1. Introduction
Plastic reconstructive surgery is used to restore functions of the human body that
have been impaired or completely lost as a result of deformities, trauma, tumor
resections, and other diseases.
The most common reason for plastic reconstructive procedures in the head and neck
region, especially in the upper aerodigestive tract, is the resection of malignant
tumors.
Dysfunction primarily caused by the tumors themselves is often further exacerbated by
tumor resection.
In general, complete organ resections such as glossectomy, complete palate resection,
laryngectomy, or transverse pharyngo-laryngectomy leave the most severe functional
deficits. These include disorders of oral and pharyngeal swallowing [1]
[2]
[3]
[4]
[5]
[6] with poor oral hygiene [5]
[6],
life-threatening aspiration [1]
[7]
[8]
[9]
[10]
[11],
and nasal regurgitation [12]
[13], as well as articulation disorders [1]
[6]
[8]
[14]
[15]
and disorders of vocal sound production [16]
[17]
[18]
[19]
[20]
[21].
However, even partial resections beyond a certain size can lead to persistent
disturbances of oropharyngolaryngeal functions. Severe swallowing problems, for
example, must be expected if more than 50% of a structure involved in the swallowing
act has to be resected [2]
[22]
[23]
[24].
Depending on the tumor location, different functions can be impaired in isolation or
in combination. Resections of the oral part of the tongue and the anterior floor of
the mouth primarily lead to disturbances of articulation and the preparatory phase
of the swallowing act [3]
[6]
[25]
[26]
[27]
[28].
Affected are bolus preparation, bolus lateralization and bolus retention [6]
[25].
In contrast, after partial losses of the base of the tongue, there is a decrease in
tongue thrust, resulting in changed pharyngeal propulsion [6]
[27].
Resections in the region of the soft palate and tonsil have similar negative
functional effects on bolus propulsion. Loss of substance in this region leads to
pressure leakage into the nasopharynx due to velopalatine insufficiency [12]
[13]
[27]
[29].
Resections of the suprahyoid floor of the mouth muscles destroy the anterior
suspension apparatus of the larynx and impede normal laryngeal elevation during the
pharyngeal swallowing phase [3]
[6]
[25]
[28]
[30]. The deficient or absent laryngeal movement
forward and upward inadequately opens the pharyngoesophageal sphincter and the lack
of “suction pressure” impedes the normal swallowing act [6]
[31].
Loss of substance in the larynx results in disruptions of the closure mechanisms of
the upper airway. These mechanisms exist in the form of “closure valves” at three
levels:
Resections in the region of these structures generally pose a risk of
life-threatening aspiration [3]
[23]
[25]
[32]
[33]. Furthermore, in most cases, the generation
of the primary vocal sound is impaired or completely lost.
Because of the serious functional disturbances described, there is an absolute
necessity to restore the anatomy or reconstruct lost tissue and organ parts after
extensive tumor resections in the upper aerodigestive tract. This has led to the
development of numerous reconstruction methods in the past, with autologous tissue
replacement usually being favored.
In the mid-1960s, it was the regional flaps, such as the deltoid [34], frontal [35], or temporalis [36] flaps, that
were used to close these defects. This required multisession surgical procedures
over many weeks.
Progress was made in the late 1970s with the development of myocutaneous island
flaps. The myocutaneous pectoralis major flap [5]
[37]
[38], the sternocleidomastoid flap [39] or the latissimus dorsi flap [40] made it possible for the first time to
restore the anatomy in the region of extensive defects with single-stage
reconstructions.
At the same time, there was a surge in the development of microvascular tissue
transplantation, which was first performed in humans as early as 1959 by Seidenberg
and colleagues [41].
Refinements in microsurgical instrumentation and improvements in vascular suturing
techniques resulted in the first clinical successes, which triggered focused
research into new donor sites.
In the years from 1979–1984, the iliac crest [42], forearm [43], humerus [44], scapula [45], and parascapular [46] grafts
were described.
Today, a large number of grafts with different tissue components from different donor
regions are available. In addition, recent developments in microsurgical transfer of
autologous tissue grafts supplied by single vascular arteries or perforator vessels
have entered clinical practice.
Due to this variety of reconstructive options, lost anatomical structures can be
optimally replaced, especially from a functional point of view. The use of different
tissues, the combination of different grafts and flaps, if necessary with preforming
of donor regions, nowadays allow reconstructions far beyond the extent of the mere
restoration of surface integrity. The type of reconstruction depends on the extent
of resection, localization, and the desired functional outcome, which is crucial for
the patient’s quality of life [3]
[4]
[8]
[10]
[47]
[48].
In order to make optimal use of the surgical options for the treatment of malignant
tumors in the head and neck region, which have developed enormously in recent
decades, a comprehensive, interdisciplinary therapy concept is the prerequisite for
oncological and functional success. In cooperation with surgeons, anesthesiologists,
radiologists, radiation therapists, speech therapists, etc., the therapeutic path
must be individually coordinated and determined accordingly.
The extent to which the necessary surgical measures have to be carried out on an
interdisciplinary basis depends, on the one hand, on the localization of the defects
in the head and neck region and, on the other hand, on the type of replacement
tissue required. In addition, our own specialist surgical options can be usefully
extended by close interdisciplinary cooperation in the interests of oncological and
functional outcomes. The most important cooperation partners of the ENT surgeons for
this are:
-
Maxillofacial surgeons (maxillary and mandibular reconstruction)
-
Plastic surgeons (graft harvesting, microvascular anastomoses)
-
Vascular surgeons (microvascular anastomoses, replacement of the carotid
artery)
-
Abdominal surgeons (jejunum graft)
-
Neurosurgeons
Basically, plastic reconstructive procedures in the head and neck region become
necessary after extensive resections of T3 and T4 tumors. They pursue 2 goals:
In order to fully meet these objectives, various general medical, social and, above
all, surgical parameters must be taken into account when selecting the
reconstruction method. The more demanding, the more complex, and the more
time-consuming the reconstruction is, the greater the requirements on the patient,
the therapy team and the aftercare:
General medical parameters: The general condition and age of the patient have a
primary effect on the postoperative complication rate. However, old age is not a
fundamental contraindication for these procedures. On the other hand,
alcohol-related diseases with reduced cardiac, pulmonary, and hepatic function limit
the indication considerably.
Social parameters: The patient’s compliance and social environment play a decisive
role in the choice of therapy. The following principle applies: The stronger the
patients’ motivation, the greater the understanding of their disease, and the better
their social environment, the more tolerated are costly reconstructions with often
protracted rehabilitation phases.
Surgical parameters: The most important surgical parameters include the location,
size, and shape of the defect. In addition, the reconstruction method is largely
determined by the type and volume of the tissue to be replaced. Also crucial for the
surgical procedure is whether it is a primary or secondary intervention and whether
surgery must be performed in an area that has already been irradiated.
The latter surgical parameters often require close interdisciplinary cooperation with
the above-mentioned surgical disciplines. Thus, the restoration of occlusion after
resections in the bony jaw including graft harvesting (fibula, iliac crest) must be
performed by colleagues from oral and maxillofacial surgery. Elevation of mucosal
grafts, such as jejunum or colon can only be performed by abdominal surgeons. In the
case of very complex multi-layered defects, the broad expertise of plastic surgery
in graft harvesting helps to implement the principle of “replacing tissue with equal
tissue”.
2. Head and neck squamous cell carcinoma (Lehnhardt, Puscz)
2. Head and neck squamous cell carcinoma (Lehnhardt, Puscz)
Head and neck squamous cell carcinomas (HNSCC) develop from the mucosa of the oral
cavity, pharynx, and larynx and are the most common malignancy in this location
[49]. In Germany, they rank
15th (women) as well as 7th (men) among the most common
tumor entities [50]. Regarding the mortality
rate, they were responsible for 1,479 (women), respectively 3,888 deaths (men) in
2019 [50]. The main risk factors are nicotine
as well as heavy alcohol consumption, but also poor oral hygiene. In addition, there
are strong associations with human papillomavirus (HPV) infections, especially the
subtype HPV-16. HNSCC are therefore now classified as HPV-associated and
non-HPV-associated [51], with HPV-associated
carcinomas tending to have a better prognosis for patients [52]. This is due to the mostly younger and
healthier patients who, unlike non-HPV-associated HNSCC, usually do not have
comorbidities from years of nicotine and/or alcohol abuse.
There are no general early symptoms that can indicate the presence of HNSCC. Rather,
any symptoms are based on the anatomical locations of their occurrence. For example,
chronic ulcers, dysphagia, dysphonia, respiratory obstruction, and even cranial
nerve deficits may indicate the presence of HNSCC. Furthermore, the symptoms that
are unspecific for all malignancies, such as unclear weight loss, pain and fatigue,
may occur.
When HNSCC is suspected, non-specific lymph node swelling should be looked for in
addition to the obligatory, detailed history. Furthermore, mirror examination or
flexible laryngoscopy is part of the diagnostic standard. Initial staging includes
panendoscopy with fine-needle or incisional biopsy to confirm the histopathologic
diagnosis and contrast-enhanced computed tomography of the head, neck, thorax, and
abdomen. In addition, sonographies and PET-CT scans can be performed.
The classification of these tumors is based on the current TNM or UICC systematics
and can be consulted in detail in the respective guidelines. The TNM or UICC
classification is also used to determine the therapy regime. This procedure should
always be discussed and determined in a multidisciplinary team, e. g., within the
framework of an interdisciplinary tumor conference.
In addition to surgical resection, which is the focus of this paper, radiotherapy and
systemic therapy are available. Early tumor stages can usually be treated curatively
by surgical or radiotherapeutic measures alone. In the case of advanced tumors or
non-curative treatment approaches, the focus is on radio- and systemic therapy.
3. Microsurgery (Lehnhardt, Puscz)
3. Microsurgery (Lehnhardt, Puscz)
Microsurgery, in the broadest sense, is a term for delicate surgical interventions on
very fine tissue structures that are used in numerous surgical disciplines. It is
characterized in particular by the fact that it enables various surgical
interventions on the smallest anatomical structures with the aid of very high
magnification optical vision aids. In addition to various magnifying glasses
systems, which usually allow magnification of up to 6x, special surgical microscopes
equipped with effective light sources are usually used as magnification instruments
for this purpose. On average, these achieve magnifications of between 6 and 40
times. In conjunction with special surgical instruments and very fine suture
materials, it is therefore possible to treat the smallest structures, e. g. the
union of arterial, venous or lymphatic systems by microvascular anastomoses in the
transplantation of tissues in reconstructive surgery.
The history of microsurgery has always been closely linked to the history of
microscopy. The invention of the first microscopes is attributed to Janssen in
Holland in 1590, and the description of a blood circuit by Harvey in 1628 and by
Hooke gave rise to scientific interest in microscopy. Antonie van Leeuwenhoek, who
built over 500 microscopes, first published a paper on his observations of
microorganisms under the microscope in 1678 [53]. Since Paré, who introduced ligation of injured vessels in 1552 in
addition to the method of conduction blockade by briefly squeezing nerves for wound
care that he propagated, the care of vascular injuries has consisted of ligation.
Lambert described as early as 1761 in his monograph entitled “A new technique of
treating an aneurysm” that Hallowell had not ligated an injured brachial artery in
1759, but reconstructed it by suturing. Between 1800 and 1900, thanks to the efforts
of Eck, Carrel, Czerny, and Guthrie, variations of vascular surgical connections
were described. The first end-to-end vascular anastomosis dates back to Jassinowski
in 1899. In addition to end-to-end or end-to-side anastomoses, interposition of
autologous vein grafts was subsequently established. The history of modern
microsurgery as it is understood today is generally associated with the first use of
a static monocular microscope for inspection of the ear by the Swedish
otolaryngologist Carl-Olof Siggesson Nylén (1892–1978). Nylén first used a tripod
microscope he had specially modified for surgical purposes in 1921 for
intraoperative inspection of the exposed endolymphatic tube in the semicircular
canal of the ear in a rabbit. His teacher Holmgren then used the microscope in
clinical use on a patient during the surgical treatment of otosclerosis in the same
year. Nylén had used a modified monocular Brinell-Leitz microscope for this purpose.
His colleague Gunnar Holmgren (1875–1954) developed a binocular microscope in 1923
and created the conditions for spatial vision during surgical dissection. However,
the use of such surgical microscopes and the clinical use of optical magnification
were initially reserved for a small circle of otologists and limited to a few
indications.
Ultimately, it was not until the early 1950s that the Carl Zeiss company initiated a
constructive development of the surgical microscope, which resulted in a fundamental
spread in various surgical fields. The prerequisite was a microscope body that could
be moved in practically all planes of space and allowed different magnification at
the same working distance. While initially a very bulky microscope body with limited
mobility and a small operating field as well as a limited depth of field limited the
possibilities, modern microscopes are now much lighter in construction. Appropriate
solid and movable mobile stands have resulted in practical applicability in various
operating rooms, which has contributed decisively to the triumph of microsurgical
technology in many surgical disciplines. An essential improvement was the
construction of a stereoscopic microscope with its own coaxial light source, which,
mounted on a sufficiently stable stand and with freely movable optics, as well as
continuously adjustable different magnifications at a constant working distance,
allows availability in different operating rooms and at various working distances
and anatomical localizations. Furthermore, fixed ceiling-mounted microscopes as well
as motor-driven adjustable objectives were added. Modern surgical microscopes are
easy to move or position due to ceiling installations. Cold light sources have
significantly improved the illumination of the microsurgical operating field. The
position of the microscope can be changed at will either with sterile hand grips or
via pedals. The head of the microscope can be tilted in any plane so that the
respective position can be adapted to the surgical field. The focus for the depth of
field allows a larger working field, and the magnification factors required
alternately during the various phases of surgery can be changed continuously during
the operation using, for example, foot switches between 6x and 40x magnification.
Today’s equipment also allows the assistant to observe the surgical procedure in the
same quality as the surgeon. In addition, image signals can of course be tapped and
projected, transmitted or recorded.
For the rapid development of microsurgery, in addition to general developments in the
surgical art of healing and the increasing clinical use of surgical microscopes, the
development and perfection of micro-instruments, micro-sutures and micro-needles
were subsequently decisive. The manufacture of fine micro-instruments, originally
derived from watchmaking and precision mechanics’ tools, as well as the
high-precision production of the thinnest suture materials with special atraumatic
micro-needles, led to an expansion and constant further development of
microsurgery.
As a result of permanent technical progress and the goal of handling and treating
ever finer structures, the limits of what is surgically possible have thus
consistently shifted toward the smaller. The clinical establishment of perforator
flap surgery, which will be discussed below, and the development of lymphatic
surgery are the main driving forces [54]
[55]. Regarding further technical innovations, a
new field has emerged in recent years with robotic-assisted microsurgery, which will
further influence and optimize microsurgery in the upcoming decades. For example,
although only two commercially available surgical robots are available for
microsurgery to date, initial clinical studies on perforator flap plasty [56] and lymphatic vessels [57] show promising results. In particular,
downscaling of the natural tremor allows to extend the limits of what is surgically
possible.
4. Frequently performed flaps in otorhinolaryngology (Lehnhardt, Puscz)
4. Frequently performed flaps in otorhinolaryngology (Lehnhardt, Puscz)
Due to the exploration of donor sites with axial vascularization, numerous grafts
with different tissue components are available today. In the head and neck region,
the forearm graft, the anterior thigh graft (ALT), and the free fibula graft are the
preferred choices.
In the following, these flap plastics will be discussed.
4.1 Radialis flap
The radialis flap is a fasciocutaneous flap that is particularly suitable for the
reconstruction or closure of smaller defects (up to approx. 8 x 16 cm). Since
the flap can even be folded, three-dimensional designs are also possible. The
flap is named after its main supplying vessel, the radial artery.
Preoperatively, it is therefore essential to check the blood supply to the donor
arm using the Allen test. However, even a positive test result is not an
absolute contraindication to harvesting, since the radial artery can be
reconstructed with a retrograde cephalic or saphenous vein graft. Osteocutaneous
variants of this graft have also been predescribed and are thus also suitable
for reconstruction of bony defects [58].
The donor arm is usually located on an arm table. An upper arm tourniquet can be
presented, but should not be used regularly for intraoperative perfusion
control. The radial border of the flap is usually the radial artery; ulnarward,
the flap may occupy up to two-thirds of the volar forearm. This also has the
advantage that the skin on the volar ulnar forearm is often less hairy. If a
tendon is to be integrated into the flap, the tendon of the palmaris longus
muscle can be integrated. The dissection usually starts from distal and goes
down to the fascia antebrachii, which is elevated as well. However,
peritendinous tissue should be left in place to avoid postoperative adhesions.
The radial artery and its accompanying vein are exposed and ligated. The flap is
then dissected proximally, and it is essential to pay attention to the dorsal
branch of the radial nerve, which passes through the brachioradialis muscle to
the distal forearm at this point. If the radial vein is weak in caliber, the
cephalic vein can also be integrated into the flap. This allows the flap to be
elevated to the proximal third of the forearm. The elevation defect must usually
be closed with split skin; primary closure is rarely possible. Postoperatively,
it should be noted that the hair growth on the flap plastic remains, so that
laser epilation may be necessary in the further course ([Fig. 1]).
Fig. 1 Surgical sketch of a radial artery flap on the right
forearm. (a) The flap plasty can be lifted along the marked flap axis
(marked in blue) and is located medial to the radial artery (RA). (b)
The flap (marked in blue) is placed below the fascia at the lateral edge
of the tendon of the flexor carpi radialis (FCR) muscle. PL, M. palmaris
longus; FDS, M. flexor digitorum superficialis; FCU, M. flexor carpi
ulnaris. (c) Cross-section of the right forearm with the plane of flap
elevation marked in blue. FPL, flexor pollicis longus muscle; FDP,
flexor digitorum profundus; BR, M. brachioradialis; UA, A. ulnaris.
Source: Beredjiklian PK et al. 2020. Hand Surgery, page 400. DOI:
10.1055/b-0040–177493.
4.2 Anterolateral thigh flap plasty (ALT)
The ALT flap plasty is one of the most widely used flap plasties in
reconstructive surgery. Due to its versatility, it has established itself as a
so-called “workhose flap” in many different anatomical regions as well as in
different specialties [59]. The initial
description of this flap was made in 1984 by Song and colleagues [60]. In the meantime, numerous anatomical
studies [61]
[62] and circumscribed surgical variants
[63]
[64] of the ALT exist, so that the surgical method is well
established.
The ALT is a fasciocutaneous perforator flap taken from the anterolateral thigh.
The arterial supply is provided by perforators from the descending branch of the
lateral circumflex femoral artery. These perforators can be marked
preoperatively by color-coded duplex sonography and are often located in the
middle third on an imaginary line from the anterior superior spina iliaca to the
lateral patellar rim ([Fig. 2]).
Fig. 2 Preoperative marking of the planned ALT harvesting point
togetherwith marked perforators and flap design.
Depending on the donor as well as the recipient region, flap sizes of up to 8 x
25 cm are possible. The perforators run either as septocutaneous perforators in
the intermuscular septum between the Mm. rectus femoris and vastus lateralis or
as musculocutaneous perforators through the M. vastus lateralis. Accompanying
the descending branch of the circumflex femoris lateralis artery are one or more
nerve muscular branches to the vastus lateralis arising from the femoral nerve.
Sensory innervation of the ALT flap is provided by branches of the lateral
cutaneus femoris nerve, which can be included in the flap plasty and coapt in
the recipient region if necessary. Elevation of the ALT flap plasty is usually
performed in the supine position. The flap plasty is first planned over the area
previously shown by Doppler sonography. A mostly straight incision is then made
at the medial edge of the flap plasty. After dissection onto the femoral fascia,
either an epifascial or subfascial dissection is performed laterally. The extent
to which the fascia is included in the flap plasty depends primarily on the
necessities at the recipient site. During the lateral preparation, the existing
perforators are identified and visualized. Depending on their location, the
necessary length of the vascular pedicle and the individual anatomical
conditions, the flap plasty can still be performed in the craniocaudal direction
at this point. In addition, as described above, the perforators necessary for
perfusion of the flap plasty are identified ([Fig. 3]).
Fig. 3 Intraoperative finding of an ALT flap plasty before
transection of the supplying perforators.
After cutting the superfluous perforators, the vascular pedicle is then traced
from peripheral to central. The preparation layer is always directly on the
vessel and never with a “safety distance”, because such a distance rather
increases the risk of injury to the pedicle. Dissection through the
intermuscular septum is usually straightforward, but in the case of
musculocutaneous perforators, dissection down to the descending branch may be
difficult and laborious. In this case, prior visualization of the descending
branch in the intermuscular septum under the rectus femoris muscle may be
helpful to more easily identify the anatomic relationships and confluence of the
perforator with the vascular axis. Care should be taken to spare the
accompanying nerves when dissecting the vascular pedicle centrally/proximally.
After complete isolation of the ALT flap plasty on the descending branch, it is
first ligated caudally and removed. If sufficient capillary bleeding from the
flap edge and timely recapillarization is observed after a “run-in” period of
several minutes, the flap plasty can be resected arterially and then venously
and transferred to the recipient site.
4.3 Free fibula graft
The free fibula graft is an osteofasciocutaneous flap plasty, which is
characterized in particular by its modularity, since it can be used both as a
pure bone transfer, but also as described above with skin island and muscle. It
was first described in 1975 by Taylor and colleagues [65], who, however, still applied a
posterior approach to elevate the graft. However, the lateral approach by
Gilbert [66], described a few years later,
has prevailed in clinical reality. Due to its elongated shape and high cortical
content, the fibula represents a good donor bone, e. g. for mandibular
reconstruction. The blood supply of the bone is provided by the homonymous
artery and vein (A./V. fibularis also: A./V. peronea). Preoperatively, however,
a CT-guided angiography of the donor leg should be performed to visualize any
vascular anomalies or supply patterns. Initially, the proximal and distal ends
of the fibula and the bone axis are marked. If a skin island is needed, it can
be drawn along the bone axis. However, it should be at least 5 cm away from the
distal fibular edge. If only the fibula is to be elevated, the incision is made
along the posterior fibular rim. The dissection extends to the fibula and the
bone is dissected. A small muscle cuff, a few millimeters wide, remains attached
to the bone. Once the proximal and distal osteotomy sites are marked, a
retractor is used to tightly encircle the bone. During osteotomy, be sure to
preserve the distal 6 cm to avoid instability in the upper ankle. In addition,
the proximal course of the peroneal nerve is marked on the fibula neck to spare
it. If the osteotomy is performed with an oscillating saw or a Giggly saw, Homan
hooks should be used to protect the soft tissues. Bone clips can be placed at
the superior and inferior ends of the flap to allow anterior and posterior
traction on the membrana interossea. The membrana interossea is transected, and
the fibular artery and associated veins are exposed. The distal portion of the
artery and veins are ligated and transected, and the flap can then be lifted
upward on the vascular pedicle and removed.
5. Reconstruction techniques (Remmert, Sack)
5. Reconstruction techniques (Remmert, Sack)
In the following, surgical methods for the restoration of anatomy and function are
presented for extensive defects in the ENT area, which are mainly performed in
interdisciplinary collaboration.
Different reconstruction methods are applied in the area of the following functional
units
-
Floor of the mouth
-
Tongue
-
Soft palate
-
Larynx and pharynx
and discussed, taking into account organ-specific anatomy and function.
Fig. 4 Minimal elevation defect after removal of an ALT flap plasty at
the left thigh.
5.1 Defects of the floor of the mouth and neighboring structures
Cross-organ tumors of the floor of the mouth (T4) grow primarily into the
external tongue muscles or break into the mandibular bone ([Fig. 5]).
Fig. 5 Reconstruction of a defect after resection of a T4 tumor of
the floor of the mouth with a neuromuscular muscle fascia flap and a
forearm graft. Resection size of a T4 tumor of the floor of the mouth in
red. Source: Remmert S. Expertise Funktionelle Wiederherstellung der
oberen Luft- und Speisewege. Stuttgart : Thieme; 2015.
DOI:10.1055/b-005-143303.
Tumors of the floor of the mouth infiltrating the tongue muslces
If the tongue body is involved, the tongue volume is replaced with an
infrahyoid muscle fascia flap ([Fig.
6] and [Fig. 7a]).
Reconstruction of the floor of the mouth and tongue mucosa is performed with
a forearm graft ([Fig. 7b]). By
forming a fold between the inferior side of the tongue and the new floor of
the mouth, the mobility of the tip of the tongue is preserved ([Fig. 7c]).
Fig. 6 Anatomy of the infrahyoid muscle group and the
infrahyoid muscle fascia flap. a Infrahyoid muscle group.
b Neurovascular infrahyoid muscle fascia flap. Source:
Remmert S. Expertise Funktionelle Wiederherstellung der oberen Luft-
und Speisewege. Stuttgart : Thieme; 2015.
DOI:10.1055/b-005-143303.
Fig. 7 Reconstruction of a defect after resection of a T4
tumor of the floor of the mouth with a neuromuscular muscle fascia
flap and a forearm graft. a Neurovascular infrahyoid muscle
fascia flap for reconstruction of the tongue volume. b
Forearm graft for reconstruction of the tongue mucosa. c
Shaping of the fold and the floor of the mouth. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
Tumors of the floor of the mouth infiltrating the mandible
It is not uncommon for T4 oral tumors to infiltrate the mandible. In these
cases, the planning and execution of the surgery must be performed in an
interdisciplinary manner together with the oral and maxillofacial surgeons.
Usually, reconstruction of the mandible is performed in one step with tumor
resection and soft tissue reconstruction. Alternatively, however, a
two-stage procedure is also possible for the reconstruction of the mandible.
In this case, the bone defect is bridged with a reconstruction plate and
only the soft tissue defect is treated in the first step. Because of the
better functional and cosmetic results and the lower complication rates, a
single-stage procedure is to be favored.
In particular, if the chin region of the mandible is lost during tumor
resection, primary bone reconstruction is the method of choice, since as a
result of “soft tissue load” or muscle traction, allogeneic material
regularly perforates the soft tissues. This results in scarring retraction
of the soft tissues, which makes subsequent reconstruction considerably more
difficult.
In the single-stage procedure, the floor of the mouth is first detached
caudally from the hyoid bone and the mandibular bone is dissected
bilaterally at a safety margin from the tumor ([Fig. 8a]). Afterwards, the now mobile
tumor conglomerate can be clearly removed from the oral cavity with a
security margin to the tongue ([Fig.
8b]).
Fig. 8 Tumor resection of a T4 tumor of the floor of the mouth
infiltrating the mandible. a T4 tumor of the floor of the
mouth after dissection of the mandible. b Situation after
complete tumor resection [78].
Source: Remmert S. Expertise Funktionelle Wiederherstellung der
oberen Luft- und Speisewege. Stuttgart : Thieme; 2015.
DOI:10.1055/b-005-143303.
The oral and maxillofacial surgeons reshape the fibula graft with the skin
island according to the tumor resectate ([Fig. 9a] and [Fig. 9b])
and perform the osteosynthetic reconstruction. The skin area from the lower
leg harvested with the fibula ideally replaces the soft tissues of the floor
of the mouth and the gingiva ([Fig.
9c]).
Fig. 9 Reconstruction of the mandible and the floor of the
mouth (case as in [fig. 7])
with a fibula graft. a Fibula graft with skin island and
tumor resection specimen. b Fibula graft after bone
transformation. c Reconstruction of the mandible, the floor
of the mouth, and the gingiva [78]. Source: Remmert S. Expertise Funktionelle
Wiederherstellung der oberen Luft- und Speisewege. Stuttgart :
Thieme; 2015. DOI:10.1055/b-005-143303.
Tumors of the floor of the mouth infiltrating the mandible and breaking
through the skin
The reconstructive measures are even more extensive if the carcinoma breaks
through the skin to the outside ([Fig.
10a]). As in the previous case, the reconstruction of the floor of
the mouth, the gingiva and the mandible is performed by a fibula graft with
skin island ([Fig. 10b]).
Fig. 10 Reconstruction after resection of a T4 tumor of the
floor of the mouth breaking through the skin to the outside.
a T4 tumor of the floor of the mouth breaking through the
skin. b Reconstruction of the floor of the mouth, the
gingiva, and the mandible with a fibula graft with skin island.
c Lateral upper arm graft at the still intact vascular
pedicle. d One year after reconstruction with fibula and
upper arm grafts. e In the area of the gingiva, incorporated
skin island of the thigh one year after reconstruction [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
For contouring the outer soft tissues of the chin, a large-area, voluminous
graft is required. The lateral humeral graft offers these properties very
well ([Fig. 10c]). Because of the use
of two grafts – one fibula and one humeral graft – twice the number of
vascular anastomoses is necessarily required. In addition, the larynx must
be brought into a position that is favorable from the point of view of
swallowing physiology. For this purpose, it is fixed to the reconstructed
mandible by means of wire sutures. In this way, a forward and upward
movement corresponding to the laryngeal elevation is achieved. With this
high level of reconstructive effort, acceptable functional and cosmetic
results can be achieved even with extensive tumors ([Fig. 10d] and [Fig. 10e]).
5.2 Defects of the floor of the mouth and neighboring structures
The choice of the reconstruction method must take into account the anatomical
structure of the tongue and the specific functions of the organ. The following
reconstruction parameters are of crucial importance:
-
Preservation or restoration of a buccoalveolar or glossoalveolar
sulcus.
These folds are an important prerequisite for the mobility of the
neo-tongue and for a dental prosthetic restoration.
-
Contact of the neo tongue with the palate
Only contact between the tongue and the palate enables bolus transport
and bolus retention.
-
Reduction of oral cavity dead space
The reduction of the dead space is achieved by restoring the volume of
the tongue.
-
Avoiding atrophy and scarring.
Due to the mainly muscular defect, the restoration of an adequate tongue volume
to reduce the oral cavity dead space should be performed with innervated muscles
as far as possible. In the form of the infrahyoid muscle flap (IHL), a
myofascial flap with a constant vascular-nerve pedicle is available, which can
be harvested in the immediate vicinity of the defect via the usual neck
dissection approach [67]
[68].
Forearm grafts are particularly suitable for mucosal replacement, for the shaping
of a glossoalveolar sulcus and for reconstruction of the neighboring regions
(lateral oropharyngeal wall, soft palate, floor of the mouth) if local flap
plasty does not allow functionally adequate closure of the defect. Compared with
jejunal grafts, they offer the advantages of higher resistance to mechanical
stress, lower morbidity graft harvesting, and possible resensitization by
micronerve suturing between the antebrachial cutaneous nerve and the lingual
nerve.
Defects of the mandible in combination with tongue defects are preferably
reconstructed primarily osseously (donor region: fibula, iliac crest or scapula)
in interdisciplinary cooperation with maxillofacial surgeons.
Tumors of the oral tongue without infiltration of neighboring
structures
In case of loss of the complete oral tongue, reconstruction is performed by
transposition of an infrahyoid muscle flap (IHL) from both sides in
combination with a forearm graft. In this procedure, the muscle flaps are
transposed into the oral cavity at the posterior border of the mylohyoid
muscle, attached to the muscles of the base of the tongue and to each other
in the midline by suturing. A forearm graft is placed to cover the
transposed muscle flaps and sutured to the mucosa of the residual tongue and
the mucosa of the alveolar ridge ([Fig.
11a–f]). Although sprouting of sensitive nerve fibers from the
periphery into the graft occurs regularly, a nerve anastomosis between the
lingual nerve and a sensitive graft nerve can improve the quality of tactile
sensation.
Fig. 11 Reconstruction of the complete oral tongue. a
Preparation of the infrahyoid muscle fascia flaps. b
Transposition of the muscle flaps at the posterior edge of the
mylohyoid muscle into the oral cavity. c Fixation of the
muscle flaps in the midline and at the tongue base by sutures.
d Placing and suturing of the forearm graft with the
mucosa of the remaining tongue as well as the mucosa of the alveolar
crest. e Placing and suturing of the forearm graft with the
mucosa of the remaining tongue as well as the mucosa of the alveolar
crest. f 12 months after surgery. (1=remaining tongue,
2=neurovascular infrahyoid muscle fascia flap, 3=forearm graft)
[78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
Tumors of the base of the tongue without infiltration of neighboring
structures
In complete resection of the base of the tongue, the loss of both lingual
arteries means that the oral portion of the tongue is no longer supplied
with blood. This tumor-free, functionally important tongue remnant can be
reperfused and preserved by interposition of a vein segment between the
arterial stumps of one side. Residual motor function can be expected by
protection of individual fibers of the hypoglossal nerve. The base of the
tongue is reconstructed by transposition of an IHL from both sides in
combination with a forearm graft. In this procedure, the muscle flaps are
fixed to the muscles of the oral tongue remnant and to each other in the
midline by suturing. For stable traction of the new tongue base over the
laryngeal inlet, the upper belly of the omohyoideus muscle is rotated 90°
into the tonsillar bed and sutured. This provides secure protection of the
laryngeal inlet to prevent aspiration. A forearm graft is placed to cover
the transposed muscle flaps and sutured to the mucosa of the residual tongue
and the lateral oropharyngeal walls ([Fig.
12a–g]).
Fig. 12 Reconstruction of the complete tongue base. a
Reconstruction of the lingual artery with vein interposition.
b Reconstruction of the lingual artery with vein
interposition. c Transfer of the muscle flap. d 90°
rotation of the upper belly of the omohyoid muscle into the
tonsillar beds on both sides. e Reconstruction of the mucosa
with a forearm graft. f Reconstruction of the mucosa with a
forearm graft. g 12 months after surgery. The remaining oral
tongue reveals a discrete volume loss. (1=vein interposition for
reconstruction of the lingual artery, 2=tumor-free residual tongue,
3=neurovascular infrahyoid muscle flap, 4=upper belly of the
omohyoid muscle, 5=forearm graft) [78]. Source: Remmert S. Expertise Funktionelle
Wiederherstellung der oberen Luft- und Speisewege. Stuttgart :
Thieme; 2015. DOI:10.1055/b-005-143303.
Tumors of the base of the tongue infiltrating neighboring
structures
Base of tongue defects may be combined with tissue loss in the soft palate,
lateral oropharyngeal wall, supraglottis, or mandible. If the lateral
oropharyngeal wall is involved, the forearm graft for the mucosal
replacement of the tongue base must be planned and shaped accordingly larger
([Fig. 13]). These additional
graft portions are sutured into the oropharyngeal wall or palatal area. If
the mandible is involved, the maxillofacial surgeon also removes and models
a vascularized bone graft and interposes it in the defect. Reconstructions
are always performed from the inside out. After resection of the tumor, the
base of the tongue is first filled with an IHL and the mucosa of the base of
the tongue and the soft palate are reconstructed with a forearm graft. The
reconstructive measures are completed by interposition of the bone graft by
means of osteosynthesis. Even 18 months after surgery and postoperative
radiotherapy, no significant graft shrinkage occurs. The reconstructed soft
palate retains its functionally important flexibility and volume ([Fig. 14a–f]).
Fig. 13 Forearm graft for reconstruction of the tongue base
and the soft palate. The dotted line shows the axes around which the
graft has to be rotated (arrows). 1=tongue base, 2=soft palate [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
Fig. 14 Reconstruction of the complete tongue base, the soft
palate, and the mandible. a Resection defect. b Soft
tissue and bone resectate. c Shape of the forearm graft.
d Forearm graft sutured into the palate and tongue base
defect. e Osteosynthesis of a fibula graft. f 18
months after surgery [78].
Source: Remmert S. Expertise Funktionelle Wiederherstellung der
oberen Luft- und Speisewege. Stuttgart : Thieme; 2015.
DOI:10.1055/b-005-143303.
Tumors of the oral tongue and base of the tongue without infiltration of
neighboring structures
In a complete glossectomy, the tongue is reconstructed by transposition of an
IHL from both sides, in combination with a forearm graft. In this procedure,
the muscle flaps are fixed to each other in the midline and to the
pre-epiglottic tissue with sutures. For a stable traction harness of the new
tongue base over the laryngeal inlet, the upper belly of the omohyoideus
muscle is rotated 90° into the tonsillar bed and sutured in place. A forearm
graft is placed to cover the transposed muscle flaps and sutured to the
mucosa of the gingiva as well as the lateral oropharyngeal walls. The
vascular pedicle is guided into the vascular sheath at the posterior margin
of the mylohyoid muscle ([Fig.
15a–g]).
Fig. 15 Reconstruction after complete glossectomy without
involvement of neighboring structures. a Transposition of the
infrahyoid muscle fascia flap (schematic illustration). b
Fixation of the muscle flaps in the midline and at the
pre-epiglottic tissue. c Construction of the muscular tongue
body. d Tension belting of the new tongue base. e
Reconstruction of the tongue mucosa. f Reconstruction of the
tongue mucosa and the cover folds. g 18 months after surgery.
(1=epiglottis, 2=neurovascular infrahyoid muscle fascia flap, 3=ansa
cervicalis, 4=upper belly of the omohyoid muscle, 5=forearm graft,
6=vascular pedicle, 7=mylohyoid muscle) [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
The aim of restoring a normal tongue base and oral tongue volume with
formation of a tongue tip as well as a glossoalveolar sulcus is to ensure
laryngeal protection and the possibility of closing the isthmus faucium. In
addition, the reconstruction must allow passive mobility of the neo tongue
for contact with the palate and with the anterior dentition. This passive
mobility is achieved by contraction of functional residual muscles in the
floor of the mouth and pharynx. Motor innervation of the transposed muscles
should prevent atrophy in the long term.
Tumors of the oral tongue and base of the tongue infiltrating neighboring
structures
Complete glossectomies may be associated with tissue loss in the floor of the
mouth and gingiva with or without mandibular involvement, defects in the
supraglottic region, and defects in the lateral oropharyngeal wall.
Reconstruction of a functional glossoalveolar sulcus is performed in cases of
major loss of the floor of the mouth and gingiva with an exposed mandible
using the forearm graft necessary to replace the mucosa of the resected
tongue. If the lateral oropharyngeal wall is involved, the forearm graft can
be planned, harvested and sutured similar to [Fig. 16].
Fig. 16 Planning of a forearm graft for reconstruction of
tongue base, the oral tongue, and the soft palate. (1=soft palate,
2=tongue base, 3=oral tongue) [78]. Source: Remmert S. Expertise Funktionelle
Wiederherstellung der oberen Luft- und Speisewege. Stuttgart :
Thieme; 2015. DOI:10.1055/b-005-143303.
In cases of mandibular involvement, a bone graft is harvested, sculpted and
interposed into the defect. In this case, a skin island for reconstruction
of the gingiva should also be included in the graft harvest. By separately
replacing the lingual mucosa (forearm graft) and the gingiva (skin island of
the bone graft), a glossoalveolar sulcus can be shaped ([Fig. 17a–c]).
Fig. 17 Reconstruction after complete glossectomy and partial
resection of the mandible. a Defect after tumor resection.
b Osteosynthesis of fibula graft and shaping of the
glosso-alveolar sulcus after reconstruction of the tongue with
neurovascular infrahyoid muscle fascia flaps on both sides and with
forearm graft. c 24 months after surgery. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
If transposition of the IHL is not possible after previous surgery and/or
after radiation, a combined graft (latissimus dorsi and scapular graft) can
be used on a vascular pedicle to reconstruct the complete tongue and lateral
oropharyngeal wall.
The skin island of the latissimus dorsi graft should be incised 1–2 cm larger
than the underlying muscle. This muscle-free skin area is nourished by
diffusion and is a prerequisite for shaping the tongue body and a
glossoalveolar sulcus. Resection of Burow triangles at the skin level allows
the tip of the tongue and the floor of the mouth to be sculpted.
The cutaneous scapular graft is used to build up the oropharyngeal wall
([Fig. 18a–d]).
Fig. 18 Reconstruction after complete glossectomy and partial
resection of the palate (recurrence surgery). a Combination
of myocutaneous latissimus dorsi graft and cutaneous scapula graft
at a common vascular pedicle. b Reshaping of a latissimus
dorsi graft to a tongue (schematic illustration). c
Construction of the soft palate and the tongue. d 12 months
after surgery. (1=scapula graft, 2=latissimus dorsi graft,
3=vascular pedicle, 4=motor nerve of the latissimus dorsi muscle,
5=soft palate (scapula graft), 6=tongue with floor of the mouth
(latissimus dorsi muscle graft) [78]. Source: Remmert S. Expertise Funktionelle
Wiederherstellung der oberen Luft- und Speisewege. Stuttgart :
Thieme; 2015. DOI:10.1055/b-005-143303.
5.3 Defects of the soft palate
To restore the anatomy as well as the function of the soft palate, the following
reconstruction parameters must be included in the planning of the reconstruction
method:
-
Adequate volume replacement for the soft palate
-
Ensure dorsal closure of the oral cavity as a prerequisite for bolus
retention.
-
Flexibility and mobility of the reconstructed palate to the
nasopharyngeal end.
Tumors of the palate without infiltration of neighboring
structures
For complete palatal defects, the forearm graft is the tissue of choice [69]
[70]
[71]
[72]. This graft fully meets the
required reconstruction parameters mentioned at the beginning. To avoid
scarring due to secondary epithelialization in these resections as well, the
graft should be folded. In this way, the back of the palate can also be
reconstructed primarily with epithelium. In this case, the planning of the
shape and size of the graft must take into account that the folding must be
performed longitudinally around the vascular pedicle. Folding transversely
to the vascular pedicle kinks it and highly jeopardizes the blood supply,
especially venous drainage ([Fig.
19]).
Fig. 19 Graft planning for the reconstruction of the complete
soft palate. When folding the graft (arrows), the course of the
vascular pedicle must be observed [78]. Source: Remmert S. Expertise Funktionelle
Wiederherstellung der oberen Luft- und Speisewege. Stuttgart :
Thieme; 2015. DOI:10.1055/b-005-143303.
Incorporation of the graft into the defect is usually performed transorally.
First, the skin for the posterior palatal surface must be fixed to the upper
defect margin with single button sutures. Successive posterior sutures
follow along the lateral and medial margins of the defect. After folding the
graft, the sutures of the palatal anterior wall can be easily placed.
Threads can also be placed as an alternative for suturing the posterior
surface of the palate. [Fig. 20a–d]
show this procedure after laser surgical complete palate resection without
reconstruction due to squamous cell carcinoma. In order to correct the
velopharyngeal insufficiency with all resulting functional losses, the soft
palate was secondarily reconstructed. [Fig.
20d] demonstrates the postoperative result with a very good
palatal volume with high flexibility and functionality. Approximately 60% of
the normal pressure is built up from the tongue thrust behind the
reconstructed velum with a downward pressure gradient [72].
Fig. 20 Situation after laser surgical resection of the
complete soft palate. a Without reconstruction with
velopalatine insufficiency and permanent swallowing disorders. The
arrows show the useless scar plate. b Pre-positioned threads
for fixation of the graft skin on the posterior surface of the
palate. c Forearm graft for secondary reconstruction of the
palate. The skin is folded around the longitudinal axis of the
vascular pedicle to form the anterior and posterior surfaces of the
palate. d Folded forearm graft placed into the defect.
e One year after secondary reconstruction of the palate
with a forearm graft [78].
Source: Remmert S. Expertise Funktionelle Wiederherstellung der
oberen Luft- und Speisewege. Stuttgart : Thieme; 2015.
DOI:10.1055/b-005-143303.
Since secondary reconstructions are usually not followed by post-irradiation,
more or less disturbing hairiness of the graft may occur ([Fig. 20e]).
After irradiation, this phenomenon is not seen because the skin appendages
are destroyed. In contrast, the volume and flexibility and thus the
functionality remain almost unaffected ([Fig. 21]).
Fig. 21 Reconstruction of the complete soft palate with a
forearm graft. Situation 2 years after surgery and irradiation. The
volume is insignificantly reduced with functional loss [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
Tumors of the palate infiltrating neighboring structures
Most commonly, carcinomas of the soft palate infiltrate the tonsillar bed and
pharyngeal walls. In rarer cases, all oropharyngeal walls are
carcinoma-infiltrated in addition to the soft palate. Then a so-called
circular oropharyngeal defect develops as a result of the resection ([Fig. 22a]). The forearm graft is also
most suitable for this situation due to its excellent formability. A graft
of approximately 14 cm length for the lower oropharyngeal circumference and
approximately 5–6 cm width for the height of the soft palate must be
planned. Since the epipharyngeal circumference is considerably smaller, the
upper graft margin is shortened accordingly ([Fig. 22b]). Then, first a tube of 2–3
cm length with the epithelium facing inward for the later mucosal
replacement of the oropharynx is formed. Then, the free, unsutured graft
corners are folded back and sutured together in the middle. This results in
an epithelialized palatal anterior surface. Modeling is performed on the
still intact vascular pedicle on the forearm ([Fig. 22c]). After dissection of the
vessels, the remodeled graft is sutured into the defect ([Fig. 22d]). It retains its shape even
after postoperative irradiation and ensures a sufficient velopalatine
closure function without nasal regurgitation and without rhinophonia aperta
([Fig. 22e]).
Fig. 22 Circular oropharyngeal defect after resection of a T4
carcinoma of the palate. a Defect. b Graft shaping.
c Graft shaping at the intact vascular pedicle in the
forearm area. The injection syringe serves as placeholder for
forming the epipharyngeal circumeference. d Implementation of
the pre-shaped graft into the defect. e Situation 2 years
after surgery and irradiation [78]. Source: Remmert S. Expertise Funktionelle
Wiederherstellung der oberen Luft- und Speisewege. Stuttgart :
Thieme; 2015. DOI:10.1055/b-005-143303.
In the case of bony involvement, the mandibular angle is usually affected by
carcinoma infiltration. With sufficient safety margin, the bone must be
resected en bloc with the soft tissue tumor. The tongue base volume is built
up with an IHL. The reconstruction of the tongue base mucosa, the lateral
oropharyngeal wall, the tonsillar bed as well as the soft palate is
performed with a forearm graft. The reconstructive measures are completed by
osteosynthetic restoration of mandibular continuity with a vascularized bone
graft. The cosmetic result 15 months after surgery shows a symmetrical
mandibular contour ([Fig.
23a–e]).
Fig. 23 Reconstruction after carcinoma of the palate
infiltrating the tonsils, the lateral oropharyngeal wall, the tongue
base, and the mandibular angle (T4). a Tumor resectate.
b Resection defect. c Soft part reconstruction
with neurovascular infrahyoid muscle fascia flaps and forearm graft.
d Mandibular reconstruction with fibula graft. e
Cosmetic outcome 2 years after surgery. (1=defect of the tongue
base, 2=defect of the tonsillar bed, 3=defect of the lateral
oropharyngeal wall, 4=epiglottis, 5=defect of the mandible) [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
5.4 Defects of the larynx and pharynx
After extensive partial resections in the setting of T3 and T4 tumors, the goals
and nature of reconstructive measures and the duration of postoperative
rehabilitation differ from those after complete organ loss.
Reconstructions after partial laryngeal resections are complicated and complex.
They are intended to restore phonation and the separating function of the larynx
for an aspiration-free swallowing act and are necessary when at least one
arytenoid cartilage has been resected or defects in the thyroid or cricoid
cartilage threaten the stability of the laryngeal framework. The return of
function, especially an aspiration-free swallowing, usually requires a lengthy
training process of weeks to months and a high compliance of the patient.
Reconstruction methods after laryngectomy without resections of neighboring
structures (pharynx, base of tongue) are focused exclusively on the generation
of the primary voice sound. All methods of surgical voice rehabilitation are
“voice shunts”. They eliminate the separation of the respiratory and digestive
pathways, potentially creating the risk of aspiration. The rehabilitation period
of a few days to weeks until the return of phonation is usually short.
Tumors of the larynx infiltrating neighboring structures
(pharynx)
In advanced tumors of the larynx and pharynx, transverse laryngopharyngectomy
continues to be part of the therapeutic options. Especially in younger
patients, modern reconstructive options can be used to achieve a significant
improvement in quality of life within a short rehabilitation period.
The reconstructive measures are focused on swallowing and voice
rehabilitation. Both goals can be achieved very well with a combination of a
forearm graft and a voice prosthesis.
After transverse laryngopharyngectomy, a voice prosthesis is placed at the
level of the tracheostoma. The prosthesis should be positioned below the
pharyngeal defect to be reconstructed in the tumor-free esophageal anterior
wall ([Fig. 24a]).
Fig. 24 Transverse laryngopharyngectomy, reconstruction with
forearm graft and voice prosthesis. a Placing of the voice
prosthesis (arrow). b Reconstruction of the pharyngeal tube,
before vertical suture. c Reconstruction of the pharyngeal
tube, after vertical suture. d Postoperative examination with
contrast enhancement after reconstruction with a forearm graft. The
red dotted line shows the neopharynx. (1=neopharynx,
2=circular-horizontal vascular pedicle, 3=trachea) [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
A forearm graft is then used to restore the continuity of the esophageal
pathway. For a wide pharyngeal tube, an 8–10 cm x 5–6 cm graft must be
elevated and sutured transversely between the oropharynx and the esophageal
inlet. Closure to form a tube is achieved by single button sutures in a
vertical direction. Thereby, the vascular pedicle pulls in a
circular-horizontal course around the neopharynx. With the given graft
dimensions, a sufficiently wide digestive pathway can be reconstructed. The
excess of circumference for the anastomosis with the esophagus should not be
reduced or only to a very limited extent in order to prevent stenosis ([Fig. 24a–d]).
Another suitable graft for reconstruction of the alimentary tract is the
jejunum graft. It offers an almost unlimited graft length, is a mucosal
graft and tubular ([Fig. 25a]).
Taking advantage of these characteristics, an extra-long jejunum segment can
be used to reconstruct the cervical esophageal pathway with simultaneous
creation of a vocal shunt [73]. After
transverse laryngopharyngectomy, the esophageal pathway is interrupted from
the base of the tongue to the esophageal inlet. In contrast to classic
laryngectomy, 1–2 cartilage rings are preserved above the tracheostoma as a
tracheal chimney. To accommodate the oropharyngeal circumference, the aboral
end of the jejunal graft must be incised longitudinally opposite the
mesenteric fat. This ensures that the vascular supply is maintained and a
funnel-shaped anastomosis with the oropharyngeal mucosa is possible. This is
performed with single button sutures penetrating through all wall layers of
the graft. A second continuous suture between the small intestinal serosa
and the oropharyngeal muscles completes the oral anastomosis.
Fig. 25 Transverse laryngopharyngectomy, reconstruction of the
pharyngeal tube and construction of a voice shunt with jejunum
graft. a Oversized jejunum graft with thread marking of the
aboral edge. b Resection defect. c Longitudinal
incision of the aboral intestinal end and funnel-shaped anastomosis
with the oropharyngeal mucosa. d End-to-side anastomosis with
the esophageal entrance after 180° turn and incision of the jejunum
graft. e Biventer reins. f Neopharynx and voice shunt
(schematic picture). g Neopharynx and voice shunt.
(1=esophagus entrance, 2=tracheal tube, 3=base of tongue,
4=prevertebral fascia, 5=neopharynx, 6=voice shunt) [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
Under pretension, the jejunal tube is then fixed downward on the prevertebral
fascia with sutures and turned 180° at the level of the esophageal entrance
(caudal hypopharyngeal resection margin). At the point of kinking, the
bilayer anastomosis with the esophageal inlet is performed after transverse
incision of the intestinal tube. The now upward directed intestine is again
turned by 180° below the floor of the mouth and led downward to the tracheal
chimney via a biventer reins. There, the anastomosis of the oral bowel end
with the tracheal chimney completes the reconstruction. The peristalsis and
thus the mucus transport are directed from the trachea to the neopharynx
([Fig. 26a–g]).
Fig. 26 Reconstruction after hypopharynx-larynx carcinoma with
simultaneous secondary carcinoma of the esophagus. a Tumor
location (red dots). b Transverse laryngopharyngectomy with
esophageal resection and reconstruction planning. c
Transverse laryngopharyngectomy with esophageal resection
(intraoperative image). d Preparation of the ascending colon
with terminal ileum. e After incision of the cecum,
end-to-side anastomosis with the oropharynx. f Anastomosis of
the ileum and the trachea. g Reconstructed esophagus, voice
shunt, and neoglottis. h Ileo-cecal valve as neoglottis.
(1=colon ascendens, 2=ileum, 3=reconstruction of the esophagus with
ascending colon, 4=reconstruction of the voice shunt with terminal
ileum, 5=ileo-cecal valve as neoglottis) [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
Patients usually start oral food intake 10 days after surgery and speech
training after 14 days. During expiration, the airflow is directed into the
neohypopharynx via the voice shunt by closing the tracheostoma. Oscillations
of the system result in the formation of a primary voice sound. Patients are
able to speak comparably quickly, as after fitting with a voice
prosthesis.
Secondary carcinomas occur in approximately 20% of cases of laryngeal and
pharyngeal carcinomas [74]. If this
second carcinoma is localized in the esophagus and diagnosed simultaneously
with laryngeal-pharyngeal carcinoma, young patients with a desire for
surgery may be offered highly complex interdisciplinary surgery in
individual cases [75]
[76]
[77].
The larynx, the pharynx and the complete esophagus are resected
transcervically and transabdominally. The reconstruction of the esophageal
pathway is performed with the ascending colon pedicled at the dextra colic
artery, and the construction of the vocal shunt is performed with the
laterally descending terminal ileum. Since the blood supply via the colic
dextra artery is insufficient to supply the small bowel segment,
microvascular anastomoses of the ileal artery and vein must be performed
with appropriate neck vessels. The ascending colon is rotated 180° and
caudally anastomosed end-to-end with the stomach. After passing through the
thorax into the neck and making an incision in the cecum, an end-to-end
anastomosis with the oropharyngeal walls is performed. The connection of the
ileum to the trachea completes the construction of the voice shunt. In this
process, the ileocecal valve (Bauhini) functions as a neoglottis for
phonation and as a closure valve for aspiration prophylaxis ([Fig. 26a–h]).
It is in these complex cases and the need for the associated restoration of
function that the potential of interdisciplinary collaboration becomes
particularly apparent.
The impact of the lack of interdisciplinary collaboration on postoperative
function and quality of life is illustrated by the following case after
glossectomy and partial mandibular resection.
In the initial surgery, a complete glossectomy and resection of the bony chin
were performed due to a T4 carcinoma. The intraoral soft tissue defect was
closed with a pectoralis major flap without reconstruction of the mandible.
The patient was unable to swallow for six years and could not speak
intelligibly.
Due to the missing mandible, the soft tissues of the chin had no support and
fell down. This resulted in complete oral closure insufficiency. The loss of
anterior suspension to the mandible (via the floor of the mouth muscles),
resulted in displacement of the larynx into the swallowing pathway toward
the spine ([Fig. 27a]). In addition,
laryngeal elevation during the swallowing cycle was impossible. The oral
cavity showed an atrophic pectoralis major flap ([Fig. 27b]). Closure of the oral cavity
to the soft palate and thus bolus retention as well as bolus transport were
impossible.
Fig. 27 Secondary reconstruction after complete glossectomy,
partial mandibular resection and reconstruction with pectoralis
major flap. a Preoperative analysis: functional loss (1, 2,
and 3) and deficient esthetic outcome. b Preoperative
analysis: atrophic pectoralis major flap as tongue replacement.
c Reconstruction: pelvic crest graft with abdominal
internal obliquus muscle. d Reconstruction: pelvic crest
graft with abdominal internal obliquus muscle after shaping.
e Reconstruction: Restoration of the mandibular
continuity and construction of new floor of the mouth. f
Reconstruction: preparation of the neurovascular infrahyoid muscle
fascia flaps. g Outcome: neotongue after augmentation with
neurovascular infrahyoid muscle fascia flap. h Outcome:
sufficient closure of the mouth, physiological position of the
larynx, no feeding tube, and normal esthetics. (1=insufficient
closure of the mouth due to missing mandibular support, 2=tracheal
obstruction of the swallowing pathway due to missing laryngeal
suspension, 3=permanent feeding tube) [78]. Source: Remmert S.
Expertise Funktionelle Wiederherstellung der oberen Luft- und
Speisewege. Stuttgart : Thieme; 2015. DOI:10.1055/b-005-143303.
Mandibular continuity was restored with a composite osteomyocutaneous iliac
crest graft. V-shaped excisions were used to match the bone to the shape of
the chin. The obliquus internus abdominis muscle associated with the graft
replaced the floor of the mouth. Two IHLs were placed between this new
diaphragma oris and the atrophic pectoralis major flap, creating sufficient
volume of neo tongue to serve as a punch for bolus transport and as a
closure to the soft palate.
Laryngeal elevation with fixation to the reconstructed bony chin placed the
larynx in a physiologic swallowing position.
Reconstruction resulted in esthetic and functional rehabilitation with oral
food intake and intelligible articulation ([Fig. 27a-h]).
With modern reconstruction procedures, the anatomy as well as the specific
functions can be restored after partial and complete organ losses.
Especially for the quality of life, it is crucial that therapy planning,
surgical implementation and aftercare are carried out in an
interdisciplinary manner, particularly in the case of complex defects.
