On CECT, the flap muscle is isodense to striated muscle elsewhere. While the 2 are distinct entities, it is not uncommon to hear them incorrectly used interchangeably. Surgical flaps and surgical grafts are both used in H&N reconstruction. This book offers invaluable insights into free-flap harvesting and transferring techniques for both residents and experienced specialists in the field of otolaryngology, head and neck, maxillo-facial and plastic surgery. MR imaging protocols vary depending on the location of the abnormality. They have better functional outcomes and cosmetic restoration than surgical grafts and other types of surgical flaps (local and regional).1⇓⇓–4 Since free flaps were first used in the 1970s, surgeons have expanded their repertoire, fine-tuned techniques, and improved outcomes.5 While FFs may be used to reconstruct defects from infection, trauma, and osteonecrosis, they are most often used following tumor extirpation. Surgical flaps are typically classified by their pattern of vascularity and their proximity to the primary defect. Free flaps were first described in head and neck reconstruction in 1959, but flaps were not a standard of care until the 1980s.1,2 One of the major postoperative complications in these surgeries is total flap … In addition, not every defect requires a free flap transfer to achieve good functional results. The pectoralis myocutaneous flap was considered the “workhorse” flap of head and neck reconstruction during the 1970s. Microsurgical free flaps are today considered state of the art in head and neck reconstruction after composite tumor resections. r head and neck reconstruction. 2 Full-thickness resection of the skin, floor of the mouth, and mandible. The MR signal intensity and enhancement pattern have been described and are predictable, with moderate-to-intense enhancement.13,24⇓–26 In the early posttreatment period, the flap may be edematous, hypointense on T1-weighted images (Fig 13), hyperintense on T2-weighted images, and enhance with gadolinium contrast. One or 2 skin paddles can be obtained; unfortunately, they are often hair-bearing in male patients, resulting in an undesired postoperative cosmetic appearance if used in certain locations (ie, oral cavity mucosal reconstruction). This review article focuses on free flaps, summarizing what defines an FF, those most commonly used, the expected postoperative imaging appearances, and associated complications. Intraoperative goal‐directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures. Axial noncontrast CT of a different patient with a fibular FF shows a complicated postoperative appearance (B), with a nonunited, diastatic, irregular symphyseal margin with a periosteal reaction in this patient with osteonecrosis of the fibular FF and native mandible. Email mij eenmalig zodra dit artikel leverbaar is. The latissimus is fastened to secure the mandible and recreate the mylohyoid sling. An example of a regional flap is the pectoralis major myocutaneous flap, supplied by the pectoral branch of the thoracoacromial artery. The first steps are to determine the location and appearance of the primary malignancy, which tissues were removed at the time of the oncologic operation, and what type of FF was used to reconstruct the resulting defect. Rectus abdominis FFs include one of the paired vertically oriented ventral abdominal muscles.5,20 They are especially advantageous because of the versatility of flap design and the length of the associated vascular pedicle, up to 10–15 cm long. When recognized and surgically treated promptly, compromised FFs have a salvage rate of 50%–75%.8 Management includes re-exploration of the site, with possible thrombectomy and anastomosis revision. Latissimus dorsi FFs are the largest muscle flaps, with a total area measuring up to 25 × 40 cm. Thus, for radiologists, it is useful to categorize free flaps by the dominant donor tissue constituents (Table 1), creating 4 main categories: muscular, fascial, osseous, and visceral FFs.17, Surgical free flaps in head and neck reconstruction, Surgical approach to free flaps in H&N reconstruction, This simplified approach has important facts to note. Postoperative imaging in patients with H&N reconstruction is challenging. betaal facturen of 2007;29:285-91 Chapter 5 Infrahyoid flap reconstruction of oral cavity and oropharyngeal 47 defects in elderly patients with severe general comorbidities Deganello A, Gitti G, Parrinello G, Larotonda G, Meccariello G, Leemans CR, Gallo O. They conducted a retrospective review of all lateral forearm flap reconstructions performed between 2016 and 2018. Beoordeling door klanten Similar to the radial forearm FF, ALT reconstruction can be used for skin and mucosal lining defects, subtotal glossectomy defects (Fig 6), pharyngeal defects, and skull base defects. One or 2 skin paddles may be harvested; one usually recreates the oral mucosal surface as shown in the diagram. One drawback is that the thickness of the FF is particularly reflective of a patient's weight and may prove too bulky for some resection cavities in obese patients due to excessive subcutaneous fat.5 Rectus abdominis FFs can also be harvested as fasciocutaneous free flaps. Lees er meer over in ons, Free Flaps in Head and Neck Reconstruction, Tot 40% korting op dameskleding, schoenen en accessoires*, Bezorging dezelfde dag, 's avonds of in het weekend*. Met deze cookies kunnen wij en derde partijen jouw internetgedrag binnen en buiten bol.com volgen en verzamelen. Conclusions. A variety of different bone shapes can be obtained depending on the contour of the defect. We hope that this image-rich review will fill that void and serve as a go to reference for radiologists interpreting imaging of surgical free flaps in head and neck reconstruction. The rectus muscle (thin arrow) lines the skull base defect, while a portion of the skin paddle recreates the oral cavity mucosal surface (curved arrow). The diagram (A) shows that free flaps can be partially rolled (upper right) or completed tubed (lower right) to reconstruct the upper aerodigestive tract. Je kunt je cookievoorkeuren altijd weer aanpassen. Like rectus FFs, they can fill large defects. • The rectus abdominis musculocutaneous free flap, based on the deep inferior epigastric artery and vein, has been used widely in reconstruction of the breast and extremities. Preoperative axial CECT (A) shows a T4a maxillary sinus SCC. In terms of blood supply, flaps can be typified as random or axial.5,7,12,13 Random flaps are supplied by the subdermal plexus of the skin and are not supplied by distinct named vessels. Interpolation Flap; Lip Reconstruction; Nasal ALA; Nasal Reconstruction; Nasal Tip - Sidewall; Pull Through Flap; Rotation Flap; Soft Triangle; Transposistion Flap; Videos; For Authors. Visceral FFs can be used in pharyngoesophageal reconstruction. This richly illustrated atlas provides a clear and comprehensive step-by-step description of surgical techniques for raising and setting free flaps from different donor sites, to reconstruct damage to the head and neck caused by cancer and trauma. We slaan je cookievoorkeur op in je account. In our practice, the first posttreatment contrast-enhanced CT (CECT) is performed with PET to increase detection of persistent tumor, nodal, or distant metastases and to differentiate residual tumor from non-neoplastic postoperative changes. An additional distinction with regional and free flaps is that they may be of simple or composite design. Postoperative T1 axial MR image (A) after reconstruction with a latissimus FF shows hypointense abnormal signal (arrows) and enlargement of the right masseter. They are mostly composite flaps, containing multiple different tissue types in addition to bone, including skin, subcutaneous tissue, fascia, and muscle (Fig 7). Slide 2-ppt slide no 2 content not found. Patients undergo frequent inspection of tissue color, capillary refill, turgor, and temperature.12,30 Various other techniques, including Doppler monitoring and needle pricks, are also used in the immediate postoperative period. servicekosten. Volg je bestelling, This category of FF is particularly useful to fill large defects (Fig 2), including skull base defects.7,19 Two of the more commonly used myocutaneous FFs are the rectus abdominis and latissimus dorsi muscle FFs. The rectus abdominis free flap … Muscular flap components are usually striated, thin, and relatively flat (Fig 11). Extensive dissection toward feeding vessels of flap near the parasternal area is avoided. Then, with microsurgical techniques, the donor pedicle is anastomosed to the recipient vessels near the defect to re-establish the blood supply to the flap.5,7,12,13. Hardware exposure and extrusion are the most commonly cited flap complications and occur in around 15% of patients.29,31 This complication is often seen in association with continued tobacco use. A, Diagram of the scapular donor site (left) and midface inset (right) demonstrates the versatile scapular osteocutaneous FF for complex midface defects. In patients with head and neck cancer not receiving free flap reconstruction, a number of studies have supported the use of short-term prophylactic antibiotics. Onze klantenservice Different segments of the bone can be harvested, including the scapular tip and up to 2 segments of the lateral border. The survival rate of a flap is around 95%, but early complications soon after a reconstructive FF operation include ischemia, infection, bleeding, and dehiscence.29 These are closely monitored clinically at the bedside and rarely require cross-sectional imaging. Now in its Second Edition, The Atlas of Regional and Free Flaps for Head and Neck Reconstruction delivers clear, heavily illustrated coverage of regional skin, muscle, and musculocutaneous flaps as well as donor sites from distant regions of the body where vascularized skin, muscle, bone, and nerves can be harvested and transferred to the head and neck. We helpen je graag. Adopting a highly practical approach, the book describes the indications and technical aspects of each procedure with sets of in-vivo pictures clearly showing the surgical passages. Up to 25 cm of the fibula may be resected with little effect on the gait as the fibula is a non-weight-bearing bone. Thus, osteocutaneous FFs have become popular solutions for many maxillary and mandibular defects.5 Long segments of bone, up to 25 cm, may be harvested and crafted as a variety of surgical constructs using surgical plates and screws. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. Following total glossectomy, right oropharyngectomy, and total laryngectomy for T4a squamous cell carcinoma (SCC) of the right oral tongue, the FF was harvested and set on the operating room back table (A) with the elongated vascular pedicle (arrowhead), skin (block arrow), and latissimus (arrow). Axial noncontrast CT shows the expected postoperative appearance (A) following right segmental mandibulectomy and fibular FF reconstruction, with a healing symphyseal interface (thin arrow) and a nonunited-but-sharp osteotomy underlying the posterior mandibular body surgical plate (thick arrow). A second free flap may be required for reconstruction of head and neck defects following complications of the initial reconstruction, presence of a second primary or tumour recurrence. Local and Regional Flaps in Head Neck Reconstruction: A Practical Approach provides comprehensive, step-by-step instruction for flap raising and insetting for the head and neck region. One of the surgical goals is to “replace like with like,” meaning reconstructing surgical cavities with tissue constituents similar to those resected. The FF fat (curved arrow) deep to the muscular component is homogeneously hyperintense. Axial flaps are typically considered more reliable than random flaps on the basis of improved distal perfusion. Each donor vascular pedicle is transected at the donor site, transferred along with the flap constituents to the primary defect, and inset at the primary defect. Following maxillectomy and orbital exenteration with ALT FF reconstruction, the patient had a biopsy-proved recurrence (white arrowheads) at the margins of the ALT FF on postoperative CECT (B) several months later. A CECT of the neck with the arms down is performed following PET, using a split-bolus technique with 110 mL of intravenous iopamidol (Isovue-370; Bracco, Princeton, New Jersey), with 55 mL injected first at 2.5 mL/s, a 40-second delay, then another 55 mL at the same rate, and a total scan delay of 90 seconds. Any of the segments can be fashioned to reconstruct the hard palate or orbital rim. Anterolateral thigh FF. Despite the complexity and increasing frequency of free flap reconstruction, there is no comprehensive head and neck resource intended for the radiologist. Free Flap Reconstruction of Head and Neck Defects Parag Parikh, MD UC-Irvine April 7, 2004. Je kunt je cookievoorkeuren altijd weer aanpassen. Swallowing and diet were assessed in patients undergoing intraoral reconstruction. This flap is easy to harvest and versatile. Alle prijzen zijn inclusief BTW en andere heffingen en exclusief eventuele This richly illustrated atlas provides a clear and comprehensive step-by-step description of surgical techniques for raising and setting free flaps from different donor sites, to reconstruct damage to the head and neck caused by cancer and trauma. 2 Figure Figure1 1 illustrates this concept. 5 van 5 - 1779 beoordelingen, * De voordelen van bol.com gelden niet voor het gehele assortiment. Additionally, some FFs (rectus abdominis and latissimus dorsi) may be harvested as either myocutaneous or fasciocutaneous. Enter multiple addresses on separate lines or separate them with commas. A free flap is a graft of human tissue which is taken together with its supplying blood vessels and placed in another part of the body where it … Because the ALT FF is harvested from the anterior and proximal aspect of the lower extremity, there is relatively little morbidity at the donor site and the patient's clothing typically covers any postoperative scarring.5,7. Vascular pedicle ossification. FF Infection. Fasciocutaneous FFs can be used to restore skin or mucosal defects (Fig 4). THE ROLE OF PERFORATOR FLAPS IN HEAD AND NECK RECONSTRUCTION. The radial forearm FF is harvested from the volar aspect of the forearm and includes the radial artery (Fig 4). Thus, an understanding of free flaps, their expected appearance on cross-sectional imaging, and their associated complications (including tumor recurrence) is crucial for the interpreting radiologist. CT should always be performed with intravenous contrast administered in a standard amount and timing of the acquisition so that serial or surveillance scans can be compared. The number of reports on its applications in the head and neck is limited. Posttreatment H&N clinical and imaging follow-up is complex, even more so when the resection site is reconstructed. This richly illustrated atlas provides a clear and comprehensive step-by-step description of surgical techniques for raising and setting free flaps from different donor sites, to reconstruct damage to the head and neck caused by cancer and trauma. Again, a standardized protocol involving the same timing and sequences is essential. Helical noncontrast CT is performed before PET for attenuation correction and anatomic localization. Free tissue flaps are the most complex and technically challenging form of flap reconstruction. Door op ‘accepteren’ te klikken ga je hiermee akkoord. Postoperative sagittal CECT (B) following base of tongue hemiglossectomy and laryngopharyngectomy shows the radial forearm FF reconstruction (long arrow). Local and regional flaps in head and neck reconstruction Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. One or 2 skin paddles may be harvested, allowing a variety of uses, such as floor of mouth reconstruction (Fig 3) or large skull base defects.5,7. It has been used more extensively and for a wider variety of reconstructions than any other flap.5 This FF is particularly advantageous because the forearm skin is usually non-hair-bearing and the forearm is least influenced by obesity.7 Primary indications for use include reconstruction of skin or mucosal lining defects, partial/hemiglossectomy defects, and pharyngeal defects. Dehiscence of FFs overlying surgical hardware can result in exposure of the surgical construct (Fig 15). This patient had fever, elevated white blood cell count, and purulent left neck drainage following radial forearm FF and fibular FF reconstruction for T4aN2c SCC of the right oral tongue. Ideal for oral and maxillofacial surgeons, facial plastic surgeons, Probably the main impact of perforator flaps in the head and neck region is to increase the sophistication of our reconstructions as well as to provide us with more choices. Line drawing (B) of the ALT donor site (outlined) axial anatomy includes the descending branch of the lateral circumflex femoral artery. Immediate postoperative picture (B) shows the skin paddle (block arrow) closing the glossectomy defect. This vascular pedicle length allows the surgeon to inset rectus FFs into almost any H&N defect, even those a distance away or on the opposite side of the head and neck from the vascular anastomoses. In addition, it discusses microvascular techniques and explores different soft-tissue, perforator and bone flaps, including novel free tissue flaps, presented for the first time in the head and neck field.