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(b) Extended supraomohyoid (anterolateral)
VV
• Lymph Node levels dissected
ed
• Lymph Node levels dissected
I-IV
• Also excised
Submandibular gland
I
II
III
METASTATIC NEC K DISE ASE
I-III
• Also excised
Submandibular gland
I
II
III
V
IV
(d) Posterolateral
IIA
III
• Lymph Node levels dissect
Level IIA
Level IIB (occipital trangle)
IIB
Level III
Level IV
Level V
IV
(c) Lateral (e) Anterior or central
• Lymph Node levels dissected
II-IV
I
II
III
V
IV
IV
• Lymph Node levels dissected
VI
• Includes nodes in the Perithyroid,
Delphian, Tracheo-oesophageal and
anteriosuperior mediastinum
Figure 69.2 Types of selective neck dissection (a) Levels I–III (supraomohyoid); (b) Levels I–IV
(extended supraomohyoid); (c) Levels III–IV (lateral); (d) Levels III–IV (posterolateral); (e) Levels VI–VII
(anterior/paratracheal).
Table 69.2 Patterns of lymphatic drainage
Primary site Echelon nodes
Oral cavity Levels I, II, and III
Oropharynx Levels II, III, and IV
Larynx Levels II, III, and IV
Hypopharynx Levels II, III, and IV
Thyroid Levels IV, VI, and VII
BOX 69.1 PROGNOSTIC NODAL FEATURES
• Site
• Size
• Number
• Extra-nodal extension (ENE)
• Matting
358 Head and Neck
METASTATIC NEC K DISE ASE
Assessment of Cervical Lymphadenopathy
Fine-Needle Aspiration Cytology (FNAC)
FNAC is easy to perform, can be reported immediately, and has overall accuracy rates
exceeding 90%. e technique is particularly useful in the assessment of a palpable node
when searching for an unknown primary, because the cytological aspirate can be subjected
to tests that may help in the search for the primary tumour. HPV or Epstein–Barr virus
(EBV) transcripts (or their surrogate markers) will point to a primary site in the oropharynx
or nasopharynx, respectively. Trucut biopsy of the lymph node, particularly under ultrasound guidance, is increasingly being used.
Ultrasound
Ultrasound can detect the presence of malignant cervical lymph nodes with sensitivity
rates between 70% and 90%. When ultrasound is combined with FNAC, the rate increases
to 90%.
Computed Tomography (CT)
e diagnostic accuracy of CT scanning in detecting malignant cervical lymphadenopathy
is higher than clinical examination. e criteria used for categorising metastatic deposits
include lymph nodes with a short-axis diameter larger than 1 cm, a cluster of three or more
borderline enlarged nodes larger than 0.8 cm, and nodal necrosis or patchy enhancement
within the nodes.
Magnetic Resonance Imaging (MRI)
MRI can detect cervical lymphadenopathy with overall similar accuracy rates to CT,
although meta-analyses have found CT to perform better than MRI. However, MRI may be
better in evaluating the N0 neck and in the presence of deep invasion.
PET CT
Currently, the widespread role of PET-CT is conned to detecting the occult primary,
detecting unknown distant metastases in certain clinical settings, and assessing residual
and recurrent disease aer irradiation. e PET-CT detection rate for nodes less than 1 cm
is reported at 71%. us, this modality has a poor detection rate (0–30%) in the setting of
the N0 neck.
Treatment of Metastatic Neck Disease
The N0 Neck
General consensus in the literature is that it is prudent to treat the neck when the risk of
occult spread is more than 15–20%. In fact, many surgeons and oncologists would perform
elective neck treatment for smaller probability (5–15%) of occult metastases. At least in oral
cavity cancer, this approach has been proven to have a signicant impact upon both overall
and disease-free survival.
Although there are no prospective trials, retrospective data from studies with large numbers
suggest that elective neck dissection (END) and irradiation are equally eective in controlling subclinical disease. Generally, when the primary tumour is being treated with radiotherapy, then elective treatment should be with radiotherapy. When the primary tumour is
treated with surgery, then elective neck surgery should be carried out (Figure 69.3).
In the presence of advanced primaries at high risk of occult spread or midline cancers, contralateral neck treatment is oen warranted.
The N+ Neck
e treatment oered to the neck oen depends on the modality used to treat the primary
site, as seen in the suggested algorithms for patients undergoing primary chemoradiation
(Figure 69.4) and primary surgery (Figure 69.5).
Head and Neck 359
METASTATIC NEC K DISE ASE
N0 neck
Is the incidence of occult
metastases >10%–15%?
Ye s
Primary
treated by
radiation
Elective
neck radiation
Primary
treated by
surgery
Selective neck dissection
I–III/IV for oral cavity
II–IV for larynx/hypopharynx
Ye s
Regular
follow-up
Consideration for elective
Figure 69.3 Algorithm for the management of the N0 neck.
N+ neck
Primary and neck treated
by chemoradiation
Complete response
Primary controlled
No distant spread
Incompete
response
No
Is the patient
suitable for regular
follow-up?
No
treatment
Conventional
imaging >8 weeks
Observe N2 disease
Neck dissection
N3 disease
N1
disease
Observe
N2 and N3
Neck
dissection
Primary controlled
No distant spread
Resectable disease
Pet-CT at 12 weeks
Observe
all
Neck
dissection
Primary uncontrolled
No distant spread
Resectable disease
Surgery to primary
and neck
PositiveNegativeNegative Positive
Neck
dissection
Figure 69.4 Algorithm for management of the N+ neck when chemoradiation is the primary
modality.
360 Head and Neck
METASTATIC NEC K DISE ASE
yF
N+ neck
Primary and neck treated
by surgery
N2 and N3 disease N1 disease
Adverse
features
group A
ChemoraditionRadiotherap
Adverse features group A:
Extracapsular spread, positive
margins
Figure 69.5 Algorithm for the management of the N+ neck when surgery is the primary modality.
Adjuvant radiotherapy or chemoradiotherapy is indicated for surgically managed N2 and
N3 disease and for N1 disease with poor prognostic features.
If the N+ neck is treated with primary radiotherapy or chemoradiotherapy, response to treatment should be determined with a 12-week PET CT scan. Complete responders can be safely
observed. Incomplete responders should be oered neck dissection. Surgical procedures
aer chemoradiotherapy are associated with more complications.
Treatment Outcomes
Regional control rates in the N0 neck are good regardless of modality, with failure rates of
3–7%. Recurrence rates in the N+ neck vary depending upon stage and presence of ENE.
Where the primary tumour has been controlled, overall recurrence rates range from 10% in
the N1 neck without ENE, 20–30% for N2 disease, and up to 85% for N3 disease.
Adverse
features
group B
No adverse
features
ollow-up
Adverse features group B:
pT3 or pT4 disease, multiple nodes,
level IV or V nodal disease, perineural
invasion, vascular embolism
Future Research
e following areas need to be addressed:
Imaging of low-volume disease
•
Signicance of occult cancer in the neck
•
Molecular detection of occult neck disease and its signicance
•
Sentinel node biopsy for occult neck cancer, in non-oral-cavity cancer
•
Selective neck dissection for palpable disease
•
Super-selective neck dissection for residual disease aer chemoradiation
•
Management of the contralateral neck
•
Quality of life aer various treatment modalities
•
Head and Neck 361
PROSTHETIC MANAGEMENT OF ORAL AND FACIAL DEFECTS
Further Reading
1. Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer 1972; 29: 1446 –1449.
2. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the
upper aerodigestive tract. Am J Surg 1990; 160: 405–409.
3. D’Cruz AK, Vaish R, Kapre N, et al. Elect ive versus therapeutic neck dissection in nodenegative oral cancer. N Engl J Med 2015; 373: 521–529.
70. PROSTHETIC MANAGEMENT OF ORAL AND FACIAL DEFECTS
Introduction
Successful complex oral and facial rehabilitation with prosthesis requires detailed planning
by a specialist multidisciplinary team. Members of the team include maxillofacial prosthodontists and extended team members, including hygienists, technicians, and the primary
care dental professionals. Osseointegrated implants are an essential tool in the reconstruction of oral and facial defects, and their use (primary or secondary) should form part of
treatment planning.
Pre-Operative Assessment
Where prosthetic rehabilitation is likely, early assessment by the maxillofacial prosthodontist is important. All dentate patients should be screened with detailed examination
and radiographs to decide on retention or extraction of teeth and potential support available to for the prosthesis. Modication of risk factors (e.g. smoking or excess alcohol consumption) should be attempted at this time to reduce risks related to implant/prosthesis
failure.
Management of the Maxillary Defect
e use of obturators in the reconstruction of maxillary defects has gradually been
reduced, with increased use of predictable free vascularised tissue transfer. e management decision should take into account the size and location of tumour, tumour subtype,
prognosis, and the patient’s tness for surgery. Ideally, very large defects are managed
with free tissue transfer, but defects up to Brown 2 can be successfully managed with an
obturator.
1
Preparation must begin before surgery with careful planning of resection margins, in particular alveolar margin bony cuts because they are integral to the accuracy and t of the
prosthesis. Depending on the size and location of the defect, components to aid the retention
of the prosthesis can be incorporated. ese include clasps on remaining teeth, circumzygomatic wires, and concomitant insertion of osseointegrated implants.
Table 70.1 Advantages and disadvantages of prosthetic use
Advantages Disadvantages
Early rehabilitation Unknown prognosis for patient
Implants placed before radiotherapy Unknown oral function post-surgery
Psychological patient benet Anatomical difculties for placement
Reduced number of surgeries Cost implications if implants not used
362 Head and Neck
PROSTHETIC MANAGEMENT OF ORAL AND FACIAL DEFECTS
Surgical Modications to Facilitate Obturator Provision
Where possible, bony cuts through the maxillary alveolus should be made through
•
edentulous bone or tooth extraction socket.
Incisions through hard palate mucosa should be made lateral to bone cuts, to create
•
keratinised mucosal ap to cover cut edge of bone.
Graing of cheek defects is done with split-thickness skin gra to produce a scar band
•
and aid retention.
Consider excision of the inferior turbinate to provide more vertical space and to pre-
•
vent future trauma.
Relining of the obturator with addition of cured silicone to provide rigid support to
•
the cheek and engage undercuts in the resection and aid retention in the immediate
post-operative period.
Modify and further reline 1–3 weeks aer surgery (general anaesthetic (GA) may be
•
required) to maintain oronasal/oroantral seal.
Further relines may be required until denitive impressions for the prosthesis can be
•
performed.
Multipart Maxillary Obturators and the Use of Osseointegrated Implants
Trismus is a common complication of combined surgery and radiotherapy, and it can lead
to diculties in taking impressions as well as insertion of the nal prosthesis. Separately
constructed components that can be held together with magnets may help circumvent this
problem. e use of implants (e.g. zygomatic implants) can help minimise the size of the
prosthesis required and aid retention.
Prosthetic Management of Facial Defects
Facial defects can either be surgical or congenital. Traditional methods of reconstruction
utilised a combination of skin adhesive, undercuts, and spectacle frames, which have all
largely been superseded by implant retention.
Preparation of the defect edges can help maximise the aesthetic result. Smoothing of sharp
corners, removal of unsupported so tissue, and the possibility of lining of the defect wall
with split-thickness skin gras should all be considered as part of the planning process.
Preservation of nasal bones is advantageous if possible, to provide vertical support for the
prosthesis and spectacles. Reduction of the projection of the nasal septum helps create space
within the defect for implant frameworks and reduces secretions in the area of the prosthesis.
Restoration of the Dentition after Ablative Surgery
Head and neck cancer patients oen have extensive dental needs. Neglected dentition is common, and when it is paired with either segmental or bony rim resection, it results in dental
rehabilitation challenges. So and hard free-tissue reconstructive techniques can oen lead
to bulky aps obstructing the dental envelope; however, they may also provide a foundation
for osseointegrated implant rehabilitation.
A decision about the patient’s dentition needs to be made prior to surgery, and the patient
should be given realistic expectations. Reduced tongue movement aer surgery can lead to
functional problems that are challenging to address with conventional dental prostheses.
Osseointegrated implants help to overcome these diculties.
Primary Dental Implant Placement
Installation of osseointegrated implants at the time of primary surgery helps provide eective prosthetic rehabilitation within a reasonable time. e majority of patients complete
their dental rehabilitation and demonstrate improvements in quality-of-life scores.
Primary dental implant placement is usually in conjunction with so-tissue reconstruction.
Advances i n 3D planning so ware are beg inning to al low primar y planned implants i n composite aps, but this approach is usually limited to benign rather than malignant reconstructions.
Head and Neck 363
GRAFTS AND FLAPS IN HEAD AND NECK RECONSTRUCTION
Secondary Dental Implant Placement
For many patients, decisions about dental rehabilitation are best le until they are fully
recovered from the eects of cancer treatment. Functional decits, patient motivation,
and disease control all form part of the planning process. CT-based computerised techniques are used to assist planning for bony healing and osteosynthesis plates and screws.
Computer soware can also be used to fabricate stereo lithic drilling guides for exact
placement.
Management of the peri-implant so tissues is another important aspect of optimal oral
rehabilitation. Reduction of excess tissue, refashioning of sulcal depth, and keratinised
so-tissue graing can all be considered.
Implant Placement in Irradiated Jaws
Radiotherapy is a signicant risk factor for failure of dental implants. To improve implant
survival, changes in implant design, 3D planning, and improved surgical techniques have
been employed.
Further Reading
1. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classication. Lancet Oncol 2010; 11(10): 10 01–1008. doi:10.1016/S1470-2045(10)70113-3
2. Butterworth CJ, Rogers SN. e zygomatic implant perforated (ZIP) ap: a new
technique for combined surgical reconstruction and rapid xed dental rehabilitation following low-level maxillectomy. Int J Implant Dent 2017; 3(1): 37. doi:10.1186/
s40729-017-010 0-8
3. Freudlsperger C, Bodem JP, Engel E, Homann J. Mandibular reconstruction with a
prefabricated free vascularized bula and implant-supported prosthesis based on fully
three-dimensional virtual planning. J Craniofac Surg 2014; 25(3): 980–982. doi:10.1097/
SCS.0000000000000551
71. GRAFTS AND FLAPS IN HEAD AND NECK RECONSTRUCTION
Large defects with no tissue laxity for closure require gra or ap reconstruction.
A gra is tissue with no blood supply, and its survival depends on gaining a blood supply
from the recipient bed. A ap is a piece of tissue with its own blood supply.
Principles
In planning, consider three key aspects of defects: What is missing? What is required? What
is available?
e reconstructive ‘toolbox’ concept means picking the ideal reconstruction for a defect.
Reconstructions consider ‘cosmetic subunits’ and ‘relaxed skin tension lines’ (RSTLs) for
incisions.
Skin Grafts
Introduction
Gras are classied by composition (e.g. skin, fat, mucosa, cartilage, bone, or composite, such
as a septal-mucosal gra). Skin gras are of two types: split-thickness skin gras (STSGs) or
364 Head and Neck
GRAFTS AND FLAPS IN HEAD AND NECK RECONSTRUCTION
Table 71.1 Comparison of split-thickness skin grafts (STSGs) and full-thickness skin grafts (FTSGs)
Factor STSGs FTSGs
Amount of dermis Epidermis and variable dermis Epidermis and all dermis
Primary graft contraction Less contraction More contraction
Secondary graft contraction More contraction Less contraction
Common harvest areas Thighs, buttocks Periauricular/supraclavicular
(for colour)
Upper arm/groin (for size)
Harvest technique Dermatome or Watson knife Blade
Size of graft Large Limited
Donor-site healing Secondary intention Primary intention
Chance of take More likely Less likely
Robustness Less robust More robust
Colour match Abnormal pigmentation Better colour match
Sensory recovery Limited Better
full-thickness skin gras (FTSGs), and they dier in dermal content. ey are compared
in Table 71.1.
Skin Graft Healing
Gra survival depends on gaining a blood supply from the recipient bed. is process is
‘take’. Take is aected by gra, recipient, and systemic factors. Gra factors include tissue
thickness. Local factors include recipient bed vascularity (exposed bone and tendon and
radiotherapy prevent take), bleeding, infection, and shearing. Potential systemic problems
include smoking, poor nutrition, and diabetes.
Flaps
Principles
Flaps are indicated for extensive defects, exposed vital structures, poor vascularity, radiotherapy, and cosmesis.
Types
Flaps are named according to anatomy (e.g. blood supply or muscle for ap) or by the classication shown in Table 71.2. Common aps discussed in this chapter are shown in bold
type in the table..
Local Flaps
Consider defect, location, cosmetic units, and RSTLs when choosing ap.
Advancement Flaps
For single-pedicle ap, para llel incisions are adva nced on one side of defect (e.g. Rintala ap on
nose). For bipedicle ap, parallel incisions are pedicled at either end and are raised in the centre and ‘bucket-handled’ (e.g. tripier ap for eyelid). V-Y aps are raised as ‘V’, are advanced
with a deep or lateral pedicle, and are closed as ‘Y’ (e.g. nasolabial ap for alar defect).
Pivot Flaps—Transposition Flaps
Rhomboid Flap
Rhomboid ap is random pattern. To create rhomboid shape around defect: note RSTLs,
note LMEs (lines of maximal extensibility) parallel to this—these make two sides of the
rhomboid—then draw two further parallel lines meeting the LME lines to make a rhomboid
shape with all sides equal length, and two angles of 60° and two angles of 120°. From the 120°
angles, drop a line equal in length to one side of the rhomboid. From this, draw a line parallel to the ap. Two options are available from each line, thereby giving a choice of four aps.
Head and Neck 365
GRAFTS AND FLAPS IN HEAD AND NECK RECONSTRUCTION
Table 71.2 ‘5 Cs’ classication of aps
Classication Flap Explanation
1. Circulation Random
pattern
Axial Direct—named artery in subcutaneous tissue, such as
2. Composition Various Cutaneous, fasciocutaneous, fascial, musculocutaneous,
3. Contiguity Local Tissue transferred is adjacent to defect (e.g. NLF ap for
Regional Tissue transferred in same region (e.g. cervicofacial,
Distant Tissue transferred from distance (e.g. supraclavicular artery
Free ap Tissue transferred as transplant
4. Contour Advancement Move forward without any rotation or lateral movement (e.g.
Pivot Move at a xed pivot point that is line of maximal tension of
5. Conditioning ‘Delay’ Flap undergoes prior ‘delay’ procedure to improve vascularity
No dened pedicle (e.g. some local aps on face)
Length:Breadth ratio is up to 4:1 on face (i.e. smaller than
axial aps)
nasolabial fold ap (NLF) with facial artery
Fasciocutaneous—vessel runs in fascia, usually from
septocutaneous vessel that passes between muscles to fascia
Classied by Cormack and Lamberty (1984)
Musculocutaneous—vessel in muscle with perforators to skin
Importantly, muscle has axial supply but skin has random
pattern.
Classied by Mathes and Nahai (1981): dominant pedicles
supply whole muscle, minor pedicle only part
Perforator ap
• Direct (cutaneous) perforator
• Indirect muscle/musculocutaneous perforator (e.g. deep
inferior epigastric perforator (DIEP) ap)
• Indirect septal/septocutaneous, such as anterolateral
thigh (ALT) ap
muscle, osseocutaneous, osseous
cheek)
nasolabial, facial artery myomucosal, submental, forehead,
temperoparietal fascial, temporalis)
island, deltopectoral, pectoralis major, latissimus dorsi,
trapezius)
• Upper limb: radial forearm, lateral arm
• Torso: subscapular (latissimus dorsi, scapular), abdomen
(rectus, DIEP), deep circumex iliac artery (DCIA)
• Lower limb: ALT, gracilis, free bular
• Enteric: jejunum
single-pedicle or bipedicle or V-Y ap)
ap
Transposition ap ‘pivots’ around point (e.g. rhomboid /
bilobed)
Rotation ap ‘rotates’ around pivot point
Bilobed Flap
A bilobed ap is a random pattern ap that consists of two transposition aps. Pivot point
is 1 radius away, with axis via horizontal line through the defect. First ap is slightly
smaller and adjacent to the defect, with axis 45° from pivot point of rst axis. Next ap is
half the size of the rst and adjacent to it, with axis 90° from rst axis. e rst ap transposes to the primary defect, the second ap to the secondary defect, and the tertiary defect
is closed directly.
366 Head and Neck
GRAFTS AND FLAPS IN HEAD AND NECK RECONSTRUCTION
Pivot Flaps—Rotation Flaps
e primary defect is ‘triangulated’, and the ap is designed as a semicircle with the radius 3
times the arc length of the triangulated defect and the circumference 8 times the arc length
of the defect. e pivot point is the distal part of the ap. Upon movement, a ‘back-cut’ may
be needed for closure, which moves the pivot point toward the defect to reduce tension but
decreases ap vascularity.
Locoregional Flaps
Nasolabial Flaps (NLF)
Background: First documented by Indian Sushruta in 600 BC. Transposition ap.
Anatomy: Axial ap based on facial and angular artery; therefore, can be proximally or dis-
tally based. Width is 1–2 cm.
Use: Proximally/superiorly based for nasal side wall and alar defects. Distally/inferiorly based
for alar/perialar defect, upper lip and commissure, and anterior oral cavity.
Advantages: Good colour match, inconspicuous donor scars in aesthetic junctions.
Disadvantages: Blunt alar groove unless planned correctly, can be bulky, and, if short, pulls
up alar.
Technique:
Plan: Base is determined by defect location. Plan length in reverse from pivot point.
•
Template defect on distal ap to check width and check that donor closes.
Place incisions along aesthetic junction (i.e. nose/cheek junction, alar groove, naso-
•
labial fold).
Procedure: Raise subc uta neous ap from tip to base. Transpose and inset and close donor.
•
For intraoral defects, a tunnel is placed traversing the facial muscles and buccinators.
Forehead Flaps (Paramedian)
Background: Original description by Indian Sushruta in 600 BC. Workhorse for nasal defect.
Anatomy: Forehead is divided into 3 zones—paramedian, median, and lateral. Paramedian
is based on supratrochlear +/- supraorbital vessels.
Use: For external/internal nasal defects, eyelids/medial canthus, and midface reconstruction.
Advantages: Good colour match, moderate size and thickness, potentially hairless, and
donor has good aesthetic result even with secondary intention healing.
Disadvantages: Requires a minimum of two stages. Need correct design or nose contracts. Arc
of rotation and short forehead limit reach or are a problem if large aps are needed. One-stage
solution includes dropping pivot point, accepting alopecia/ha iry reconstruction, or use of specic
design (e.g. Millard ap). Two-stage options are rst-stage ‘delaying’ ap or tissue expansion.
Technique
Plan: Assess height of forehead. Find origin of supratrochlear artery (1 cm medial to
•
supraorbital foramen above midpoint of pupil). Line drawn vertically up is axis of ap.
Plan pedicle length in reverse from pivot point and template defect on distal ap. Keep
‘extra’ 15% in pedicle length from pivot.
Procedure: Incise around the ap and pedicle, raise ap distal to proximal in plane
•
under fronta lis, and 1 cm superior to the supraorbital ridge, go subperiosteal to protect
the vessel. Rotate and inset ap into defect. Gra underside of pedicle for haemostasis.
If unable to close donor, then dress. Flap is thinned +/− pedicle division at 3 weeks.
Distant Flaps
Pectoralis Major Flaps
Background: Previously workhorse, now used for salvage cases. Muscle or musculocutaneous
(rarely osteomyocutaneous).
Head and Neck 367
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