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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4451_Библиотеки_им_академика_М_И_Перельмана
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Fig. 73 Tongue ap for the buccal mucosa defect
Fig. 74 Follow-up photo showing slight trismus with
well-inset free radial forearm ap for the oral commissure
and lower lip defect
Fig. 76 One-year follow-up photo showing good epithelisation of FRAFF
Fig. 77 One-year follow-up of the oor of mouth
advancement with buccal fat pad grafting for marginal
mandibulectomy defect
Fig. 75 Upper lip and commissure defect reconstructed
with the FRAFF
Fig. 78 Bipaddle FRAFF for the buccal mucosa and
cheek skin defect
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Fig. 79 One-year follow-up of the oor mouth advancement with the skin grafting
N. M. Nagarkar et al.
Fig. 82 Deltopectoral ap reconstruction for the osteoradionecrosis debridement of the mandible
Fig. 80 Six-month follow-up showing good mouth opening in FRAFF reconstruction
Fig. 81 Six-month follow-up of buccal fat pad grafting
for buccal mucosa malignancy
Fig. 83 Forehead ap reconstructions are usually not
done commonly as the rst line of management. This was
done for patients with a second primary in the oral cavity
and previously operated neck
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Fig. 84 Tongue ap for marginal mandibulectomy defect
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Fig. 87 Intraoral view of PMMC ap
Fig. 85 Contractures may form within the oral cavity if a
large buccal mucosa defect is not reconstructed with a ap
Fig. 86 Chest wall wound showing well-healed PMMC
ap scar
Fig. 88 Postoperative view of FRAFF: ap monitoring
can be done by colour, skin turgor and scratching the ap
with a 22G needle, checking the ap blood sugar and correlating it with the peripheral blood sugar
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N. M. Nagarkar et al.
Fig. 91 Intraoral view of free bula osteocutaneous ap
Fig. 89 Radial free forearm ap defect closed with the
split skin grafting
Fig. 90 Excellent contour following mid-segmental
mandibulectomy defect reconstruction with free bula
osteocutaneous ap
Fig. 92 Free bula osteocutaneous ap for midsegmental mandibulectomy
Fig. 93 Mid-segmental mandibulectomy with deltopectoral ap reconstruction after 1year
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Fig. 94 Follow-up of free bula osteocutaneous ap for
recurrent ameloblastoma resection with skin involvement
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Fig. 97 Intraoral view of free bula osteocutaneous ap
for the posterior segmental mandibulectomy
Fig. 95 Excellent contour following free bula osteocutaneous ap
Fig. 96 Contour following the right segmental mandibulectomy reconstruction with free bula osteocutaneous
ap
3.5 Reconstruction Options
The aims are to restore the form and function.
Whether to repair a defect depends on its size and
depth, and whether there is a through-andthrough defect into the neck:
Fig. 98 Primary closure was done to close the buccoalveolar defect
• Buccal soft tissue defect only: Small defects
can be closed primarily or left to granulate and
heal by secondary intention like a tonsillec-
tomy defect. Larger defects that include resec-
tion of the buccinator muscle that are left to
granulate may lead to signicant trismus due
to scarring and contraction of the scar tissue.
• Marginal mandibulectomy: A marginal man-
dibulectomy defect can be strengthened with
an onlay bula or radial forearm osseocutane-
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Fig. 99 A dental step prosthesis can be used to prevent
the upper dentition impinging on the lower alveolar
reconstruction
N. M. Nagarkar et al.
Fig. 101 Reconstruction with the anterolateral thigh ap
for composite defect
Fig. 100 The prosthesis prevents the upper dentition
impinging on the FFOCF, especially while taking adjuvant radiotherapy
ous ap or a vascularised soft tissue ap may
be used to close the exposed bone.
• Segmental mandibulectomy: If the resection
crosses the midline and includes the
mandibular arch, e.g. mid-third mandible segment, reconstruction with an osseocutaneous
free ap is mandatory to avoid a debilitating
Andy Gump deformity:
– For lateral and posterior segmental or
hemimandibulectomy defects, reconstruc-
Fig. 102 Heister’s mouth gag can be used to rehabilitate
the patients with reduced mouth opening
Fig. 103 Plate can be exposed due to ORN: such exposed
plates must be removed, and a vascularised ap must use
to close the ORN wound
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Fig. 104 Hyperpigmentation can occur in the eld of
radiation
Fig. 105 Mucositis can occur as a consequence of
radiotherapy
tion with a pectoralis major myocutaneous
ap is an acceptable alternative if osseocutaneous free ap reconstruction is not possible or is inadvisable, e.g. in the elderly,
frail and unt.
• Large soft tissue defect: A large soft tissue
defect following, e.g. a “bite excision” or
infratemporal fossa clearance can be reconstructed with pedicled aps (forehead, temporalis, pectoralis major, deltopectoral) or free
aps (radial free forearm, anterolateral free
thigh).
• Facial skin defect: The skin can be reconstructed by bipaddling a radial free forearm,
anterolateral thigh or pectoralis major ap to
provide both inner and external skin covers.
Else a double ap, i.e. one ap to cover the
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inner mucosal and soft tissue defect and the
other to cover the skin loss, can be used:
– Commissure defects—primary closure of
the lip commissure usually leads to trismus
and reduced mouth opening:
Estlander ap can be modied to feed
the oral commissure defects.
One must be extremely careful while
dealing with the commissure defects
following midline lip split incision. The
intervening lip and skin may be devascularised due to loss of blood supply
from the superior and inferior labial
arteries.
The bipaddled ap can be fed into the
commissure by deepithelisation of splitting the ap. A small intervening skin
may be left at the point of skin paddle
fold to create the new commissure.
– Whenever oncologically safe, the commis-
sure must be left intact as it is the functional unit of the lip, helping in oral
competence.
• Split skin graft: Split skin grafts can be
employed for supercial defects. The graft is
harvested from the thigh, and the mucosal
defect is quilted with the skin graft with
absorbable sutures. Pressure is applied to the
graft by using a bolster, e.g. BIPP impregnated gauze, which is tied over the graft and
kept in situ for 5days. However, using a split
skin graft for deeper and larger defects causes
brosis that may cause trismus.
• Buccal fat pad graft: The buccal fat is conveniently located in the posterior part of the buccal space and can be gently delivered into the
defect and used to ll the defect. It subsequently mucosalises. In some cases, it may
cause a scar band and trismus.
• Pectoralis major ap: This was the workhorse
of oral cavity reconstruction prior to the
advent of free microvascular tissue transfer
aps. The pectoralis major ap has a robust
blood supply and has a long pedicle length
which makes it amenable to reconstruction of
a defect as superior as the lower border of the
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N. M. Nagarkar et al.
zygoma; the shape of the ap can be adjusted
to the shape of the defect; and a large ap can
be harvested. It remains a good choice when
free aps are not available, as a salvage procedure for a failed free aps or when patients
cannot tolerate a long procedure, e.g. the
elderly and inrm.
• Nasolabial ap: The nasolabial ap has advantages that the donor site is adjacent to the
defect and that the ap is thin and pliable and
has a robust blood supply that permits shaping
of the ap to precisely ll the defect. A larger
defect, particularly when located anteriorly,
can be covered with bilateral nasolabial aps.
• Tongue ap: Advantages are that the ap is
harvested adjacent to the defect and that there
is insignicant donor site morbidity. Generally
a posteriorly based ap is used.
• Floor of mouth advancement can be used to
close the marginal mandibulectomy defects.
• Temporalis ap: This is favoured by some surgeons. It is based on the deep temporal artery
which courses close to the coronoid process of
the mandible which this has to be preserved.
• Forehead ap: It has a robust blood supply and
is pliable, and the entire forehead can be utilised. It is however associated with signicant
cosmetic morbidity and is therefore generally
reserved as a second-line reconstructive option.
• Deltopectoral ap: It is quick and easy to harvest, has consistent anatomy and is a pliable
ap. For oral cavity repair, it generally requires
a second-stage surgery after 3weeks to disconnect the pedicle.
• Radial free forearm ap: It is a thin, pliable
ap with a consistent blood supply and a long
vascular pedicle. It is quick and easy to harvest. Donor site morbidity is worse than with
anterolateral thigh free aps. Its pliability
makes it amenable to reconstruct a variety of
oral defects. It can also be harvested as an
osseocutaneous ap.
• Anterolateral free thigh ap: It can be harvested with the muscle and hence used for
larger soft tissue defects. Donor site morbidity
is insignicant.
• Radial osseocutaneous ap: This can be complicated by fractures of the remaining radius
and restriction of forearm range of
movement.
• Free bula ap: Advantages include long bone
length, a segmental blood supply making multiple osteotomies feasible and minimal donor
site morbidity. Single vascular pedicle is most
commonly used for maxillary and orbital
defects.
3.6 Postoperative Care
• Airway: Elective tracheostomy is always indicated if mandibular resection crosses the midline with excision of both genial tubercles
resulting in the tongue dropping back, extensive composite palatal resection or buccal
mucosal resection requiring reconstruction
with a bulky ap.
• Position: Maintain the patient at 15 degrees
head high to reduce venous congestion and
bleeding. Maintain a head position that avoids
twisting of the vascular pedicle of a free ap.
• Feeding: Patients are fed by nasogastric feeding tube for at least 5 days, and until that
patient is able to tolerate their own saliva.
• Antibiotics: A broad-spectrum antibiotic is
administered for 24h.
3.7 Rehabilitation
• Jaw stretching exercises: Trismus is one of the
most common and most disabling sequelae of
surgery for buccal cancer because of scarring
and shortening of the muscles of mastication,
as well as scarring in the tumour bed and of
the ap or skin graft. Jaw stretching exercises
should commence after initial wound healing,
i.e. about 5–7days after surgery, and should
be continued for a long period of time.
• Bite guide prosthesis: Unopposed contraction
of the opposite muscles of mastication results
in deviation of the lower jaw following hemimandibulectomy. A bite guide prosthesis prevents this deviation and should be used for at
least 6–8weeks following surgery until complete healing has occurred.
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4 Principles ofManagement
ofPalatal Tumours
Small lesions may be treated with transoral-wide
local excision with resection performed to the
level of the bony portion of the hard palate with
anticipated reepithelialisation. The periosteum of
the palatal bone acts as a barrier to spread; excision with bony preservation may be adequate for
small lesions. Involvement of the periosteum
requires removal of a portion of the bony palate,
and partial or subtotal maxillectomy is required
for larger lesions and for those that involve the
maxillary antrum. For malignancies that extend
along the greater palatine nerve, biopsy of this
nerve is important for identifying neurotropic
spread. Small- to medium-sized defects may be
reconstructed with the aid of a temporalis, palatal
island, facial artery musculomucosal or buccal
fat pad ap. For lesions that result in a palatal
defect after resection, prosthetic rehabilitation
can offer the patient an excellent functional
result. In this circumstance, a maxillofacial
prosthodontist may construct a splint preoperatively for use at the time of resection. A splitthickness skin graft is used to cover edges of the
bone from the osteotomy and surrounding soft
tissue. The cavity is then packed with petroleum
gauze, and a screw or wire xation can be used to
secure the prosthesis to the maxilla and to provide support to the underlying repair. The temporary prosthesis is removed approximately 1week
later, and the packing is evacuated; an interim
prosthesis is worn until a more permanent option
can be tailored to the resultant defect:
1. Approaches to the surgical management of
tumours limited to the hard palate and alveolar ridge include:
(a) Wide local excision—palatectomy—fen-
estration procedure.
(b) Partial lateral maxillectomy: Surgical
approach for tumours of the hard palate
that involve the maxillary sinus and nasal
cavity.
(c) Inferior maxillectomy: Surgical approach
for tumours of the hard palate that do not
involve the oor of the maxillary sinus
and nasal cavity.
2. Approach to benign mucosal tumours of the
palate (biopsy-conrmed benign tumours
only involving the mucosa (i.e. pleomorphic
adenoma, etc.))
(a) Wide excision 0.5-cm margins of the
lesion.
(b) The deep margin should be the perios-
teum of the hard palate.
(c) If there is a concern for tumour involve-
ment deep to the periosteum, the surface
of the hard palate is drilled with a burr to
remove the supercial layer of the bone.
3. Reconstruction—A palatal island rotational
ap or rotational ap based on either the
greater palatine or ascending palatine arteries
is used to cover the site of the defect.
4.1 Technique ofInfrastructure
Maxillectomy
• The approach can be either intraoral or by
upper cheek ap approach.
• Intraoral approach: Retract the lips with a
hands-free cheek retractor, a bite block or a
side-biting mouth gag to gain access to the
oral cavity.
• Intraorally, mark the margins of the resection
with a marking pen or electrocautery.
• Margins should be a minimum of 1cm for any
lesion suspicious of malignancy or biopsyproven malignancy.
• The maxillary sinus is entered, and the infe-
rior aspect of the maxillary sinus is thoroughly
evaluated.
• A sagittal saw is used to make precise
osteotomies:
– The osteotomy is usually completed with
the osteotome at the level of the pterygoid
plates.
• The nasal cavity is entered, and the septum is
transected with heavy curved Mayo scissors
1–2cm superior to the oor of the nose.
• The soft palate is transected with electrocau-
tery, and any residual soft tissue attachments
are transected with scissors.
• After the mucosa of the maxillary antrum is
removed as previously described, the inferior
turbinate is also removed to prevent infection
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N. M. Nagarkar et al.
and oedema, which would interfere with the
application of a palatal prosthesis.
• More extensive tumours limited to the hard
palate and alveolar ridge can be removed by
simply extending the osteotomies.
• Once the specimen is removed, it is sent to the
pathology laboratory for frozen section diagnosis and assurance of clear surgical margins.
• A split skin graft can be placed to cover the
cheek, and an obturator is planned.
The surgical steps of infrastructure maxillec-
tomy and its follow-up are depicted in Figs.106,
107, 108, 109, 110, 111, 112 and 113.
4.2 Rehabilitation
The four major means of rehabilitation include:
1. Dental prosthetic management: A patient with
a limited lesion of the alveolar ridge alone or
the alveolar ridge and palate that does not
involve more than half the hard palate can be
rehabilitated relatively easily. Preoperative
dental impressions are made, and a surgical
splint is fashioned and inserted at the time of
resection as described earlier. Prostheses are
designed according to the Aramany classication. The permanent prosthesis will have teeth
Fig. 106 Marking for the intraoral infrastructure
maxillectomy
Fig. 107 Infrastructure maxillectomy defect
Fig. 108 Specimen of infrastructure maxillectomy
Fig. 109 Medial view of the infrastructure maxillectomy
defect
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