Reconstruction Principles in Head and Neck

Recon Goals & Basics - Setting the Stage

• Primary Aims:
  • Restore function: speech, swallowing, airway patency.
  • Achieve aesthetic form and symmetry.
  • Ensure durable coverage; prevent complications (fistula, infection).
• Fundamental Principles:
  • Replace "like with like" tissue.
  • Prioritize robust vascular supply for flaps.
  • Tension-free wound closure is critical.
  • Minimize donor site morbidity.

⭐ The reconstructive ladder (from direct closure to free tissue transfer) dictates the simplest effective solution.

Recon Ladder - Climbing Choices

• Principle: Simplest effective method first.
• 1. Secondary Intention: Small, superficial defects.
• 2. Primary Closure: Minimal tension.
• 3. Skin Grafts:
  • STSG: Large areas.
  • FTSG: Better cosmesis, smaller areas.
• 4. Local Flaps: Adjacent tissue (random/axial).
• 5. Regional Flaps: Pedicled (e.g., PMMC, Deltopectoral).
• 6. Free Flaps: Microvascular; for complex defects (e.g., RFFF, Fibula).

⭐ Free flaps offer superior vascularized tissue for complex 3D defects, vital for function and aesthetics. 📌 Mnemonic: "See Primary Grafts Locally, Regionally, Freely."

Skin Grafts - Patchwork Perfection

• Autologous transfer of epidermis & a variable amount of dermis, completely detached from donor site blood supply before transfer.
• Types:
  • Split-Thickness Skin Graft (STSG):
    • Epidermis + portion of dermis.
    • Donor sites: Thigh, buttock, scalp. Harvested with dermatome (e.g., 0.010-0.018 inches).
    • Pros: Better take, can cover large areas. Cons: ↑contraction, ↓cosmesis, fragile.
  • Full-Thickness Skin Graft (FTSG):
    • Epidermis + entire dermis.
    • Donor sites: Postauricular, supraclavicular, preauricular, upper eyelid.
    • Pros: ↓contraction, better cosmesis & durability. Cons: Limited size, needs well-vascularized bed.
• Graft take phases: 1. Plasmatic imbibition (0-48 hrs) 2. Inosculation (2-5 days) 3. Revascularization (>5 days).
• 📌 Causes of graft failure (HIS BED): Hematoma, Infection, Seroma, Bad recipient Bed (poor vascularity), Excessive tension, Dependent position (shear).

⭐ Meshing an STSG (e.g., ratios 1:1.5 up to 1:9) significantly increases its surface area coverage and allows for drainage of fluid from beneath the graft, improving take on contaminated or exudative wounds.

Flap Fundamentals - Vascular Victories

Flap: Tissue unit transferred with its intrinsic blood supply; maintains viability.

• Vascular Patterns:
  • Random: Dermal-subdermal plexus.
  • Axial: Specific arterio-venous system (e.g., Pectoralis Major Myocutaneous - PMMC).
• Classification by Movement:
  • Local: Advancement, rotation, transposition.
  • Regional: Pedicled from nearby territory.
  • Distant (Free Flaps): Require microvascular anastomosis.
• Key Principle: Tension-free closure, adequate perfusion.
• 📌 Adequate Blood Supply Crucial (ABSC).

⭐ Most common free flap failure: Venous thrombosis (early post-op, <72 hrs).

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Workhorse Flaps - H&N Hit Parade

Key flaps for H&N reconstruction:

• PMMC (Pectoralis Major Myocutaneous):
  • Pedicled; thoracoacromial a.
  • Bulky, reliable. Oral cavity, pharynx.
• DP (Deltopectoral) Flap:
  • Pedicled; internal mammary a. perforators.
  • Thinner. Skin defects, fistula repair.
• LD (Latissimus Dorsi) Flap:
  • Pedicled/free; thoracodorsal a.
  • Large, versatile. Scalp, major defects.
• RFFF (Radial Forearm Free Flap):
  • Free; radial a.
  • Thin, pliable, sensate option. Oral lining.
• ALT (Anterolateral Thigh) Flap:
  • Free; lateral circumflex femoral a. (descending br.)
  • Versatile (skin/fascia/muscle). Large defects.
• FFF (Fibula Free Flap):
  • Free; peroneal a.
  • Osseocutaneous. Mandible reconstruction.

  ⭐ The Fibula Free Flap is preferred for mandible reconstruction due to its long bone stock (up to 25 cm), consistent anatomy, and ability to support dental implants. oka

• The Reconstructive Ladder (or Elevator) guides choices from direct closure to free flaps.
• "Like with like" principle is key for optimal tissue replacement and function.
• Vascular pedicle integrity is paramount for flap survival.
• Key flaps: PMMC (workhorse), RFFF (oral lining), ALT (versatile), Fibula (mandible).
• Aim for three-layer closure: internal lining, structural support, and external cover.
• Prioritize functional outcomes (speech, deglutition) and aesthetics.
• Immediate reconstruction is generally preferred for most major H&N defects.