Using skin flaps for pharyngeal reconstruction has many advantages. Skin is the most donatable and easily accessible organ in the body; it is relatively ischemia-tolerant; providing it is sufficiently pliable and thin, it can be formed into a tube easily; morbidity associated with harvest can be insignificant; and tracheo-neoesophageal speech is better than that achieved with visceral flaps. The fact that skin flaps do not provide a moist or secreting surface and that they are adynamic appears to make no difference with respect to a functional swallow compared to visceral flaps. The most common microvascular skin flaps used are the radial forearm and lateral thigh. The radial forearm flap is easily tubed and readily available in most patients (Fig. 24). It is rapidly harvested with large donor vessels. The ease, reliability, and functionality of this flap for pharyngeal reconstruction are unsurpassed. A useful alternative is the lateral thigh flap, although its harvest is more difficult (Fig. 25). Harvested from the lateral aspect of the thigh, the donor site can be closed primarily in most instances leaving only a linear scar. As with a radial forearm flap, a two-team approach is possible, reducing operative time. First described by Baek in 1983, the lateral thigh flap is based on the third perforating branch of the profunda femoris artery running in the intermuscular septum between the vastus lateralis and biceps femoris muscles. In selected patients, flap thickness rarely exceeds 5 mm, so forming it into a tube is quite easy (Fig. 26). A V-plasty should be done at the distal anastomosis and a marker segment is attached for remote monitoring (as with the radial forearm) (Fig. 27). Sensory reinnervation is possible but unnecessary. Contraindications include local obesity (saddle-bag thighs), previous trauma, severe peripheral vascular disease, or prior hip replacement surgery that may have disrupted the perforating vessels.
RECONSTRUCTION AFTER MAXILLECTOMY Introduction
The maxillectomy surgical defect varies widely with respect to size, orientation, and complexity. The traditional radical maxillectomy defect is usually amenable to prosthetic rehabilitation with good success. In fact, traditional teaching favors a prosthetic-only approach because it allows easy inspection of the cavity for tumor surveillance after removal of the prosthetic appliance in the office. Proponents of flap reconstruction for these classic defects argue that leaving the cavity open is worthless because patients with tumor recurrence are most often unresectable anyway. In addition, they cite the fact that maxillary carcinoma carries a poor prognosis and flap reconstruction improves the patient's quality of life because it frees them from having to care for the prosthesis and the large cavity that tends to gather crusts and bits of food. Although these arguments are compelling, flap reconstruction is a more complex and uncertain endeavor than prosthetic rehabilitation. Although reconstructive surgery after maxillectomy is an increasingly popular alternative to prosthetic rehabilitation, the use of prosthetic appliances remains the popular choice.
Although the classic radical maxillectomy defect (maxilla including the hemi-hard palate sparing the orbital rim and globe) is most commonly found after resection of maxillary sinus carcinoma; lesser or greater removal of hard and soft tissues may be needed in selected patients. In general, surgical reconstruction is reserved for maxillectomy defects that are quite small (amenable to local or regional flap coverage) or large (significantly larger than after routine radical maxillectomy). With the advent of microsurgical flaps, the ability to close large complex defects successfully has improved dramatically. In fact, microsurgical flap reconstruction has become the mainstay of treatment in these cases. Local and regional flaps such as the temporalis and various oral transposition flaps (e.g., palatal and buccinator myo-mucosal) are used rarely and usually reserved for smaller defects.
The goals of rehabilitation after maxillectomy using a prosthesis or a flap are similar §
and include restoration of a sealed oral and oropharyngeal cavity and normal speech @
and swallowing. After routine maxillectomy, a skin graft is used to line the cavity, bolstered with temporary packing supported by an interim (initial) surgical prosthesis. A subsequent prosthesis is fashioned after the skin graft has healed to obturate the cavity and close the oronasal fistula.
Although the functional goals (speech and swallowing) are similar, flap reconstruction of large complex maxillectomy defects also includes obtaining a healed wound, soft and hard tissue obliteration of the surgical cavity, restoration of facial contour, and soft tissue coverage of cheek and orbital defects (19). Both in prosthetic management and flap reconstruction, restoration of an even and stable distribution of occlusal forces is needed for successful mastication.
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