Principles of Orofacial Reconstruction

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PRINCIPLES OF

OROFACIAL
RECONSTRUCTION
Introduction

• The defect left after the excision of small oral cavity


or oropharyngeal tumor can often be closed
primarily with little morbidity.

• Larger defects will require formal reconstruction in


order to minimize problems associated with speech
and swallowing.
Goals of Orofacial Reconstruction

•Improve mastication, deglutition and speech


•Restoration of sensation to the denervated
lower lip
•Restoration of sensation to the resurfaced
portions of the oral cavity
•Rehabilitation with a functional dental
appliance
TIMING OF RECONSTRUCTION

• Two choices
a)Delayed: wait a period of time post-ablation and
then return patient to OR for reconstruction(usu. 6
months) Radiation, scarring, contracture, muscle
atrophy, increased hospitalization, poor cosmesis and
fibrosis can contribute to a suboptimal result
–6-12 months or longer
–Looks bad
–Fibrosis means you ultimately don’t get good bony
union or heal
• This is a poor concept
TIMING OF RECONSTRUCTION

• b) immediate: primary reconstruction is best


accomplished by free tissue transfer with
less scarring, fibrosis, fewer hospitalizations,
and decreased complication. Will see clear
benefits with respect to cosmesis, oral
competence, deglutition/mastication,
speech, sense of wholeness and dental
rehabilitation
–Probably your best option
1. Primary closure
• Often possible following excision of a small tumor in
the oral cavity.

• Normal tongue function and mobility should not be


compromised in order to achieve primary closure.
Choice of flap

This will depend on:

• Site and size of defect


• Desired functional result
• Donor site availability and morbidity
2. Free grafts:
a. skin grafts
• Skin grafting involves the transfer of skin which has been
completely separated from its blood supply and which
require a vascular bed to support its survival.

• Skin graft can be full thickness or partial thickness

• Small areas of skin grafts are best harvested from the upper
arm: in younger patients from the inner aspect, and in older
thin skinned patients from the outer aspect.

• If larger split skin grafts are required then upper thigh


provides a good donor site.
Full thickness skin graft
• Contains epidermis and all of dermis
• Can only be used to cover small defects
• Good cosmetic results can be obtained
• Donor sites include post-auricular skin and supraclavicular fossa.
Partial thickness graft
• Contains epidermis and superficial part of dermis
• Usually taken from donor site with dermatome or Humby
knife
• Donor site epithelium grows back from sweat glands and
hair follicles
• Graft can be 'meshed' to increase the area that can be
covered
• Partial-thickness grafts can not be used on infected wounds
• Not suitable for covering bone, tendon or cartilage
• Cosmetic result is often not good
Skin grafts

• Partial thickness graft

Partial thickness skin graft Full thickness skin graft


2. Free grafts:
b. Bone grafts
• In well vascularized tissues bone grafts of either rib
or iliac crest can be used to reconstruct the
mandible.
• Vascularised bone grafts are preferred in patients
who require postoperative radiotherapy.
3. Local Flaps

Local flap is a segment of skin or mucosa which is


transferred to an adjacent new site with its own blood
supply;
• Have a precise artery, most suitable for intraoral
reconstruction
Types of local flaps
• Tongue flaps
• Temporales muscle flap
• Nasolabial flaps
• Buccal fat pad flap
4. Distant flap
a-Axial Forehead (anterior branch of superficial temporal)
Deltopectoral (Internal mammary artery)

b-Myocutaneous
Trapezius (Transverse cervical artery)
Temporalis (superficial temporal artery)
Sternocliedomastoid Muscle (occipital, superior
thyroid)

c-Osseomyocutaneous
Pectoralis major
Trapezius
5. Free flaps with microvascular re-anastomosis

The transfer of certain distant axial cutaneous or


myocutaneous flaps from areas well away from the
head and neck can be achieved by dividing the pedicle
of the flap and reanastomosing these vessels to
vessels in the neck.
a- Fasciocutaneous; (Radial forearm flap).
b- Osseofasciocutaneous; (Radial forearm flap, Groin
flap).
c- Myocutaneous; e.g rectus abdominis free flap for
total glassectomy.
d- Visceral free jejunal transfer; for reconstructing the
lining of the oral cavity or oropharynx
ARTERIAL AND VENOUS ANASTOMOSIS
• Arterial connections into external carotid artery
system, most commonly the facial artery, and also the
superior thyroid artery
–On occasion use the lingual artery
• Recipient veins include the internal and external
jugular veins, facial veins, or cephalic vein from arm
–both an artery and a vein when doing free flap
surgery
–The biggest problem with free tissue transfer is
venous outflow
Iliac Crest Free Flap

• Most commonly used for mandibular defects in the head and neck
• best for angle/body defects
• can be used for symphyseal and parasymphyseal defects
Bone graft
Autogenous graft

• Fresh autogenous bone is the most ideal bone graft


material most commonly used in oral and maxillofacial
surgery.
• Can be taken in several different forms as
block graft- solid piece of both cortical and cancellous
bone
the iliac bone often used as a source of this type of graft
The entire thickness of the ileum can be split to obtain a
thinner piece of block graft
Ribs also constitute a form of block graft
Advantages of Autogenous grafts

•It provides osteogenic cells bone formation


•No immunological response occur
•Reduce risk of transmission of diseases from
the donors
Disadvantages of Autogenous grafts

• It requires another site of operation thus the morbidity of the


donor site especially with composite graft causing greater
functional and cosmetic defect.
• Because the soft tissue attached to the graft maintain the blood
supply only minimal stripping of the graft is possible thus the size
and the shape of the graft cannot be altered to any significant
degree.
Allogenic grafts (Allografts) or
homograft (genetically dissimilar)
• This type of grafts are taken from another individual
of the same species
• Since the individual are usually genetically dissimilar
treating the graft to reduce the antigencity is needed
• The most commonly used allogenic grafts are freez-
dried.
• All of these treatment destroy the osteogenic cells
therefore the grafts can not participate in
osteogenesis and only act passively offering a hard
tissue matrix, therefore the health of the graft bed is
much more important in this set of circumstances
than in autogenous grafts.
Advantages of Allograft
•It does not require another site of operation. A
similar bone or bone of similar shape to that
being replaced can be obtained for example an
allogenic mandible can be used for
reconstruction of mandiblectomy defect.
Disadvantages of Allograft
•It does not provide viable cells for osteogenesis.
Xenogenic graft

• Also known as xenografts or hetrografts


• Xenografts are taken from one species and grafted to
another
• The antigenic dissimilarity of these grafts is greater
than allogenic grafts
• The organic matrix of these grafts is antigenetically
dissimilar to that of human bone therefore the graft
must be vigorously treated to prevent rapid rejection.
Advantages of xenograft
• It does not require another site of operation in the
host
• Large quantity of bone can be obtained
Disadvantages
• It does not provide viable cells for osteogenesis
• Must be vigorously treated to reduce antigenicity
Isograft genetically identical (twins)
• Bone taken from genetically similar twin
• This grafts has the advantages of auto grafts plus
there is no need for another operation site in the
same patient.
Aloplast-non-biological material
• Non biological material like stainless steel,
hydroxyapatite, silastic, Titanium
Advantages
• No operation necessary therefore less morbidity
• Large quantity of the material available for
reconstruction of defects.
Disadvantages
• It does not provide viable cells for osteogenesis
• If infected may need replacement hence another
operation.

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