using an air drill is mobilized from its attachment to the temporal bone (Fig. 19). This maneuver represents the single most important step in allowing the temporal bone to be removed without harm to the intracranial circulation. A partial or subtotal resection of the temporal bone may be accomplished by creating a controlled fracture line across the axis of the petrous bone with an orthopedic chisel (Fig. 20). Depending on the location of the tumor, the temporal bone may be resected lateral to the cochlea for tumor localized to the external auditory canal (Fig. 21). It is worth noting that any resection medial to the cochlea results in division of the facial nerve and cochlear-vestibular nerves. A facial nerve-tohypoglossal nerve anastomosis may be accomplished for facial rehabilitation. The wound is then closed with a skin-muscle flap obtained from the chest (Fig. 22). The patient is then ready to receive radiation therapy. Important observations are as follows: 1. Although the degree of surgical complexity is great, morbidity and mortality are surprisingly low, an observation shared by 35 and Gacek and G ~ o d r n a n . ~ ~ 2. Total gross removal of tumor can be accomplished without undue sacrifice of vital intracranial structures.

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Figure 19. The intratemporal portion of the carotid artery is mobilized from its bony attachments by an approach through the temporomandibular joint.

Figure 20. An extended partial resection is necessary when tumor invades the bony external auditory canal.

Figure 21. A, A lateral view of the resected specimen. 13,Medial view of the same specimen demonstrating an intact resected tympanic membrane and ossicles.

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Figure 22. In this case, closure of the wound has been accomplished with a pectoralis major myocutaneous flap.

3. The final decision for resectability is made intraoperatively, only after the medial extent of the disease is determined by subtemporal craniotomy. 4. Radiation therapy delivered postoperatively eradicates residual microscopic tumor in high-risk areas determined at the time of surgical exposure. Such practice limits the radiated field, thereby avoiding unnecessary exposure of vital intracranial structures, including the brain stem and spinal cord. This cannot be accomplished with planned preoperative radiation. 5. In addition, the use of postoperative radiation does not compromise or impair the healing wound, thereby avoiding life-threatening cerebrospinal fluid leaks and meningitis. 6. Osteoradionecrosis is prevented by the avoidance of open mastoid cavities, which heal by secondary intent. Open mastoids are contaminated wounds harboring high levels of aerobic and anaerobic microorganisms; for this reason, they tolerate radiation less well. By covering the surgical defect with vascularized skinmuscle flaps, we believe that early wound stabilization is achieved without risk of subsequent infection and necrosis. The

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-

--.

C

Peroneal artery and vein

Figure 23. See legend on opposite page

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35

Figure 23 (Continued). A composite resection of the anterior mandible, requiring intraoral lining as well as outer coverage (A), was reconstructed with a fibula osteocutaneous free flap (6).This flap is based on the peroneal vessels to the bone (C), and several septocutaneous perforating vessels to the overlying skin. The skin paddle in this patient was divided into two separate paddles, one for inner lining (D), and the other for outer coverage (E).

historical use of successful pedicled reconstruction paved the way for the use of free flaps in common use today. Cancers of the skull base are not hopeless. A system of management that evolves through the cooperation of the otolaryngologist, plastic surgeon, neurosurgeon, and radiotherapist uniquely reduces morbidity. Curability is determined by early diagnosis and the completion of highrisk surgery and radiation by an experienced team of specialists.

RECONSTRUCTION OF THE MANDIBLE

With the advent of vascularized bone grafts, reconstruction of resected mandibular defects has become much more gratifying to both patient and surgeon.63 An intact bony mandibular arch plays an important role in mastication, anterior tongue suspension, articulation, and co~mesis.'~ Loss of this arch without bony reconstruction can lead to a significant decrease in the quality of a patient's life. A consensus has yet to be reached as to whether all bony defects of the mandible require bony reconstruction; however, we routinely reconstruct mandibular defects with bone. Reconstruction of the jaw bone using metal plates is fraught with complications, including erosion of the plates through the overlying skin, plate stress fractures, and plate screw l ~ o s e n i n g s . ~ ~ Several donor sites can provide adequate bone for jaw reconstructions: the fibula, scapula, and iliac crest are the most common donor 27, 54, h4,67 The radius and other more morbid donor sites are used less frequently.

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ARIYAN et a1

Transverse branch

Subscapular artery Circumflex scapular artery Thoracodorsal artery

Descending branch

tissimus dorsi muscle Periosteal branches (proximal two-thirds of sc margin)

Angular branch

Serratus branch of thoracodorsal artery

Figure 24. The scapular free flap is based on the branches of the subscapular artery (A) to the bone and to the overlying skin. A skin paddle outlined on the descending branch (B) can be harvested on a separate vascular branch than the branch to the bone (C). This allows the bone to b e placed in position for the mandible in one anatomic plane (D), while the skin paddle can be positioned in a different plane for the intra-oral lining (E). Illustration continued on opposite page

Fibula

The fibula osseocutaneous free flap26,27 is currently our preference for most jaw reconstructions. This flap is based on the peroneal artery and its two venae comitantes (Fig. 23). The artery travels along the bone's length after dividing at the tibioperoneal bifurcation. The artery gives off branches that travel within the posterior intermuscular septum and sometimes travel within the soleus muscle (musculocutaneous perforators) to feed the overlying skin (septocutaneous perforators)." These perforators often can be identified preoperatively with the use of Doppler, which allows the design and centering of the cutaneous paddle over these perforators. Skin paddles as wide as 6 cm can be closed primarily, whereas larger skin paddles and the donor site can be closed by skin grafting. The skin paddle's reliability is good but has been described by Although versatile, the skin flap's long axis some to be ~npredictable.~~ always must follow that of the bone. The fibula provides a long (22-25 cm) and relatively thick piece of bone that can be osteotomized and "plated" along its length to introduce curves to its otherwise straight shape. Osseointegrated implants can be

RECONSTRUCTION OF THE HEAD AND NECK

Figure 24 (Continued).

37

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ARIYAN et a1

used for dental prosthesis and rehabilitati~n.~~ A subtotal or complete mandibular resection can be reconstructed easily with the free fibula flap because of its abundant bone length. This flap can be harvested simultaneously while the ablative team is completing their resection. The vessels are large, allowing for ease of anastomosis. The peroneal artery measures between 1.8 and 2.5 mm in diameter, and the veins measure between 0.5 and 1 cm in diameter. The vascular pedicle can vary in length depending on the quantity of bone required; thus, if all the harvested bone of the fibula is required, the length of the pedicle may be only 4 to 6 cm. Not uncommonly, recipient vessels are needed in the contralateral neck, but we have not been required to use vein grafts to extend the length of this flap's pedicle. The fibular flap also can be used simply as bone alone if skin is not required. Aggressive rehabilitation of the leg is begun 2 days after surgery in patients whose donor site wound was closed primarily and 7 days after surgery when a skin graft was required. Patients are usually ambulating without assistance when they are discharged from the hospital.

Scapula

The scapula flap can be a useful flap in head and neck reconstruction when large quantities of skin or two separate skin paddles are required. Skin flaps measuring as large as 9 x 15 cm usually can be closed primarily. The drawback to this flap is that the quality of bone is not as good as that found with the fibula or iliac crest. The scapula flap derives its blood supply from the circumflex scapular artery, which is a branch of the subscapular artery (Fig. 24). The vessels are large and allow for easy anastomosis (2-2.5 mm artery, and 3-4 mm veins), and the pedicle length from the subscapular artery to the edge of the scapula bone is 4 to 5 cm. Traveling with its respective venae comitantes, the circumflex scapular artery gives off osseous and cutaneous branches. The cutaneous branch further divides into a transverse and descending branch. Useful in some large resections, these two branches allow the flap to have potentially two separate skin paddles. These two skin branches often can be identified by use of a Doppler. Because of the separate vascular branches to the skin and bone components of the flap, the orientation of these two portions does not need to coincide and can therefore extend its applications. Because patients are usually placed in the lateral decubitus position to harvest this flap, harvesting cannot be performed simultaneously during the ablative team's resection. The lateral border of scapula can be harvested from 1 cm inferior to the glenoid fossae down to the tip of

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39

the scapula, harvesting 10 to 14 cm of bone depending on the patient's size and sex. This bone can be osteotomized to custom fit various curves that are required to recreate the jaw bone, but the bone quality does not readily allow for osseointegrated implants.

Iliac Crest The iliac crest provides a varied group of composite free flaps. Because of the location of the iliac crest, this is a cosmetically desirable donor site. Most of the incisions can be hidden under bathing suits or underwear. The flap's skin paddle is closely aligned in the direction of the bone and limits its flexibility. Ample muscle can be harvested and used for either intraoral reconstructions with skin grafts or extraoral defects. All iliac crest flaps are based on the deep circumflex iliac artery and its venae comitantes (Fig. 25). The vessels are branches of either the femoral vessels, just distal to the inguinal ligament, or the external iliac vessels, just proximal to the inguinal ligament. The deep circumflex iliac

\

vessels Lateral cutaneous nerve

Figure 25. The iliac bone free flap is based on the deep circumflex iliac vessels, with several osteocutaneous perforating vessels supplying the overlying skin.

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ARIYAN et a1

vessels supply the iliac bone itself and run along its medial wall. Periosteal vessels from the underlying bone emerge to supply the overlying bone. The ascending branch of the deep circumflex iliac artery supplies the internal oblique muscle, transversalis muscle, and overlying skin. The deep circumflex iliac artery measures between 1.5 and 2.5 mm in diameter and the vein measures 2.5 to 3.0 mm in diameter. A length of bone measuring approximately 14 cm can be harvested in a man extending from the anterior superior iliac spine to the posterior iliac spine. Even part of the anterior spine can be used as an ascending ramus. The iliac bone is bicortical, and its apex is curved in shape. The curved quality of the bone can be used to mimic the mandible, and osteotomies often may not be necessary. The bone can accept osseointegrated implants easily for dental restoration. As stated earlier, this flap may include both skin and muscle components, namely the internal oblique muscle. The skin paddle is restricted because it must run parallel to the direction of the bone. The muscle is thin and can enhance the bulk of reconstruction intraorally and can be used for carotid coverage in the neck. Potential complications that may be encountered when using this flap include hernia, if the transversalis fascia is not adequately secured to the remaining ilium; numbness in the lateral thigh, if the sensory nerve from TI2 is sacrificed during the dissection; and pain on ambulating, which can be a problem in elderly persons.

Other Bones

Several sites for bone harvesting have become less popular when considering reconstruction of the jaw. The pectoralis major osseomyocutaneous flap has been used less commonly because of the small amount of bone in the rib. We also prefer not to use the radial forearm osseofasciocutaneous flap because the thinned radius is at risk for pathologic fractures.59The dorsalis pedis flap removes the second metatarsal but is not a large or durable a segment of bone for the jaw.

Osseointegrated Implants

The development of the titanium osseointegrated implants and vascularized bone grafts have allowed the patient who has undergone mandibular reconstruction to have dental r e s t o r a t i ~ n The . ~ ~ bone flap integrates the implants and allows weight-bearing dentures to be fitted for the patient. Weight-bearing dentures of this type cannot be established with metal plate reconstructions alone.

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41

References 1. Akiyama H, Hiyana M, Miyazona H: Total esophageal reconstruction after extraction of the esophagus. Ann Surg 182547, 1975 2. Ariyan S: Functional radical neck dissection. Plast Reconstr Surg 65768, 1980 3. Ariyan S: One-stage reconstruction for defects of the mouth using the sternomastoid myocutaneous flap. Plast Reconstr Surg 63:618,1979 4. Ariyan S: The viability of rib grafts transplanted with the periosteal blood supply. Plast Reconstr Surg 65140, 1980 5. Ariyan S: The pectoralis major myocutaneous flap: A versatile flap for reconstruction in the head and neck area. Plast Reconstr Surg 63:73, 1979 6. Ariyan S, Finseth FJ: The anterior chest approach for obtaining free osteocutaneous rib grafts. Plast Reconstr Surg 62:676, 1978 7. Barwick W, Goodkind D, Serafin D: The free scapular flap. Plast Reconstr Surg 69:779, 1982 8. Bocca E, Pignataro 0 : A conversation technique in radical neck dissection. Ann Otol Rhino1 Laryngol 77:1005, 1968 9. Bocca E, Pignataro 0 , Sasaki CT: Functional neck dissection: A description of operative technique. Arch Otolaryngol 106:524, 1980 10. Boland 1, Paterson R: Cancer of the middle ear and external auditory meatus. J ~ a r ~ n65468, ~ o l 1955 11. Chen Z, Yan W: The studv and clinical application of the osteocutaneous flap of fibula. ~ i c r o s u r ~4:11, e r ~ 1993 ' 12. Chicarilli ZN, Ariyan S, Cuono CB: Free radial forearm flap versatility for the head and neck and lower extremity. J Reconstr Microsurg 2:221, 1986 13. Coleman JJ, Searles JM, Hester TR, et al: Ten years experience with the free jejunal autograft. Am J Surg 154:394, 1987 14. Conley JJ, Novack AS: The surgical treatment of malignant tumors of the ear and temporal bone. Arch Otolaryngol 71:46, 1960 15. Crile G: Excision of cancer of the head and neck with special reference to plan of dissection based on 132 operations. JAMA 47:1780, 1906 16. Cuono CB, Ariyan S: Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plast Reconstr Surg 73:811, 1984 17. Dandy WE: Orbital Tumor: Results Following the Transcranial Operative Attack. New York, Oskar, 1941 18. Demergasso F, Piazza MV: Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: An original technique. Am J Surg 138533, 1979 19. deVries EJ, Stein DS, Johnson JR, et al: Hypopharyngeal reconstruction: A comparison of two alternatives. Laryngoscope 99:614, 1989 20. Dufresne C, Cutting C, Valauri F, et al: Reconstructioll of mandibular and floor of mouth defects using the trapezius osteomyocutaneous flaps. Plast Reconstr Surg 79:687, 1987 21. Fletcher GH: Elective irradiation of subclinical disease in cancers of the head and neck. Cancer 29:1450, 1972 22. Frodel JL Jr, Funk GF, Capper DT, et al: Osseointegrated implants: A comparative study of bone thickness in four vascularized bone flaps. Plast Reconstr Surg 92:449, 1993 23. Gacek RR, Goodman M: Management of malignancy of the temporal bone. Laryngoscope 87:1622, 1977 24. Harii K, Ebihara S, Ono I, et al: Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 75463, 1985 25. Harrison DF: Surgical repair in hypopharyngeal and cervical esophageal cancer: Analysis of 162 patients. Ann Otolaryngol 90:372, 1981 26. Hidalgo DA: Aesthetic improvements in free-flap mandible reconstruction. Plast Reconstr Surg 88574, 1991 27. Hidalgo DA: Fibula free flap mandible reconstruction. Microsurgery 15238, 1994 A

A

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28. Hidalgo DA, Rekow A: A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 96:585, 1995 29. Jesse RH: The philosophy of treatment of neck nodes. Ear Nose Throat J 56:125,1977 30. Kennedy JT, Krause CJ, Loevy S: The importance of tumor attachment to the carotid artery. Arch Otolaryngol 103:70, 1977 31. Ketcham AS, Hoye RC, VanBuren JM, et al: Complications of intracranial facial resection of tumors of the paranasal sinuses. Am J Surg 112:591, 1966 32. Leonard JR, Maran AG: Reconstruction of the cervical esophagus via gastric anastomosis. Laryngoscope 802349, 1970 33. LeQuesne LP, Ranger D: Pharyngolaryngectomy with immediate pharyngogastric anastomosis. Br J Surg 53:105, 1966 34. Lewis JS: Cancer of the ear: A report of 150 cases. Laryngoscope 70:551, 1960 35. Lewis JS, Page R: Radical surgery for malignant tumors of the ear. Arch Otolaryngol 83:114, 1966 36. Lindberg RD, Fletcher GH: The role of irradiation in the management of head and neck cancer: Analysis of results and causes of failure. Tumori 64:313, 1978 37. MacFee WF: Transverse incisions for neck dissection. Ann Surg 151:279, 1960 38. Malecki J: New trends in frontal sinus surgery. Acta Otolaryngol 50:127, 1959 39. Margarino G, Scala M, Gipponi M, et al: Mandible reconstruction with metallic endoprosthesis following Commando's operation for advanced head and neck cancer: Personal experience. Eur J Surg Oncol 19:320, 1993 40. Martin H, Del Valle B, Ehrlich H, et al: Neck dissection. Cancer 4:441, 1951 41. Martinez SA, Oller DW, Gee W, et al: Elective carotid artery resection. Arch Otolaryngo1 101:744, 1975 42. Mathes S, Nahai F: Muscle flap transposition with functional preservation: Technical and clinical consideration. Plast Reconstr Surg 66:242, 1980 43. McGregor IA: The temporal flap in intra-oral cancer: Its use in repairing the postexcisional defect. Br J Plast Surg 16:318, 1963 44. Meoz-Mendez RT, Fletcher GH, Guillamondegui OM, et al: Analysis of the results of irradiation in the treatment of squamous cell carcinomas of the pharyngeal walls. Int J Radiat Oncol Biol Phys 4579, 1978 45. Metha SA, Sarkar S, Metah AR, et al: Mortality and morbidity of primary pharyngogastric anastomosis following circumferential excision for hypopharyngeal malignancies. J Surg Oncol43:24, 1990 46. Million RR, Fletcher GH, Jesse RH, Jr: Evaluation of elective irradiation of the neck for squamous-cell carcinoma of the nasopharynx, tonsillar fossa, and base of tongue. Radiology 80:973, 1963 47. Orringer MB: Technical aids in performing transhiatal esophagectomy without thoracotomy. Ann Thorac Surg 38:128, 1984 48. Quillen CG: Latissimus dorsi myocutaneous flaps in head and neck reconstruction. Plast Reconstr Surg 63:664, 1979 49. Sasaki CT, Ariyan S, Spencer D, et al: Pectoralis major flap-reconstruction of the anterior skull base. Laryngoscope 95:162, 1985 50. Sasaki CT, Milmoe G, Spencer D, et al: Cancer of the ear and temporal bone. Conn Med 43:547, 1979 51. Schramm VL, Myers EN, Maroon JL: Anterior skull base surgery for benign and malignant disease. Laryngoscope 89:1077, 1979 52. Schusterman MA, Shestak K, deVries EJ, et al: Reconstruction of the cervical esophagus: Free jejunal transfer versus gastric pull-up. Plast Reconstr Surg 85:16, 1990 53. Seidenberg B, Rosenak SS, Hurwitt ES, et al: Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 149:162, 1959 54. Shenaq SM, Klebuc MJ: The iliac crest microsurgical free flap in mandibular reconstruction. Clin Plast Surg 21:37, 1994 55. Silver CE: Gastric pull-up operation for replacement of the cervical portion of the esophagus. Surg Gynecol Obstet 142:243,1976 56. Sinha PP, Aziz HI: Treatment of carcinoma of the middle ear. Radiology 126:485,1978 57. Sisson GA, Bytell ED, Becker SP, et al: Carcinoma of the paranasal sinuses and craniofacial resection. J Laryngol Otolaryngol 90:59, 1976

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58. Soutar DS, Scheker LR, Tanner NS, et al: The radial forearm flap: A versatile method for intraoral reconstruction. Br J Plast Surg 36:1, 1983 59. Soutar DS, Widdowson WP: Immediate reconstruction of the mandible using a vascularized segment of radius. Head Neck 8:232, 1986 60. Spiro RH, Baines MS, Shah JP, et al: Gastric transposition for head and neck cancer: A critical update. Am J Surg 162:345, 1991 61. Stell PM: Esophageal replacement by transposed stomach. Arch Otolaryngol 91:166, 1970 62. Suarez D: El problema de las metastasis lingfaticas y alejados del cancer de laringe e hiopfaringe. Rev Otorhinolaryngology 2393, 1963 63. Urken ML: Composite free flaps in oromandibular reconstruction: Review of the literature. Arch Otolaryngol Head Neck Surg 117:724, 1991 64. Urken ML, Weinberg H, Vickery C, et al: The internal oblique-iliac crest free flap in composite defects of the oral cavity involving bone, skin, and mucosa. Laryngoscope 101:257, 1991 65. VanBuren JM, Ommaya AK, Ketcham AS: Ten years' experience with radical combined craniofacial resection of malignant tumors of the paranasal sinuses. J Neurosurg 28:341, 1968 66. Walker RK, Cahow CE, Sasaki CT: Gastric pull-up replacement of the pharynx and esophagus in cancer of the pharynx and larynx. Conn Med 51:499, 1987 67. Yim KK, Wei FC: Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery 15:245, 1994

Address reprint requests to Stephan Ariyan, MD, MBA Department of Surgery Sections of Plastic Surgery and Otolaryngology Yale University School of Medicine New Haven, CT 06510