SOFT TISSURE RECONSTRUCTION OF

ORAL AND MAXILLOFACAIL

REGION

Reconstruction Reconstructive maxillofacial surgery

refers to the wide range of procedures designed to rebuild or enhance soft or hard tissue structures of the maxillofacial region

Maxillofacial reconstruction is of prime importance in the management of orofacial defects caused by disorders such as neoplastic disease

indicated in patients with oral squamous cell carcinoma (SCC), also employed

in cases of benign tumours, trauma, osteoradionecrosis, infection, chronic non-union of bone, clefts, congenital

deformitieas

Early wound closure and the restoration of form, cosmetics and function are the

goals of reconstructive surgery.

RehabilitationMaxillofacial rehabilitation is the second

important step in the management of patients with orofacial defects, as it

restores the function of the region

Functional Considerations

Oral sphincterSpeech, mastication and

deglutitionProvides a watertight closure for

boluspreparationPrevents escape of saliva

Functional Considerations

Alveolar RidgesCovered with thin, adherent mucosaElevated above floor of mouthLingual and buccal sulci direct the flow

of foodand saliva during bolus processing

Functional Considerations

Floor of the mouthAllows unrestricted mobility of the oral

tongueCollects food and saliva (bolus

preparation)

Functional Considerations

Oral (mobile) tongueSpeech and deglutitionMobility allows for:Articulation of speechBolus manipulation in preparation for

deglutitionSensory functions: proprioception, pain,

tasteAssists in mastication and bolus processing

Functional Considerations

Hard palateOpposes tongueImportant for speech and bolus

preparation

Functional Considerations

Buccal MucosaLines the cheekFunctions in mastication and deglutitionAllows expansion for masticationThin to avoid restriction of dental closure

Functional Considerations

Base of tongueOften involved with oral cavity defectsParticipates in taste, deglutition and

speechMust occlude oropharynx during deglutitionSome consonants require BOT to touch

hardpalate

Patient FactorsIndividualize optionsType of tissueAnticipated functional gainAnticipated donor morbidityNeed for innervationSuccess rateIntraoperative positioningOperative timeDental restoration Overall medical status

Patient FactorsPreoperative counselingComplete medical historyDiabetes, atherosclerosis, previous

radiationCardiopulmonary status (operating time,aspiration risk)Smoking historyPatient expectations and motivation arevery important

flaps

flaps

flapsFlaps are segments of tissue that

retain some form of blood supply, which allows it to be living tissue, when

transferred Grafts do not have an intact blood

supply or drainage, i.e., skin grafts and bone grafts, and have to re-establish a

blood supply and drainage from the recipient bed.

flapsSoft tissue flaps can be classified

according to the method of movement (i.e., local or distant);

according to blood supply, such as axial or random pattern; according to the

compositionof the flap, such as cutaneous, myocutaneous,

osteomyocutaneous, or fasciocutaneous.

flapsAxial flaps receive their blood supply

from a single nutrient vessel while random pattern flaps receive capillary

blood supply in a random pattern from all directions and not from a single

nutrient vessel The Thebuccal advancement flap is a good

example of random flap

Local flapsthose that are derived from the

immediate area of resection and common examples of these include the

buccal pad of fat flap, naso-labial flap, facial artery musculo-mucosal (FAMM)

flap These types of flaps are advanced,

transposed or rotated into position

Local flap buccal pad of fat flap

One of the most common and most versatile flaps used for reconstruction of

small to medium defects in mouth blood supply derived from the buccal

and deep temporal branches of the maxillary from vessels from the

transverse facial artery

It has been used reliably to reconstruct soft and hard palatal, retro-molar fossa,

buccal mucosa ,and oro-pharyngeal defects

Facial artery musculo- mucosal flap

flap based on the facial artery utilizing buccal mucosa and a small amount of buccinator it can be used either in the

anterior maxilla region, the lips , anterior floor of mouth

Nasolabial flap These flaps are cutaneous flaps based

on the facial arteryThey have been found to be useful as

either superiorly based for anterior maxilla or oro-nasal defects or inferiorly

based for floor of mouth defects

Regional flap pectoralis major

This is a myocutaneous flap utilizing the pector major muscle and its overlying

skinIt is based on the pectoral branch of the

thoraco-acromial artery for soft tissue reconstruction of mucosa

and bony defects of the jaws

Temporalis flaphas been used for reconstruction of

maxillary, orbito- zygomatic , and anterior cranial fossa defects

The blood supply is from the deep temporal branches of the maxillary

artery

Free flaps radial forearm free flap

is the workhorse of oral reconstruction due to its versatility, reliability and

Flexibility It is particularly suitable for

reconstruction of the floor of mouth, soft palate , tonsillar fossa when restoring

the anterior maxilla and non-tooth bearing areas of the mandible and when

soft tissues need to reconstructed

The main disadvantages of this flap are inadequacy of available bone and donor site

morbidity such as limited motion, grip strengthNote = The cutaneous component of the radial

forearm free flap, when placed intra-orally, appears white due to the epidermal nature of

the epitheliumdermal structures, such as hair follicles, are

preserved in the transfer of flaps with a cutaneous component hair may grow from

these flap

Fibula free flapfibula free flap is now the mainstay of

reconstruction of bony continuity defects of the jaws, particularly Mandible ,

bony reconstruction of the maxilla and orbital floor,

can be osteotomized and thus can be contoured into the shape of the resected

mandible without compromising the blood supply

Disadvantages include donor site morbidity and numbness of the foot and

toe

Lliac crest flap The iliac crest free flap offers the best

bone stock for dental implants The natural contours of the bone are helpful for

reconstructing lateral and hemimandiblectomy defects

Iliac crest free flap prepared for recipient site

Iliac crest free flap at recipient site, with internal fixation

Scapular free falpA scapular free flap is an

osteocutaneous flap and is a recommended choice for complex

defects involving skin, bone and mucosa This flap,

in general, accepts osseointegrated dental implants well

Floor of Mouth ReconstructionRequires soft and mobile tissueAllow mobility of oral tongueAvoid scar contracture (i.e., secondaryintention)Avoid bulk (glossoptosis, obliteration oflower lip sulcus

Floor of Mouth ReconstructionSmaller defectsSplit thickness skin graftHarvest from lateral thigh at 0.017 inProvides water-tight closure, no hairStabilize with bolsterSurvives over muscle and cancellous

bone (viaimbibition and neovascularization)

Floor of Mouth Reconstruction

Floor of Mouth ReconstructionModerate defects involving a largerportion of mylohyoidNasolabial flapBased on angular arteryBetter for older patients with lax skinRequires two stages and temporary

fistulaBite block necessary

Floor of Mouth ReconstructionModerate defects (continued)Regional flapsForehead flap (rarely used)Platysma flapFacial artery musculomucosal flap

(FAMM)Deltopectoral flap (historical

significance)

Floor of Mouth ReconstructionForehead flapSuperficial temporal arteryReliable 2/3 across the foreheadTunneled into cheek below zygomaRequires orocutaneous fistulaObvious donor site (skin graft)Second stage to inset flap

Floor of Mouth ReconstructionSubmental artery island flapThin, supple skinSubmental branch of facial arteryPrimary closure of donor sitePoor reliability if:Facial artery sacrificedIrradiated necks

FAMM flapBranch of facial arteryContains mucosa, buccinator muscle,

and fat2 x 8 cm flap without injury to facial

nerve

Fasciocutaneous free flapsThin nature and pliabilityRadial forearm has low incidence of

failure tothis siteProvides tongue mobility and free

movementof food during deglutition

Anterior Tongue ReconstructionVery difficult to reconstructComplex intrinsic musculature andFunctionRedundancy is advantageousNear hemiglossectomy does not

significantlyalter function

Anterior Tongue ReconstructionDefects <50% can be closed primarily-/+ STSGLarger or composite defects require morebulk (i.e, fasciocutaneous free flap) Lateral arm free flap is good for defectsincluding posterior aspect of tongue/FOM

Anterior Tongue Reconstruction

Anterior Tongue Reconstruction

Lateral Arm free flapPosterior radial collateral arteryPaired venae comitantes12 x 18 cm paddle possible (6 x 8 cm allowsfor primary closure)Potential sensate flap (posterior cutaneousnerve)Disadvantages: donor site appearance, hairgrowth, elbow pain, lateral forearmnumbness

Buccal Cavity Reconstruction

Small defects – primary closure possibleLarger superficial defectsQuilted skin/mucosal graftsTemporoparietal fascial flap (STSG for

lining)Large full-thickness defectsPectoralis major myocutaneous flapLatissimus dorsi myocutaneous flapFasciocutaneous free flaps

Mandibular Reconstruction

GoalsReconstitutemandibular continuityAllow for future dentalrestorationAnterior defectsWorst functionaldefects“Andy Gump”deformityLateral defectsEasier to reconstructLess functionalproblemsMandibular

Mandibular Reconstruction

Fibula osseocutaneous free flap ideal foranterior defects (minimal soft tissuedefect)Based on peroneal vesselsMultiple osteotomies allowable (forcontouring)25 cm of bone available (entire defects)Sensate (lateral cutaneous nerve)Reliable for osseointegrated dental implants

Mandibular Reconstruction

Scapular free flap for anterior defects withmassive soft tissue loss (i.e., total glossectomy)Circumflex scapular artery and vein14 cm of bone available (lateral aspect)Allows osseointegrated implantsLong pedicle to axillary arteryMultiple fasciocutaneous/musculocutaneous flapsavailable (scapular, parascapular, latissimus dorsi,serratus anterior)Major drawback: patient positioning

Mandibular Reconstruction

Lateral mandible defectsRegional/Distant/Free flap with mandibularswingLow profile reconstruction plate with softtissue coveragePatient factors which prevent dental restorationPlate exposure rate of about 5%Compared to anterior exposure rate near 20%Osseocutaneous free flaps (iliac, scapular,fibula)

Iliac crest free flap for lateral defectsInternal oblique musculature includedContour similar to native mandibleReliable for osseointegrated implantsDeep circumflex iliac arteryDisadvantages (difficult harvest, donor sitedeformity, abdominal weakness,postoperative hematoma, lateral thighpain/anesthesia)Split inner cortex modification reducesmorbidity

Thank you