Color Atlas of Head and Neck Surgery: A Step-by-Step Guide 3030298086, 9783030298081

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Siba P. Dubey Charles P. Molumi Herwig Swoboda Editors

Color Atlas of Head and Neck Surgery

A Step-by-Step Guide Second Edition

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Color Atlas of Head and Neck Surgery

Siba P. Dubey  •  Charles P. Molumi Herwig Swoboda Editors

Color Atlas of Head and Neck Surgery A Step-by-Step Guide Second Edition

Editors Siba P. Dubey Department of Otolaryngology School of Medicine and Health Sciences University of Papua New Guinea Port Moresby, National Capital District Papua New Guinea

Charles P. Molumi Department of Otolaryngology Port Moresby General Hospital Port Moresby, National Capital District Papua New Guinea

Port Moresby General Hospital Port Moresby, National Capital District Papua New Guinea Herwig Swoboda Department of Otorhinolaryngology - Head and Neck Surgery General Hospital Hietzing with Neurological Center Rosenhügel Vienna, Austria

© Springer International Publishing Switzerland 2015 First Edition ISBN 978-3-030-29808-1    ISBN 978-3-030-29809-8 (eBook) https://doi.org/10.1007/978-3-030-29809-8 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Every day we learn from our patients; this book is dedicated to them.

Foreword 1

The first edition of the Color Atlas of Head and Neck Surgery: A Step-by-Step Guide was published in 2015. The two authors Dr Siba P. Dubey and Dr Charles P. Molumi have presented their vast experience on surgical procedures in head and neck arena. The positive response to the first edition was overwhelming. The second edition is based on the concept of the first edition; the presentation of head and neck surgical procedures with essential step-by-step approach is followed by clear illustrations. The structure of the chapter based on anatomical regions has been retained; this allows easy access to any surgeon who needs a quick reference before carrying out an operation the next day. In the second edition, there are 20 chapters in total, in contrast to the 10 chapters in the first edition. Less common procedures are replaced by more appropriate ones. Many of the chapters are new such as laser, robot surgery, and surgery for sleep apnea. Many reconstruction procedures are combined into chapters on axial flaps and free flaps, and these reconstruction options are essential procedures for contemporary head and neck surgeons. For the chapter on lip and facial defects, the authors have presented many reconstructive options for small to very large defects of the lip. Some are very challenging defects. I am particularly impressed by the chapter on skull base presenting so well, making a complicated operation appear simple. The photographs throughout the second edition are crystal clear and very well labeled. The excellently illustrated surgical anatomy has greatly aided the understanding of each surgical procedure. This reflects the vast experience of the three editors and other contributors from the advanced setups. The wide range of operations in this book is useful for trainees, residents, registrars, fellows, consultants, and even the professors. Dr Dubey, Dr Molumi, and Dr Swoboda must be congratulated on their efforts in composing this second edition Color Atlas of Head and Neck Surgery: A step-by-step guide, which in my opinion should be on the book shelf of all surgeons who perform head and neck operations in both developed countries and in a hospital away from major institutions in developing country. Hong Kong, SAR, China August, 2019

William Ignace Wei, MS, FRCS, FRCSE, FRACS (HON.), FACS (HON.)

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Foreword 2

At the beginning of this millennium, oncology is undergoing great changes and innovations, I refer in particular to the development of precision medicine which allows treatments to be tailored to the molecular and genomic characteristics of each tumor and of the individual patient and to immunotherapy, which has favorably modified the natural history of many cancers, especially breast, liver, melanomas, etc. With regard to head and neck cancers, epidemiological data show an increasing incidence of tongue cancers in young people and of HPV-related oropharyngeal tumors. These data, together with the ever more in-depth knowledge on carcinogenesis, natural history of cancers, and the daily multidisciplinary working method have strongly contributed to the improvement of results achieved by the different therapeutic modalities. In the field of surgery, the development of new HD and 3D devices to improve the vision of the operative field, of innovative cutting tools, and the new laser- and robotic-assisted surgical technologies must be emphasized. Due to this extraordinary and rapid development, the cultural baggage acquired during the degree in medicine and surgery and post-graduation courses becomes obsolete in a few years. It is therefore essential that not only the young specialists, but also the experienced surgeons participate in continuous and personalized training and updating initiatives. Prof Siba P. Dubey and Dr Charles P. Molumi in the first edition of Color Atlas of Head and Neck Surgery: A Step-by-Step Guide took this need into account by offering surgeons the information to properly perform the different surgical procedures, through an original presentation rigorous and of simple and practical consultation. In this second edition, the Editors (Prof Dubey, Dr Molumi, and Prof Herwig Swoboda) have expanded the topics by addressing more surgical techniques, including surgery of parapharyngeal space, of orbital region, neck dissections, and pediatric surgery, expanding the chapters dedicated to reconstructive surgery and incorporating the new laser- and robot-­ assisted technologies. In addition, they have added further value to the “Atlas” by involving several surgeons experienced in different pathologies and technologies, maintaining the original “step-by-step” approach, giving space to the discussion of potential problems related to individual techniques and providing simple and effective guidelines to solve them. This is certainly a valuable guide for each surgeon—young and/or experienced—to improve their surgical technique through “a useful handbook for daily consultation.” I am confident that all those who designed and contributed to this Atlas will be rewarded for their effort by the success it deserves. Milan, Italy August 2019

Fausto Chiesa, MD

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Preface to the Second Edition

In view of the encouraging response to the first edition, we decided to produce an expanded second edition. From ten chapters in the first edition, there are 20 chapters in the second, including separate chapters on Neck Dissections, Excision of Parapharyngeal Tumors, Skull Base Surgery, Pediatric Head and Neck Surgery, Microvascular Reconstruction, Laser and Robot Surgeries, Rhinoplasty, Orbital Surgery, Maxillofacial Surgery, and Surgery of Sleep Apnea. In preparing the second edition, the editors and authors want to achieve a balance between the theoretical and practical knowledge required in performing a surgical procedure. This edition highlights the basic points a surgeon must have in mind before starting the surgical procedure, namely, the operative steps, potential problems, and suggested solutions. A few appropriate references to operative procedure are also included. We felt that a multi-authored book with contributions from experts with in-depth knowledge of the surgical procedure from different institutions around the world will best deliver that practical knowledge to the reader. These contributors were requested to follow the same philosophy of the first edition A Step-by-Step Guide with the help of “live color photographs.” It has been the intention of the editors to incorporate those surgical specialties which converge in the surgical management of head and neck pathologies, namely, Otolaryngology, Head and Neck Surgery, Surgical Oncology, Maxillofacial, Plastic and Thoracic Surgery. Contributions from these specialties provide important insights into the overall management of patients affected by these pathologies. We very much appreciate the valuable advices from Prof Eugene N. Myers, Pittsburgh, USA. Editors are extremely grateful to Prof William Ignace Wei, MS, FRCS, FRCSE, FRACS (Hon.), FACS (Hon.), Emeritus Professor in Surgery, The University of Hong Kong, and currently Director, Li Shu Pui ENT Head & Neck Surgery Centre, Hong Kong Sanatorium & Hospital, Hong Kong SAR, China, and Dr Fausto Chiesa, MD, Emeritus Director, Head and Neck Programme, European Institute of Oncology, Milan, Italy, for writing the “Forewords” for the second edition. Deep appreciation is due to the Rector, Medical University of Vienna, Vienna, Austria, for awarding the first editor the Visiting Professorship and kindly allowing Prof Dubey to use the academic facilities of his Institution to complete this edition. We also appreciate the help of Ms Dilli George, Librarian, School of Medicine and Health Science, who expertly took care of the bibliography. We acknowledge the help of Dr Noah Tapaua, the Cardiothoracic Surgeon, Port Moresby General Hospital, who helped us with his professional expertise in a few operative procedures. We are also grateful for the help of Mr Veali Vauna, the IT expert at the Port Moresby General Hospital. This book would not have been published without the help of Springer Nature, Milan, Italy, and Mr Dhanapal Palanisamy, Springer Nature, and Ms Vinodhini Subramaniam, Project Manager, SPi Global, Chennai, India. Port Moresby, Papua New Guinea Port Moresby, Papua New Guinea  Vienna, Austria 

Siba P. Dubey Charles P. Molumi Herwig Swoboda xi

Contents

1 Axial Flaps�������������������������������������������������������������������������������������������������������������������   1 2 External Nasal Defects Repair�����������������������������������������������������������������������������������  69 3 Free Flap in Head and Neck Reconstruction����������������������������������������������������������� 103 4 Harvesting of Free Grafts for Head and Neck Surgery������������������������������������������� 161 5 Laser Microsurgery for Glottic Cancer ������������������������������������������������������������������� 175 6 Lips and Facial Defects Repair ��������������������������������������������������������������������������������� 187 7 Maxillofacial Surgery������������������������������������������������������������������������������������������������� 241 8 Neck Dissections ��������������������������������������������������������������������������������������������������������� 311 9 Nose and Paranasal Sinuses Surgery ����������������������������������������������������������������������� 343 10 Orbital Surgery����������������������������������������������������������������������������������������������������������� 393 11 Parapharyngeal Space and Upper Lateral Neck Tumor Surgery ������������������������� 421 12 Pediatric Head and Neck Surgery����������������������������������������������������������������������������� 431 13 Robot Surgery������������������������������������������������������������������������������������������������������������� 449 14 Surgery of Salivary Glands ��������������������������������������������������������������������������������������� 461 15 Skull Base Surgery����������������������������������������������������������������������������������������������������� 485 16 Surgery for Benign Laryngotracheal Conditions ��������������������������������������������������� 539 17 Surgery of Miscellaneous Cervicothoracic Pathology��������������������������������������������� 559 18 Surgery for Laryngeal Malignancy��������������������������������������������������������������������������� 569 19 Surgery of Thyroid Gland ����������������������������������������������������������������������������������������� 615 20 Surgery for Obstructive Sleep Apnea Syndrome����������������������������������������������������� 627 Index������������������������������������������������������������������������������������������������������������������������������������� 647

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Contributors

Mohssen  Ansarin Department of Head and Neck Surgery and Otorhinolaryngology, European Institute of Oncology, Milan, Italy Augusto  Cattaneo Department of Head and Neck Surgery and Otorhinolaryngology, European Institute of Oncology, Milan, Italy Francesco Chu  Department of Head and Neck Surgery and Otorhinolaryngology, European Institute of Oncology, Milan, Italy M. Costales  Hospital Universitario de Asturias, Oviedo, Spain Siba  P.  Dubey Department of Otolaryngology, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, National Capital District, Papua New Guinea Port Moresby General Hospital, Port Moresby, National Capital District, Papua New Guinea Josef  Freudenthaler Division of Orthodontics, University Clinic of Dentistry, Medical University of Vienna, Vienna, Austria Phillip  Huyett Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Florian  Katauczek Department of Oral and Maxillofacial Surgery, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria José Luis Llorente Pendas  Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain F. López  Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain Nicholas  McIvor Clinical ORL Department, Auckland City Hospital, Support Building, Level 7, Park Road, Grafton, Auckland, New Zealand Konstantinos Mitsimponas  James Cook University Hospital, Middlesbrough, UK Charles  P.  Molumi Department of Otolaryngology, Port Moresby General Hospital, Port Moresby, National Capital District, Papua New Guinea Emeka Nkenke  Department of Oral and Maxillofacial Surgery, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria Christos  Perisanidis Department of Oral and Maxillofacial Surgery, National and Kapodistrian University of Athens, Athens, Greece Stefano  Sellari-Franceschini Depart of Otolaryngology—Head and Neck Surgery, University of Pisa, Pisa, Italy Ryan  J.  Soose Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

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xvi

C.  Suarez University of Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain Herwig  Swoboda Department of Otorhinolaryngology  - Head and Neck Surgery, General Hospital Hietzing with Neurological Center Rosenhügel, Vienna, Austria Eleftherios Vairaktaris  Medical School, University of Cyprus, Nikosia, Cyprus Konstantin Zauza  Division of Conservative Dentistry and Periodontology, University Clinic of Dentistry, Medical University of Vienna, Vienna, Austria

Contributors

1

Axial Flaps

1.1

Deltopectoral Flap

Siba P. Dubey and Charles P. Molumi

1.1.1 Operative Steps 1. The deltopectoral flap is designed in rectangular shape in the upper thorax extending from the sternum to the anterior deltoid region. The base of the flap is situated parasternally 2 c m from the sternal edge. The superior boundary follows the clavicle, and the inferior boundary is parallel to the previous line over the third or fourth intercostal space. The flap extends horizontally beyond the deltopectoral groove onto the deltoid region, to an extent depending on the needed length to reach the defect, and ends in a curvilinear distal end. Shrinkage of approximately 10% over time should be taken into account when designing the skin island (Fig. 1.1). 2. The skin incision is performed over the deltoid muscle, and flap elevation is started in the lateral aspect, deep to the deltoid and pectoral major muscle fascia. The incision is made deep to the deltoid fascia at the deltoid region and deep to the pectoral fascia at the chest. The flap is raised from distal to the base. The plane of dissection lies between the deltoid muscle and the deltoid fascia including the latter in the flap. The flap elevation is

continued past the deltopectoral groove between the deltoid and the pectoralis major muscle (Fig. 1.2). 3. The elevation of the flap is stopped at least 2 cm lateral to the sternal margin in order to protect the intercostal vessels supplying to the skin paddle (Fig. 1.3). 4. In cases where the flap is to be tubed, the adequate flap length is ensured so that it reaches the defect without tension (Fig. 1.4). 5. The flap is sutured first in place and the pedicle is tubed. The donor site defect is covered with a split-thickness skin graft (Fig. 1.5). 6. The flap pedicle is kept for at least 3 weeks until neovascularization of the recipient site occurred. In the second stage, the pedicle of the flap is divided and returned into place or cut and discarded. The deltopectoral flap achieves usually a very good postoperative result, providing tissue with a reasonable color match (Fig. 1.6). 7. Reconstruction with deltopectoral flap can be done in one stage. A tunnel is created into the neck to pass the flap through it (Fig. 1.7), and the donor site is dealt as above. 8. The area of the flap to be in the tunnel to be de-­ epithelialized is marked with the scalpel (in Fig. 1.7) and the flap is de-epithelialized (Fig. 1.8). 9. The flap is tubed to repair the pharynx following pharyngolaryngectomy (Figs. 1.9 and 1.10). 10. Excision of carcinoma of lip and adjoining cheek, and its repair with deltopectoral flap (arrow) (Fig. 1.11).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_1

1

2

1  Axial Flaps

1.1

Elevated deltopectoral flap

Pectoralis major muscle

Deltoid muscle

1.2

1.1 Deltopectoral Flap

3

Cheek defect

Elevated deltopectoral flap

Deltopectoral groove

1.3

1.4

4

1  Axial Flaps

1.5

Recipient area

Donor area

1.6

1.1 Deltopectoral Flap

5

Part of flap under tunnel

1.7

De-epithelialized part of flap

1.8

6

1  Axial Flaps

Epithelium lined tube with deltopectoral flap

1.9

Anastomosis of deltopectoral flap tube

1.10

1.1 Deltopectoral Flap

7

1.11

8

1  Axial Flaps

1.1.2 Potential Problems

References to Operative Procedure

1. Flap necrosis 2. Detachment of flap from donor site when tubed

1. Bakamjian VY (1965) A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plastic Reconstr Surg 36:173–184 2. Chaffoo AK, Goode RL (1988) How I do it: modification of the deltopectoral flap for pharyngoesophageal reconstruction. Laryngoscope 98:460–462 3. Kingdom TT, Singer MI (1996) Enhanced reliability and renewed applications of the deltopectoral flap in head and neck reconstruction. Laryngoscope 106:1230–1233 4. Andrews BT, McCulloch TM, Funk GF, Graham SM, Hoffman HT (2006) Deltopectoral flap revisited in the microvascular era: a single-institution 10-year experience. Ann Otol Rhinol Laryngol 115:35–40

1.1.3 Suggested Solutions 1. Always perform “distal-to-proximal” flap harvesting to protect the vascular pedicle. Take care not to injure perforating intercostal arteries to the skin paddle. Avoid excessive use of monopolar cautery during flap elevation. Do no extend the flap too far beyond the deltopectoral groove and on to the shoulder. Care should be taken not to injure small perforating vessels to the skin paddle during de-epithelialization. 2. Ensure that the length of the flap is not under tension. Place strong silk sutures at the base of the flap to anchor the flap to the skin to prevent holding the weight of the flap.

1.2 Facial Artery Musculomucosal Flap

1.2

Facial Artery Musculomucosal Flap

Siba P. Dubey and Charles P. Molumi

1.2.1 Operative Steps 1. The airway is secured by nasal intubation. With the patient in supine position and the head extended, the face and head are prepared. The flap lies obliquely from the retromolar trigone to the level of the ipsilateral labial sulcus (Fig. 1.12). The anterior incision lies 1 cm posterior to the oral commissure. The orifice of the parotid duct marks the posterior limit of the flap (Fig. 1.12). The width of the flap is 1.5–2  cm and is well anterior to Stenson’s duct. The maximum length of the flap is 8–9 cm. 2. When incising the anterior border of the flap, the superior labial artery is identified (Fig. 1.13). It is ligated and by following its proximal course, the facial artery is identified. 3. The flap is elevated in the layer underneath the facial artery including the overlying buccinators muscle and a

9

small portion of the orbicularis oris muscle close to the oral commissure. The buccopharyngeal fascia represents the dissection plane. The inferior labial artery is identified and ligated (Fig. 1.14). 4. Dissection is continued underneath the fascia to the neck over the mandible. The flap is completely mobilized from the neck with the facial artery and vein in view (Fig. 1.15). 5. The flap is mobilized to the neck with its vascular pedicle (Fig. 1.16). 6. The mandibular division of the facial nerve which runs over the facial artery is dissected and preserved. The flap with its vascular pedicle is passed under the nerve (Fig. 1.17). 7. With artery forceps, a tunnel is created communicating the floor of mouth and neck (Fig. 1.18). 8. The flap is mobilized to the oral cavity (Fig. 1.19). 9. The donor area and the defect are closed with interrupted sutures (Fig. 1.20). 10. The flap 6 weeks after operation (Fig. 1.21).

10

1  Axial Flaps

Partially elevated FAMM flap

Upper lip

1.12

1.13

1.2 Facial Artery Musculomucosal Flap

11

1.14

1.15

12

1  Axial Flaps

FAMM flap

Sternocleidomastoid muscle

Vascular pedicle of facial artery and vein

Mandibular branch of facial nerve

1.16

1.17

1.2 Facial Artery Musculomucosal Flap

13

1.18

1.19

14

1  Axial Flaps

1.20

FAMM flap donor area

FAMM flap recipient area 1.21

1.2 Facial Artery Musculomucosal Flap

1.2.2 Potential Problems 1 . Avoid the Stenson’s duct during closure of the donor area. 2. Pedicle of the flap might cross over molar teeth.

1.2.3 Suggested Solutions 1. Bigger donor area is skin grafted to avoid tension or kinking of the Stenson’s duct during direct suturing. 2. A bite-block is used temporarily. 3. Nasogastric tube insertion and temporary tracheostomy may be necessary in the immediate postoperative period. 4. Submental abscess, cheek hematoma, if happens, is dealt accordingly in the postoperative period. References to Operative Procedure 1. Pribaz J, Stephans W, Crespo L, Gifford G (1992) A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 90:421–429

15

2. Joshi A, Rajendraprasad JS, Shetty K (2005) Reconstruction of intraoral defects using facial artery musculomucosal flap. Br J Plast Surg 58:1061–1066 3. Massarelli O, Gobbi R, Raho MT, Tullio A (2008) Three-­ dimensional primary reconstruction of anterior mouth floor and vertical tongue using “trilobed” buccinators myomucosal island flap. Int J Oral Maxillofac Surg 37:917–922 4. Ayad T, Kolb F, De Mones E, Mamelle G, Temam S (2008) Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation. Head Neck 30:437–445 5. Massarelli O, Baj A, Gobbi R, Soma D, Marelli S, De Riu G, Tullio A, Gianni AB (2013) Cheek mucosa: a versatile donor site of myomucosal flap. Technical and functional consideration. Head Neck 35:109–117

16

1.3

1  Axial Flaps

Latissimus Dorsi Myocutaneous Flap

Siba P. Dubey and Charles P. Molumi

1.3.1 Operative Steps 1. The patient is placed in a lateral decubitus position. The head and neck are carefully supported to prevent impingement of the brachial plexus by the clavicle. The contralateral axilla is padded and ipsilateral arm is supported in abducted position. An interrupted line, which roughly demarcates the anterior edge of the latissimus dorsi muscle, is drawn along from the midpoint of the axilla to a point between the anterior and posterior superior iliac spine of the iliac crest. The flap is marked out on the skin just posterior to this line (Fig. 1.22). 2. The skin is incised along the anterior marked edge of the skin paddle and extended superiorly to the axilla and inferiorly to the iliac crest. The incision is extended to the fascia over the latissimus dorsi muscle and the whole length of the latissimus dorsi muscle is delineated (Fig. 1.23). 3. The anterior edge of the latissimus dorsi muscle is elevated and separated from the serratus anterior muscle. The serratus anterior branches of the thoracodorsal artery and vein lying on the superficial surface of the serratus anterior are identified (Fig.  1.24). Blunt ­dissection is continued toward the axilla and the thoracodorsal artery and its accompanying venae commitantes are identified.

4. The inferior portion of the flap is dissected to the desired muscle length both cephalically and medially along the vertebral column. The medial aspect of the skin island is harvested (Fig. 1.25). 5. The latissimus dorsi muscle is cut at the caudal and posterior ends. The dissection is continued toward the axilla. The thoracodorsal artery is identified and kept within the flap (Fig. 1.26). 6. The angular artery branching off the thoracodorsal artery is identified and the dissection is proceeded toward the tip of the scapula. The vessels to serratus anterior are clearly visualized (Fig. 1.27). 7. A subcutaneous tunnel is created in the subplatysmal plane above the clavicle connecting with the axillary tunnel. The axillary tunnel is created above the pectoralis major muscle. A large clamp is introduced from the supraclavicular incision and advanced to the axilla. The flap is being mobilized into the axillary tunnel (Fig. 1.28). 8. The flap is gently taken to the defect in the neck (Fig. 1.29). The flap can be mobilized further when extra length is required by ligating the serratus anterior branches of the thoracoacromial artery and by skeletonizing or transecting the tendinous insertion of the latissimus dorsi muscle to the humerus. 9. The flap is used to close the defect in the neck (Fig. 1.30). The donor site is closed with interrupted sutures (Fig. 1.31). 10. The appearance of donor and recipient sites 3  weeks postoperatively (Fig. 1.32).

1.3 Latissimus Dorsi Myocutaneous Flap

Inferior angle of scapula

17 Midaxillary line

Flap area

Outline of iliac crest

1.22

Latissimus dorsi muscle

1.23

18

1  Axial Flaps

Axilla

Branches of thoracodorsal vessels

Serratus anterior muscle

Latissimus dorsi muscle

1.24

Axilla

Skin paddle

Vertebral column

Latissimus dorsi muscle

1.25

1.3 Latissimus Dorsi Myocutaneous Flap

19 Axilla

Latissimus dorsi muscle

Posterior end of flap

Caudal end of flap

1.26

Under surface of flap

Thoracodorsal vessels

Vessels to serratus anterior muscle Angular vessels

1.27

20

1  Axial Flaps

Flap grasped by forceps through tunnel

Axilla

Latissimus dorsi myocutaneous flap

1.28

Latissimus dorsi myocutaneous flap in neck

1.29

1.3 Latissimus Dorsi Myocutaneous Flap

21

1.30

1.31

22

1  Axial Flaps

Flap in neck

Donor site

1.32

1.3 Latissimus Dorsi Myocutaneous Flap

1.3.2 Potential Problems 1 . Difficulty identifying the vascular pedicle 2. Shearing of skin pedicle from the muscle 3. Venous congestion and loss of skin pedicle 4. Loss of pedicle length 5. Flap failure 6. Difficulty closing donor site 7. Brachial plexus injury

23

7. During the pedicle dissection, a thin cuff of tissue around the pedicle should be preserved. Fatty loose tissue around the pedicle provides a cushion effect and helps to identify twisting of the pedicle. 8. Skin paddle shall not be designed too far anteriorly beyond the latissimus dorsi muscle; anterior extension shall be limited to a maximum of 2 cm. Skin paddle shall not be designed above the tip of the scapula. References to Operative Procedure

1.3.3 Suggested Solutions 1. The insertion of the vascular pedicle is approximately 12  cm inferior from the insertion of the muscle to the humerus. 2. Always remember to use anchorage sutures between the edges of skin paddle to the muscle to prevent shearing off the muscle. 3. When the flap is tunneled to the neck above the pectoralis major muscle, there is loss of length of the pedicle. When more pedicle length is needed, tunnel the flap between the pectoralis major and minor muscle (interpectoral tunnel). Skeletonizing or transecting the tendinous insertion of the latissimus dorsi muscle to the humerus allows complete mobilization of the flap. 4. Always mark the skin pedicle as fusiform shape to assist better closure. 5. The commonest cause of flap failure is kinking of the pedicle or compression of the pedicle in its transition from the tunnel to the neck. 6. During the procedure, do not hyperabduct the arm so as to avoid brachial plexus injury.

1. Quillen CG, Shearin JC Jr, Georgiade NG (1978) Use of the latissimus dorsi myocutaneous island flap for reconstruction in the head and neck: case report. Plast Reconstr Surg 62:113–117 2. Schuller DE (1982) Latissimus dorsi myocutaneous flap for massive facial defects. Arch Otolaryngol 108:414–417 3. Logan AM, Black MJM (1985) Injury to the brachial plexus resulting from shoulder positioning during latissimus dorsi flap pedicle dissection. Br J Plast Surg 38:380–382 4. Hayashi A, Maruyama Y (1991) Subclavicular approach in head and neck reconstruction with the latissimus dorsi musculocutaneous flap. Br J Plast Surg 44:71–74 5. Haughey BH, Fredrickson JM (1991) The latissimus dorsi donor site: current use in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 117:1129–1143 6. Hayden RE, Kirby SD, Deschler DG (2000) Technical modifications of the latissimus dorsi pedicled flap to increase versatility and viability. Laryngoscope 110: 352–357 7. Ong HS, Ji T, Zhang CP (2014) The pedicled latissimus dorsi myocutaneous flap in head and neck reconstruction. Oral Maxillofac Surg Clin N Am 26:427–434

24

1.4

1  Axial Flaps

Inferiorly Based Nasolabial Flap

Siba P. Dubey and Charles P. Molumi

1.4.1 Operative Steps 1. The medial incision exactly follows the nasolabial fold in upper two-thirds and 3–4 mm medial to the fold in the lower third. The base of the flap is 1.5–2.0 cm wide. The cranial end of the flap can extend as high as within 0.75 cm anterior to the medial canthus. The inferior limit of the flap is at the level of ipsilateral angle of mouth. The skin incision is begun superiorly around the flap design and incision carried deep to the dermis. The angu-

lar artery is ligated as the incision is extended deeper. The dissection is continued inferiorly in a plane above the muscles and nerves toward the base of the flap (Fig. 1.33). 2. The incision is made in the buccinators muscle bed and a transbuccal tunnel is created through the oral mucosa for transfer of the flap to the oral cavity. The tunnel should accommodate 1–2 fingers (1.5–2.0  cm). The skin along the inferior 1.5 cm of the flap is de-epithelialized in order to allow for single-stage closure of the skin (Fig. 1.34). 3. The gingivolabial defect is closed with the nasolabial flap (Fig. 1.35). 4. The donor site along the nasolabial grove is undermined and closed in layers (Fig.  1.36). The patient previously underwent transmandibular approach.

1.4 Inferiorly Based Nasolabial Flap

25

1.33

1.34

26

1  Axial Flaps

1.35

1.36

1.4 Inferiorly Based Nasolabial Flap

27

1.4.2 Potential Problems

References to Operative Procedure

1. The tip of the flap necrosis when the perforating vessels are disrupted. 2. Too narrow tunnel compromises the vascular supply of the flap. 3. Interference of the flap from the opposing dentition. 4. Depressed scar in the nasolabial fold. 5. Long-term visible fullness lateral to the angle of mouth in two-stage procedure.

1. Georgiade NG, Mladick RA, Thorne FL (1969) The nasolabial tunnel flap. Plast Reconstr Surg 43:463–466 2. Hagan WE (1986) Nasolabial musculocutaneous flap in reconstruction of oral defect. Laryngoscope 96: 840–845 3. Hagan WE, Walker LB (1988) The nasolabial musculocutaneous flap: clinical and anatomical correlations. Laryngoscope 98:341–346 4. Ducic Y, Buryne M (2000) Nasolabial flap reconstruction of oral defects: a report of 18 cases. J Oral Maxillofac Surg 58:1104–1108 5. Lazaridis N, Tilaveridis I, Karakasis D (2008) Superiorly or inferiorly bases “island” nasolabial flap for buccal mucosa defects reconstruction. J Oral Maxillofac Surg 66:7–15 6. Ioannides C, Fossion E (1991) Nasolabial flap for the reconstruction of defects of the floor of the mouth. Int J Oral Maxillofac Surg 20:40–43 7. Lazaridis N, Zouloumis L, Venetis G, Karakasis D (1998) The inferiorly and superiorly based nasolabial flap for the reconstruction of moderate-sized oronasal defects. J Oral Maxillofac Surg 56:1255–1259, discussion 1260 8. Maurer P, Eckert AW, Schubert J (2002) Functional rehabilitation following resection of the floor of the mouth: the nasolabial flap revisited. J Craniomaxillofac Surg 30:369–372

1.4.3 Suggested Solutions 1. To prevent tip necrosis, the inferior width of the flap should be about 2.0 cm in order to keep the perforating vessels intact. 2. Always anticipate that the width of the tunnel will narrow significantly with postoperative edema and compromise the flap vascular supply. Create the tunnel wide enough to allow free passage of the flap into the oral cavity. 3. Care should be taken to minimize trauma to the flap from opposing dentition or a block-bite is used to protect the flap. 4. Minimal inversion at the time of closure of the donor site to avoid depressed scar at nasolabial flap. 5. To remove all transbuccal component of the flap and not just divide it, flush with cheek tissue in the oral cavity to avoid long-term fullness.

28

1.5

1  Axial Flaps

Superiorly Based Nasolabial Flap

Siba P. Dubey and Charles P. Molumi

1.5.1 Operative Steps 1. The determined width and length of the flap are marked out with the medial incision in nasolabial groove, and tip of the incision narrows down to a point (Fig. 1.37).

2. The flap is elevated from the tip toward the base. The incision is made deep to the dermis and the flap is elevated in a plane superficial to the muscles. The surrounding area is undermined to improve the rotation of the flap without causing tension (Fig. 1.38). 3. The flap is rotated to the defect and one to two deep sutures are placed along the base of the flap to recreate the groove. The rest of the flap is used to close the defect. The nasolabial incision is closed (Fig. 1.39).

1.5 Superiorly Based Nasolabial Flap

29

1.37

1.38

30

1  Axial Flaps

1.39

1.5 Superiorly Based Nasolabial Flap

31

1.5.2 Potential Problems

References to Operative Procedure

1. Creation of dog ear at the tip of the donor site during closure. 2. Scaring and visible evidence of surgery. 3. Vascular supply disruption leading to flap necrosis.

1. Georgiade NG, Mladick RA, Thorne FL (1969) The nasolabial tunnel flap. Plast Reconstr Surg 43:463–466 2. Hagan WE, Walker LB (1988) The nasolabial musculocutaneous flap: clinical and anatomical correlations. Laryngoscope 98:341–346 3. Lazaridis N, Tilaveridis I, Karakasis D (2008) Superiorly or inferiorly based “islanded” nasolabial flap for buccal mucosa defects reconstruction. J Oral Maxillofac Surg 66:7––15 4. Takeda A, Akimoto M, Park K, Kounoike N, Shimakura Y, Nemoto M, Uchinuma E (2014) Single-stage reconstruction of a full-thickness alar defect using a folded nasolabial flap combined with a redundant skin turnover flap. J Craniofac Surg 25:2144––2146 5. Bi H, Xing X, Li J (2014) Nasolabial-alar crease: a natural line to facilitate transposition of the nasolabial flap for lower nasal reconstruction. Ann Plast Surg 73:520–524

1.5.3 Suggested Solutions 1. Design the flap so that the inferior tip of the flap narrows down to a point which allows for closure of the donor site without undermining thereby avoiding creation of a dog ear. 2. Design the flap so that the medial incision falls on the nasolabial groove. The scar disappears in the nasolabial groove. 3. Remember to avoid injury to the perpendicular branches of the facial artery, as they penetrate the muscle on their way to perfuse the overlying skin.

32

1.6

1  Axial Flaps

Pectoralis Major Myocutaneous Flap

Siba P. Dubey and Charles P. Molumi

1.6.1 Operative Steps 1. After the appropriate size and arch of rotation are determined, the incision is marked out. The clavicle and the approximate course of the vascular pedicle from the acromion to the xiphoid process are marked out (Fig. 1.40). 2. Carry the skin incision to the fascia of the pectoralis major muscle around the skin paddle. The skin of the lateral chest wall is undermined and the lateral border of the pectoralis muscle is identified. From the lateral border the pectoralis major muscle a plane is created between the pectoralis major and minor muscles (Fig. 1.41). 3. The pectoralis major and minor muscles are separated by blunt dissection using fingers in the avascular plane. The pectoralis major muscle is elevated with a retractor. The pectoral branch of the thoracoacromial artery is visualized on the undersurface of the pectoralis major muscle. One of the branches of pectoral nerve exiting the pectoralis major muscle is also identified (Fig. 1.42). 4. The pectoralis major muscle is elevated off the chest wall by sharp dissection along the intercostal muscles. This procedure releases the inferior edge of the flap from its

origin along the lower ribs (Fig. 1.43). Bleeding from perforating vessels is cauterized to ensure hemostasis. 5. The pectoral branch of the thoracoacromial artery which is located along the medial aspect of pectoralis minor muscle is kept under vision on the undersurface of the pectoralis major muscle. One of the pectoral nerves exiting the pectoralis minor muscle is visualized (Fig. 1.44). 6. The medial attachment of the pectoralis major muscle is released beginning inferiorly and moving in a cephalic direction to the level of the clavicle (arrow). The lateral attachment of the pectoralis major muscle to the humerous (double arrow) is released while keeping the vascular pedicle in full view (Fig. 1.45). The pectoral nerve is transected and the flap is completely mobilized. 7. A tunnel is created is created superficial to the clavicle for the passage of the flap into the neck. The tunnel is at least four fingers wide to pass the flap easily into the neck without shearing the musculocutaneous perforators or strangulating the vascular pedicle. The pectoralis major myocutaneous flap is transferred to the neck to be used to reconstruct the defect as required (Fig. 1.46). 8. The flap is passed deep to the mandible to close defects in the oral cavity (Fig. 1.47a) or over the tonsil and lateral pharyngeal wall (Fig. 1.47b) or passed superficial to the mandible to the cheek skin defects (Fig. 1.47c). The chest wall skin of the donor site is undermined and closed.

1.6 Pectoralis Major Myocutaneous Flap

33

Skin paddle outline

1.40

Pectoralis major muscle

Skin paddle

1.41

34

1  Axial Flaps

Pectoral branch of thoracoacromial vessels

Pectoralis major muscle

Pectoral nerve

Pectoralis minor muscle

1.42

Intercostal muscle

Pectoralis major muscle

1.43

1.6 Pectoralis Major Myocutaneous Flap

35

Pectoralis major muscle

Pectoral branch of thoracoacromial vessels Pectoral nerve

Pectoralis minor muscle

1.44

Pectoralis major muscle

Acromial branch of thoracoacromial vessels

Pectoral nerve

1.45

36

1  Axial Flaps

Pectoralis major muscle

Tunnel under skin

Pectoralis minor muscle

1.46

1.47a

1.6 Pectoralis Major Myocutaneous Flap

Posterior pharyngeal wall

37

Uvula Pectoralis major myocutaneous flap

Tongue

Laryngoscope

1.47b

1.47c

38

1.6.2 Potential Problems 1. The skin paddle may not be over the pectoralis major muscle. 2. Entering a wrong plane when separating the pectoralis major muscle from pectoralis minor muscle. 3. Entry into the thoracic cavity. 4. Difficulty in closing the donor site and creating of dog ear during primary closure. 5. Compromising of vascular supply to deltopectoral flap which may be considered as an alternative in a rare situation when the pectoralis major muscle flap fails. 6. Detachment of the skin paddle from the muscle.

1.6.3 Suggested Solutions 1. Identify the pectoralis major muscle early by undermining of the skin of the lateral chest wall in the deltopectoral groove and ensure that the skin paddle is over the pectoralis major muscle. 2. The plane between the pectoralis major and pectoralis minor muscle is an avascular plane and fingers are passed with ease while separating them. In case of any difficulty or if bleeding is encountered, most probably, surgeon entered in the wrong plane. It is always wise to elevate the pectoralis major muscle off the chest wall and identify the vascular pedicle on its undersurface. 3. Always bear in mind to avoid entering the thoracic cavity when dissecting along the intercostal muscles. It is wise to bevel the instrument while dissecting and during hemostasis of intercostal perforators in the second and third intercostal spaces. 4. Design the skin paddle so that the outside of the perimeter of the skin island is shaped into a fusiform shape to help close and to avoid creation of dog ear. 5. The upper limb of the incision of the pectoralis paddle should correspond to the lower border of the deltopec-

1  Axial Flaps

toral flap. When doing the medial release of the pectoralis muscle, always stay lateral to the row of the internal thoracic or internal mammary artery perforators. 6. To avoid detachment of the skin paddle from the muscle, always carry the incision on the skin paddle outward so that the base of the skin paddle is wider than the paddle itself, and suture the edges of the skin paddle to the pectoralis muscle fascia at several points. References to Operative Procedure 1. Withers EH, Franklin JD, Madden JJ, Lynch JB (1979) Pectoralis major myocutaneous flap: a new flap in head and neck reconstruction. Am J Surg 138:537–543 2. Ariyan S (1979) The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 63:73–81 3. Conley J, Sachs ME, Parke RB (1982) The new tongue. Otolaryngol Head Neck Surg 90:58–68 4. Maisel RH, Liston SL (1980) “How I do it”—plastic surgery. Practical suggestions on facial plastic surgery: pectoralis major myocutaneous flap. Laryngoscope 90:2051–2056 5. Robertson MS, Robinson JM (1986) Pectoralis major muscle flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 112:297–301 6. Carlson ER (2003) Pectoralis major myocutaneous flap. Oral Maxillofac Surg Clin N Am 15:565–575 7. Sesterhenn AM, Zimmermann AP, Wagner U, Werner JA, Kalder M (2008) Improved technique of harvesting the pectoralis major myocutaneous flap for reconstruction in female head & neck cancer patients. Clin Otolaryngol 33:378–780 8. McLean JN, Carlson GW, Losken A (2010) The pectoralis major myocutaneous flap revisited: a reliable technique for head and neck reconstruction. Ann Plast Surg 64:570–573

1.7 Pedicled Calverial Bone Graft

1.7

Pedicled Calverial Bone Graft

Siba P. Dubey and Charles P. Molumi

1.7.1 Operative Steps 1. Wide bony defect and soft tissue scarring secondary to extensive aural cholesteatoma with complications (Fig. 1.48). 2. The skin flap is raised superficial to the superficial temporal artery and later in a supragaleal plane (Fig. 1.49). The posterior branch of the superficial temporal artery is identified and traced in the posterosuperior direction in the same plane till the part of the calvaria overlying the posterior half of the parietal bone is reached (Fig. 1.50). 3. The inferior 20% of the galea and periosteum with vascular pedicle are kept intact; the rest of the galea and periosteum over the measured part of the bone are incised. Partial cut is made on the outer table of the compact calvarial bone with a saw. With a fine drill burr, holes are made at the proximal edge of the cut. Multiple sutures are

39

inserted from pericraniofascial layer through the holes in the bone to prevent separation of the pericraniofascial layer from bone flap. The outer table of the calvarial bone is cut till the cancellous (diploic) layer is reached and elevated using a curved osteotome. 4. A tunnel is created between the periosteum and the bone flap at the inferior 20% of the circumference. Using a mastoid drill and diamond burr, this part of the bone is cut keeping the vascular pedicle intact, and the bone flap with the covering periosteum is elevated using a curve osteotome. The elevated bone flap covered by galea and periosteum and the bone flap is fixed with latter by sutures (arrows); the flap pedicled on the posterior branch of superficial temporal artery is completely free to be mobilized (Fig. 1.51). 5. The scar tissue in the recipient area is excised and its bony margin is exposed. The bone flap is rotated and fixed to cover a wide defect of the temporo-occipital bone. A split thickness skin graft is placed on the pericraniofascial layer of the bone flap (Fig. 1.52). 6. The defect heals satisfactorily 3  months after operation (Fig. 1.53).

40

1  Axial Flaps

1.48

Anterior terminal branch of superficial temporal artery

Posterior terminal branch of superficial temporal artery

Superficial temporal vessels

Pinna

1.49

1.7 Pedicled Calverial Bone Graft

41

Vascular pedicle

Pinna

1.50

Osteoperiosteogaleal flap

Stiches

Vascular pedicle

Pinna

1.51

42

1  Axial Flaps

1.52

1.53

1.7 Pedicled Calverial Bone Graft

1.7.2 Potential Problems 1. To avoid thin bone of the calvaria; to avoid bone overlying intracranial venous sinus, namely, superior sagittal sinus. 2. Fracture of the inner cortex results due to forceful elevation of the graft by holding an osteotome at an acute angle. 3. Injury to the feeding artery, namely, superficial temporal and its posterior branch.

1.7.3 Suggested Solutions 1 . The parietal bone is consistently noted to be the thickest. 2. Curved osteotome is held at a proper angle of incidence and carefully introduced within the diploic space which runs parallel to the inner and outer cortex; in this way, inner and out cortices are separated and fracture of the inner cortex is avoided.

43

3. All feeding vessels are kept intact by dissecting in the subfollicular plane.

References to Operative Procedure 1. McCarthy JG, Zide BM (1984) The spectrum of calvarial bone grafting: Introduction of the vascularized calvarial bone flap. Plast Reconstr Surg 74:10–18 2. Cutting CB, McCarthy JG, Berenstein A (1984) Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flap. Plast Reconstr Surg 74:603–610 3. Frodel JL Jr, Marentette LJ, Quatela VC, Weinstein GS (1993) Calvarial bone graft harvest: techniques, considerations, and morbidity. Arch Otolaryngol Head Neck Surg 119:17–23 4. Kline RM, Wolfe SA (1995) Complications associated with the harvesting of cranial bone grafts. Plast Reconstr Surg 95:5–13

44

1.8

1  Axial Flaps

Palatal Flap

Siba P. Dubey and Charles P. Molumi

1.8.1 Operative Steps 1. The patient is intubated with endotracheal tube and the patient placed in head extended position. The area of excision is marked out with diathermy (Fig.  1.54). The diseased area is removed in one block (Fig. 1.55). 2. The palatal incision line is placed 1 cm medial to the teeth and 1.5 cm in front of the soft and hard palate junction

(Fig.  1.56). The palatal mucoperiosteal flap is elevated from the bony hard palate in the anteroposterior direction by blunt and sharp dissection from nonpedicle to the vascular pedicle side (Fig. 1.57). 3. The flap so elevated can be used in the nearby raw area within an arc of 180° without strangulating the vascular pedicle. The pterygoid hamulus is removed before placement of the flap. The flap is rotated to resurface the mucosal defect located in the retromolar area (Fig. 1.58). 4. The raw area in the hard palate used to epithelialize within a month.

1.8 Palatal Flap

45

Retromolar area of excision

Tongue

1.54

Tongue

Retromolar lesion excised

1.55

46

1  Axial Flaps

1.56

Greater palatine neurovascular pedicle

1.57

Tongue

Flap over defect

1.58

1.8 Palatal Flap

47

Opened up greater palatine canal

Greater palatine foramen

Neurovascular bundle reflected posteriorly

1.59a

Palatal flap

Neurovascular bundle at greater palatine canal

1.59b

48

1.8.2 Potential Problems 1. The conventional palatal flap has limited arc of rotation and mobility due to the location of the vascular pedicle within the bony canal. Hence, it is useful in limited nearby areas. 2. Discomfort over the hard palate in the immediate postoperative period.

1  Axial Flaps

Consequently, the flap becomes more rotatable and is used along a wide arc over 180° (Fig. 1.59b). In this way, the flap can be used to cover posterior part of the inferior alveolus, adjoining part of the floor of mouth and cheek, tonsillar fossa, and upper pharynx. 2. Bleeding from the lesser palatine vessels (if present) must be cauterized with bipolar forceps under microscope. 3. The palate is covered by prosthesis prepared before operation.

1.8.3 Suggested Solutions

References to Operative Procedure

1. We increased the arc of rotation by decompressing the greater palatine canal and mobilizing the vascular pedicle outside the canal as shown in the prepared skull (Fig. 1.59a). The posteromedial part of the greater palatine canal is drilled under microscope with 300 mm lens. The greater palatine vascular pedicle is freed and the caudal part of the vascular pedicle is removed from the canal.

1. Gullane PJ, Arena S (1985) Extended palatal island mucoperiosteal flap. Arch Otolaryngol 111:330–332 2. Genden EM, Lee BB, Urken ML (2001) Palatal island flap for reconstruction of palatal and retromolar trigone defects revisited. Arch Otolaryngol Head Neck Surg 127:837–841

1.9 Platysma Myocutaneous Flap

1.9

Platysma Myocutaneous Flap

Siba P. Dubey and Charles P. Molumi

1.9.1 Operative Steps 1. Two parallel vertical incisions are outlined starting at the chin medially and mastoid process laterally. The lower extent of the vertical incision is either slightly above (Fig.  1.60a) or slightly below (Fig.  1.60b) the clavicle depending on the required length and placement of the flap. 2. Additional transverse incisions are placed at the lower end of the vertical incision to create the skin paddle

49

(Fig.  1.61). The proximal transverse incision is made through the skin only and the cervical skin above the skin paddle is elevated in supraplatysmal plane. The myocutaneous flap is developed by starting at the lower transverse incision by elevating the skin paddle with attached muscle in a subplatysmal plane to the level of mandible. 3. The platysma myocutaneous flap is rotated either 90° or 180° depending on the location of the defect, wrapped around the body of the mandible, and sutured into position with a single layer of absorbable suture (Figs. 1.62 and 1.63). The neck wound is closed after inserting a drain. 4. The postoperative appearance after 6 months of the platysma myocutaneous flap placement over lower alveolus and adjoining floor of the mouth (Fig. 1.64).

50

1  Axial Flaps

1.60a

1.60b

1.9 Platysma Myocutaneous Flap

51

1.61

1.62

52

1  Axial Flaps

1.63

1.64

1.9 Platysma Myocutaneous Flap

1.9.2 Potential Problems 1. Preoperative irradiation, prior radical neck dissection, and ligation of both facial artery increase the risk of partial or complete failure of the flap. 2. Total or partial flap necrosis, orocutaneous fistula, and flap de-epithelialization may occur in the postoperative period.

1.9.3 Suggested Solutions 1. The submental artery should be preserved distal to the submandibular gland. Small amount of tissues is left attached on either surface of the platysma muscle. Both the above improve the survivability of the flap. 2. Excess rotation and tension, and kinking of the flap should be avoided. 3. Flap epithelialization and closure of fistula can occur with maintenance of orodental hygiene in the postoperative period. Nasolabial flap or facial artery musculomucosal

53

flap is used to close the orocutaneous fistula and help epithelialize the raw area if platysma myocutaneous flap fails.

References to Operative Procedure 1. Futrell JW, Johns ME, Edgerton MT, Cantrell RW, FitzHugh GS (1976) Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 136:504–507 2. Cannon CR, Johns ME, Atkins JP, Keane WM, Cantrell RW (1982) Reconstruction of the oral cavity using platysma myocutaneous flap. Arch Otolaryngol 108:491–494 3. McGuirt WF, Matthews BL, Brody JA, May JS (1991) How I do it: platysma myocutaneous flap: caveats reexamined. Larungoscope 101:1238–1244 4. Ruark DS, McClairen WC, Schlehaider UK, Abdel-Misih RZ (1993). Head and neck reconstruction using platysma myocutaneous flap. Am J Surg 165:713–719

54

1.10 Submental Artery Island Flap Siba P. Dubey and Charles P. Molumi

1.10.1 Operative Steps 1. The inferior limit of the flap is outlined by an index finger-­thumb pinch test to assess primary closure. The skin inferior to the inferior border of the mandible is pinched to determine the greatest amount of skin which can be taken while allowing for advancement of the remaining neck skin to close the skin at the inferior border of the mandible. The patient is placed in head extended supine position. The upper limit of the flap is marked 1 cm inferior to the mandibular arch in the submental region from the ipsilateral angle of the mandible to a contralateral point across the midline (Fig. 1.65). 2. The flap is elevated from the contralateral side of the pedicle in the subplatysmal plane (Fig. 1.66). When dissecting the upper margin of the flap, the marginal mandibular branch of the facial nerve which lies just deep to the platysma and overlying the facial artery is identified and preserved. 3. At the midline, the dissection is continued over the mylohyoid muscle and the ipsilateral anterior belly of digastric muscle (i.e., on the side pedicle) (Figs. 1.67a, b). 4. The attachment of the anterior belly of digastric muscle is detached from the mandible and it is sectioned at the intermediate tendon to include it in the flap. The dissection is proceeded toward the pedicle on the surface of the

1  Axial Flaps

submandibular gland until the facial artery and vein are reached (Fig. 1.68). 5. The facial artery and vein are traced proximally and downward retraction on the gland reveals the submental artery. The facial vessels and submental artery and vein are dissected from the submandibular gland and the mylohyoid muscle. Dissection is carried down to the origin of the facial artery and vein till a pedicle of desired length is obtained (Fig. 1.69). 6. The submental flap is ready to be mobilized to the defect (Fig. 1.70). 7. The pedicle is lengthened to desired length to reach the defect to be closed. In this case, it is used to close a large soft tissue defect that resulted in the postaural region. The flap with its pedicle is passed below the bridge of skin. The flap covers the retro- auricular defects; drain inserted and donor area closed (Fig. 1.71a, b). 8. For closure of defects in the tongue after partial glossectomy, the flap is passed into the oral cavity deep to the mandible and mobilized into the oral cavity (Fig. 1.72). 9. A distally based flap based on reverse flow is created by ligating the facial artery and vein proximal to the origin of the submental artery to cover the cranially located defect. The position of the mandibular branch of the facial nerve, which is the pivotal point for flap rotation, restricts the distal dissection of the pedicle. The nerve is carefully dissected out and the flap is passed under it (Fig. 1.73). 10. A distally based reverse flow submental flap is able to reach defects in the palatal region following total maxillectomy (Fig. 1.74a, b).

1.10 Submental Artery Island Flap

55

Normal or contralateral side

Pathological or ipsilateral side

1.65

Chin

Platysma muscle

Contralateral side

1.66

56

1  Axial Flaps

Subplatysmal plane Submenta artery flap Central tendon of digastric muscle

Anterior belly of digastric muscle Submandibular salivary gland

Anterior belly of digastric muscle insertion to mandible

Inferior border of mandible Contralateral side

1.67a

Transected mandibular attachment of anterior belly of digastric muscle

Contralateral side

1.67b

Floor of mouth

Contralateral side 1.68

1.10 Submental Artery Island Flap

57

Submental artery flap

Anterior jugular vein

Marginal mandibular branch of facial nerve

Submandibular salivary gland

Facial artery Submental artery

1.69

Ipsilateral side

Ipsilateral anterior belly of digastric muscle

Contralateral anterior belly of digastric muscle

Submental artery flap 1.70

58

1  Axial Flaps

Mastoid cavity

Submental artery flap

Postauricular defect 1.71a

Submental artery flap covering postauricular defect

1.71b

1.10 Submental Artery Island Flap

59

Submental artery flap covering glossectomy defect

1.72

Submental artery flap

Facial artery and vein

Mandibular branch of facial nerve 1.73

60

1  Axial Flaps

Maxillectomy defect

Tongue

1.74a

Tongue

Submental artery flap on reverse flow covering maxillectomy defect

1.74b

1.10 Submental Artery Island Flap

1.10.2 Potential Problems 1. Poor planning in flap design leads to failure in closure of donor site. 2. Having the superior incision too high leads to visible scar over the mandible. 3. The flap may be too thin in a thin patient. 4. Limited arc of rotation and excessive stretching of the vein lead to flap failure. 5. Cosmetic concern arises in the postoperative period after healing due to inappropriate closure of the donor site. 6. Twisted pedicle and compression of the pedicle of the flap lead to flap failure.

1.10.3 Suggested Solutions 1. Ensure that there is enough laxity by pinch test at the inferior limit of the flap; a flap of 7 × 18 cm is possible without any problem of closure. Design the island flap in a lenticular fashion to allow easy closure of the donor site. 2. It is very crucial to have the anterior extent of the flap approximately 1  cm inferior to the lower border of the mandible to prevent scarring in case incision is too superior. The location of the incision at this point avoids the risk of damage to the facial artery which courses close to the bone. 3. Keep the skin flap thick by keeping the subcutaneous adipose tissue with the flap and dissecting close to the submandibular gland. 4. Division of the facial vessels distal to the origin of the submental artery provides additional 1–2  cm of pedicle length. The vein can be anastomosed to the internal jugular vein if stretched.

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5. Do not flex the neck to facilitate closure of donor site to avoid hypertrophic scars. Restrict undermining to the cervical skin for closure. Never undermine the mandibular skin, as it can cause eversion of the lower lip. Always hitch (suture) cervical platysma to the hyoid bone to preserve a well-defined cervicomental angle. 6. Care should be taken to ensure that there is enough room to tolerate pedicle size so it is not compressed postoperatively, as it interferes with venous outflow or perfusion. Always check for the contour and position of the pedicle before suturing. References to Operative Procedure 1. Martin D, Pascal JF, Baudet J, Mondie JM, Bokhari Farhat J, Athoum A, Le Gaillard P, Perri G (1993) The submental island flap: A new donor site. Anatomical and clinical applications as a free or pedicle flap. Plast Reconstr Surg 92:867–873 2. Curran AJ, Neligan P, Gullane PJ (1997) How I do it: submental artery island flap. Laryngoscope 107:1545–1549 3. Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF (1996) The submental flap. Br J Plast Surg 49:85–89 4. Merten SL, Jiang RP, Caminer D (2002) The submental artery island flap for head and neck reconstruction. ANZ J Surg 72:121–124 5. Yilmaz M, Menderes A, Barutcu A (1997) Submental artery island flap for reconstruction of the lower and mid face. Ann Plast Surg 39:30–35 6. Taghinia AH, Movassaghi K, Wang AX, Pribaz JJ (2009) Reconstruction of the upper aerodigestive tract with the submental artery flap. Plast Reconstr Surg 123:562–570

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1.11 Temporoparietal Fascial Flap (TPFF) Siba P. Dubey and Charles P. Molumi

1.11.1 Operative Steps 1. An incision line is drawn starting from the preauricular line and extended in the cephalic direction in a Y- or Z-shaped way to aid in anterior and posterior flap elevation. The incision line is stopped 2–3 cm above the superior temporal line (Fig. 1.75a, b). 2. The incision is begun at the superior aspect of the preauricular region. The incision is carried through the dermis taking extra care not to injure the superficial temporal vessels which run close to the preauricular site of incision. The skin flap is raised in the subfollicular plane superficial to the superficial musculoaponeurotic system (SMAS). Hair follicles may be visible in some areas; the branches of the superficial temporal vessels and frontal branch of facial nerve are kept in view during elevation of the flap (Fig. 1.76). The elevation of the skin flap is carried out till the superior temporal line is reached in both anterior and posterior direction. The elevation is ceased when an adequate dimension of the flap is raised to cover the raw area created by parotidectomy.

1  Axial Flaps

3. Once the desired width and length of the flap is measured, the TPFF is elevated by first incising the fascia and staying superficial to the fascia covering temporalis muscle. The branches of the superficial temporal artery are cut and ligated at the superior margin of the flap (Fig. 1.77). 4. The elevation of the TPFF is continued inferiorly in the nonvascular plane of the loose areolar tissues that separates the temporoparietal fascia from the fascia covering the temporalis muscle while viewing the vascular pedicle (Fig. 1.78). 5. The TPFF is elevated till the root of the helix and zygoma is reached. The TPFF is directed to the defect over the zygoma, taking care not to injure the superficial temporal vessels and frontal branch of facial nerve (Fig. 1.79). 6. The temporoparietal fascial flap (TPFF) is fixed by suturing its edges to the margins of the wound over abdominal fat; it is done for overcorrection to compensate for shrinkage in the postoperative period; temporalis muscle and superficial temporal artery are also visible (Fig.  1.80). Suction drains are inserted and the incision is closed in layers (Fig. 1.81).

1.11 Temporoparietal Fascial Flap (TPFF)

63

1.75a

Superficial temporal vessels

1.75b

Hair follicles of skin flap

Frontal branch of facial nerve

1.76

64

1  Axial Flaps

Ligated superficial temporal vessels

Temporoparietal fascial flap

Fascia covering temporalis muscle

Superficial temporal vessels

Frontal branch of facial nerve

1.77

Temporoparietal fascial flap

Pinna

Temporalis muscle covered by its fascia 1.78

1.11 Temporoparietal Fascial Flap (TPFF)

65 Skin flap with hair follicles

Temporalis muscle covered by its fascia

Frontal branch of facial nerve

Temporoparietal fascial flap

1.79

Temporalis muscle covered by its fascia

Superficial temporal vessels

Temporoparietal fascial flap covering fat 1.80

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1  Axial Flaps

1.81

1.11 Temporoparietal Fascial Flap (TPFF)

1.11.2 Potential Problems 1. Raising the flap in deeper plane provides the risk of injuring the superficial temporal artery or raising the temporal parietal fascia with the skin flap. 2. Injury to the frontal branch of the facial nerve. 3. Injury to feeding superficial temporal artery resulting in flap failure. 4. Inadequate flap size. 5. Postoperative alopecia that can be seen in and near the area of the scalp incision.

1.11.3 Suggested Solutions 1. Visualizing the hair follicles on the underside of the scalp flap is the assurance that the temporoparietal fascia is not being elevated with the skin reflection. Have a clear understanding of the location of the temporoparietal fascia which lies immediately deep to the skin and subcutaneous tissue of the scalp overlying the temporal fossa. It is continuous with the superficial musculoaponeurotic system inferior to the zygomatic arch and with the galea aponeurotica above the superior temporal line. 2. Take extra care while elevating the skin flap anteriorly, as the frontal branch of facial nerve can be injured. Identify the frontal branch of the facial nerve after elevation of the skin flap using a nerve stimulator. It lies along a line between a point 0.5  cm below the tragus and a point 1.5  cm above the lateral eyebrow. Further dissection is performed while directly viewing the nerve. 3. Always keep in mind that the dominant blood supply is the superficial temporal artery, a terminal branch of the external carotid artery. The artery ascends behind the

67

ramus of the mandible and becomes superficial, piercing through the substance of the parotid gland 5 mm in front of the tragus. Always use bipolar diathermy to dissect. Keep the dissection just below the air follicle. When narrowing the flap pedicle at the base of the tragus, cut the fascia medially and laterally while directly viewing the vascular pedicle. 4. Always check for the desired length of the flap by using a suture with the fixed point in the preauricular area and rotated to the furthest point of the defect. The length is then transferred superiorly to the cranial end of the TPFF. 5. Always bevel the scalpel in haired skin areas to reduce the likelihood of cutting through hair follicles and avoid the use of diathermy when elevating the skin flaps. References to Operative Procedure 1. Matsuba HM, Hakki AR, Romm S, Little JW 3rd, Spear SL (1990) How I do it: variations on the temporoparietal fascial flap. Laryngoscope 100:1236–1240 2. Rose EH, Norris MS (1990) The versatile temporoparietal fascial flap: adaptability to a variety of composite defects. Plast Reconstr Surg 85:224–232 3. Cheney ML, Varvares MA, Nadol JB Jr (1993) The temporoparietal fascial flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 119:618–623 4. David SK, Cheney ML (1995) An anatomic study of the temporoparietal fascial flap. Arch Otolaryngol Head Neck Surg 121:1153–1156 5. Sultan MR, Wider TM, Hugo NE (1995) Frey’s syndrome: prevention with temporoparietal fascial flap interposition. Ann Plast Surg 34:292–296, discussion 296–297.

2

External Nasal Defects Repair

2.1

I sland Forehead for External Nose Defects

Siba P. Dubey and Charles P. Molumi

2.1.1 Operative Steps 1. A skin island flap is marked out avoiding the hairline. The location depends on the ability of the flap to rotate 180° subcutaneously and reach the nasal defect without tension (Fig. 2.1). 2. The island flap skin except the pedicle is incised to the subgaleal (supraperiosteal) plane (Fig. 2.2). 3. A separate incision is made on the skin island flap pedicle. The skin is dissected up to the subdermal plane (Fig. 2.3).

4. Beginning at the level of the distal end of the skin island flap, a 2 cm length of tissue is elevated at the level of the frontogaleal layer with the subcutaneous tissue (Fig. 2.4). 5. The periosteum is incised and the flap is elevated in the subperiosteal plane for a distance between 2 and 2.5 cm from the supraorbital margin (Fig. 2.5). 6. A tunnel is created in the subcutaneous plane from the nasal defect to the forehead (Fig.  2.6). The flap is tunneled to the defect. 7. By gentle traction from the nasal side, the flap is mobilized to the nasal defect (Fig. 2.7). 8. The flap is sutured with interrupted sutures to the defect. The donor site is closed with interrupted sutures (Fig. 2.8).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_2

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70

2  External Nasal Defects Repair

2.1

2.2

2.1  Island Forehead for External Nose Defects

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2.3

2.4

72

2  External Nasal Defects Repair

2.5

2.6

2.1  Island Forehead for External Nose Defects

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2.7

2.8

74

2.1.2 Potential Problems 1 . Injury to the feeding supratrochlear vessels 2. Constriction of the flap pedicle at the tunnel compromising the vascular supply

2  External Nasal Defects Repair

2. The width of the tunnel must be double that of the flap pedicle and with no tension at the flap pedicle. In addition, excise the procerus muscle to reduce swelling in the tunnel at the proximal portion of the flap. References to Operative Procedure

2.1.3 Suggested Solutions 1. It is vital to ensure that the flap is harvested superficial to the frontalis muscle in the distal part and together with this muscle close to the periosteum in the proximal part to protect the vessels. Use a Doppler probe to determine the correct location artery and design the skin island flap along this artery; then raise the flap from distal to proximal.

1. Converse JM, Wood-Smith D (1963) Experiences with the forehead island flap with a subcutaneous pedicle. Plast Reconstr Surg 31:521–527 2. Sharma RK (2011) Supratrochlear artery island paramedian forehead flap for reconstructing the exenterated patient. Orbit 30:154–157

2.2  Modified Rieger Glabellar Rotation Flap

2.2

 odified Rieger Glabellar Rotation M Flap

Siba P. Dubey and Charles P. Molumi

2.2.1 Operative Steps 1. The dorsal nasal flap is created by making the initial inferior incision laterally from the edge of the defect to the nasofacial groove on the side of the pedicle. The vertical limb on this side is then drawn slightly lateral to the groove upward toward the medial canthus, stopping short of the medial canthus to preserve the pedicle. Two oblique glabellar incisions are extended downward on each side, each to a point 1 cm superior to the canthal tendon. The vertical incision on the side contralateral to the pedicle is extended from the glabellar incision down to the alar groove. This incision is then connected to the defect with an incision along the alar groove. These incisions are designed to allow rotation of the glabellar apex downward to the medial canthal

75

tendon. In cases with total loss of ala, the skin above the defect is marked out to be raised as a turn-over flap for inner lining (Fig. 2.9). 2. The dorsal nasal flap is elevated in a plane immediately superficial to the periosteum and includes the procerus muscle. The medial canthal tendon is identified, and 7–10 mm of tissue superior to the tendon is bluntly dissected directly on the periosteum of the nasal bone to avoid transecting the arterial supply of the flap. The ipsilateral oblique incision is carried into the glabellar skin, and the contralateral limb is carried downward to a point just superior to the opposite medial canthus. The flap is elevated as a skin-only flap, but the procerus is left in place to ensure viability. The entire skin of the nasal dorsum including the glabella and part of the cheek is mobilized. The skin above the defect is elevated as a turn-over flap for inner lining (Fig. 2.10). 3. The flap is mobilized to cover the defect and sutured with interrupted sutures (Fig. 2.11). 4. Although there is narrowing of the nasal opening, the external nasal profile is cosmetically acceptable (Fig. 2.12).

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2  External Nasal Defects Repair

2.9

2.10

2.2  Modified Rieger Glabellar Rotation Flap

77

2.11

2.12

78

2.2.2 Potential Problems 1. Rotation of a large flap often creates a secondary defect in the nasofacial groove area. 2. Closure of the glabellar defect creates a dog-ear. 3. Difficulty closing of defect and tenting.

2.2.3 Suggested Solution 1. Resect the midline dog-ear primarily. The associated skin is harvested as a full-thickness skin graft that is thinned and sutured into the superior aspect of the dorsal defect. Creation of any of these dorsal nasal flaps may result in a dog-ear at the point of rotation. This dog-ear may be revised if necessary in the office 3–4 weeks after completion of the primary procedure. 2. The glabellar apex is sutured down to the canthal tendon to avoid webbing and to reduce tension at the distal tip.

2  External Nasal Defects Repair

3. This secondary defect is closed by a cheek advancement procedure that may necessitate excision of a crescent of skin lateral to the ala and an incision in the superior nasolabial fold to allow advancement of the flap. To avoid tenting, the cheek flap is sutured to the soft tissue or periosteum of the lateral nasal wall. References to Operative Procedure 1. Rieger RA (1967) A local flap for repair of the nasal tip. Plast Reconstr Surg 40:147–149 2. Eren E, Beden V (2014) Beyond Rieger’s original indication; the dorsal nasal flap revisited. J Craniomaxillofac Surg 42:412–416 3. Johnson TM, Swanson NA, Baker SR, Brown MD, Nelson BR (1995) The Rieger flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg 121: 634–637

2.3  Repair of Alar Defect with Nasal Dorsum Turn Over Flap and Superiorly Based Nasolabial Flap

2.3

 epair of Alar Defect with Nasal R Dorsum Turn Over Flap and Superiorly Based Nasolabial Flap

Siba P. Dubey and Charles P. Molumi

2.3.1 Operative Steps 1. Alar defect requires two flaps, one each for the roof of the vestibule and nasal dorsum with nasal alar rim. A nasal dorsal turn-over flap of the skin above the defect is used to form the roof of the nasal vestibule and nasal alar rim and a superiorly based nasolabial flap to create nasal dorsum and the nasal alar rim (Fig. 2.13).

79

2. The superiorly based nasolabial flap is raised as described in the Chapter on Axial flap. 3. A nasal dorsal turn-over flap of the skin above the defect is raised with adequate base to maintain vascularity (Fig. 2.14). 4. The scared edges of the ala on each side are excised. The nasal vestibule is created by suturing the nasal dorsal turn-over flap to the edges of the nasal ala (Fig. 2.15). 5. The superiorly based nasolabial flap is placed over the bed of the nasal dorsum and the nasal dorsal turn-over flap (Fig. 2.16). 6. The superiorly based nasolabial flap is sutured to the nasal dorsum and the ala. The alar rim is formed by suturing the anterior ends of the turn-over flap and superiorly based nasolabial flap (Fig. 2.17).

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2  External Nasal Defects Repair

2.13

Superiorly based nasolabial flap

Nasal dorsal turn-over flap

2.14

2.3  Repair of Alar Defect with Nasal Dorsum Turn Over Flap and Superiorly Based Nasolabial Flap

81

Cranially retracted superiorly based nasolabial flap

Caudally retracted nasal dorsal turn-over flap

2.15

Cranially retracted superiorly based nasolabial flap

Caudally retracted nasal dorsal turn over flap

2.16

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2  External Nasal Defects Repair

2.17

2.3  Repair of Alar Defect with Nasal Dorsum Turn Over Flap and Superiorly Based Nasolabial Flap

2.3.2 Potential Problems 1 . Nasal alar collapse 2. Retraction of nostril

2.3.3 Suggested Solutions 1. Reconstructed ala may require stabilization with an auricular conchal cartilage graft. 2. Sufficient flap length is essential to avoid retraction of the nostril. References to Operative Procedure 1. Lazaridis N, Tilaveridis I, Karakasis D (2008) Superiorly or inferiorly based “islanded’ nasolabial flap for buccal mucosa defects reconstruction. J Oral Maxillofac Surg 66:7–15

83

2. Lazaridis N, Zouloumis L, Venetis G, Karakasis D (1998) The inferiorly and superiorly based nasolabial flap for the reconstruction of moderate-sized oronasal defects. J Oral Maxillofac Surg 56:1255–1259, discussion 1260 3. Takeda A, Akimoto M, Park K, Kounoike N, Shimakura Y, Nemoto M, Uchinuma E (2014) Single-stage reconstruction of a full-thickness alar defect using a folded nasolabial flap combined with a redundant skin turnover flap. J Craniofac Surg 25:2144–2146 4. Bi H, Xing X, Li J (2014) Nasolabial-alar crease: a natural line to facilitate transposition of the nasolabial flap for lower nasal reconstruction. Ann Plast Surg 73:520–524

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2.4

2  External Nasal Defects Repair

 epair of Alar Defect with Full-­ R Thickness Skin Graft

Siba P. Dubey and Charles P. Molumi

2.4.1 Operative Steps 1. A circumferential incision of 5 mm margin from the basal cell carcinoma is marked (Fig. 2.18). 2. The skin incision is made using a sharp scalpel circumferentially through the full thickness of the skin but remaining superficial to the nasal cartilages. Hemostasis is done with bipolar forceps (Fig. 2.19). The margins of the speci-

men are indicated with different suture knots and sent for frozen-section biopsy (Fig. 2.20). 3. A full-thickness skin graft of the size of the defect is harvested from the postauricular region (Fig. 2.21). 4. The full-thickness postauricular skin graft is placed over the defect, the skin edge to the full-thickness skin graft is approximated, and interrupted sutures are placed. After every third suture, a knot with a long end is left to be used to tie a bolster dressing (Fig.  2.22). The postoperative appearance of the nasal alar defect (Fig. 2.23). 5. The postauricular donor site is closed with interrupted sutures. The wound heals with minimal scaring (Fig. 2.24).

2.4  Repair of Alar Defect with Full-Thickness Skin Graft

85

2.18

2.19

86

2  External Nasal Defects Repair

2.20

2.21

2.4  Repair of Alar Defect with Full-Thickness Skin Graft

87

2.22

2.23

88

2  External Nasal Defects Repair

2.24

2.4  Repair of Alar Defect with Full-Thickness Skin Graft

2.4.2 Potential Problems 1 . Inadequate resection margins. 2. Flap failure. 3. Graft harvested is smaller than the defect. 4. Accidental injury to the nasal cartilages. 5. Undesirable esthetic result.

89

3. Elevating one edge of the incision and applying adequate traction with skin hooks allow for dissection to proceed in a uniform plane remaining deep to the dermis but over the cartilage. 4. Accurate approximation of epidermis to epidermis is important for a desirable esthetic result. References to Operative Procedure

2.4.3 Suggested Solutions 1. Resect the tumor with full thickness of the skin and obtain several frozen sections from the margins to ensure adequacy of excision. 2. Always do an accurate approximation of the skin edge to the full-thickness skin graft. Obtain a paper template of the defect after excision and frozen sections to harvest the size flap from the donor site.

1. Rank BK, Wakefield AR (1958) Surgery of basal cell carcinoma. Br J Surg 45:531–547 2. Johnson T, Zide MF (1997) Freehand full-thickness grafting for facial defects: a review of methods. J Oral Maxillofac Surg 55:1050–1056 3. Gurunluoglu R, Shafighi M, Gardetto A, Piza-Katzer H (2003) Composite skin graft for basal cell carcinoma defects of the nose. Aesthet Plast Surg 27:286–292

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2.5

2  External Nasal Defects Repair

Schmid–Meyer Frontotemporal Flap

Siba P. Dubey and Charles P. Molumi

2.5.1 Operative Steps 1. The flap is mobilized in stages approximately 16–20 days apart. In about 8 weeks, the flap swung downward on the freshened defect edges, and the flap is sutured into the defect. This flap based on supraorbital and supratrochlear arteries in between 2 parallel lines (A and B) is marked out (Fig. 2.25). 2. The skin is incised along the lines ‘A’ and ‘B’ superficial to the periosteum. The flap is tubed while the temporal part is covered with split-skin graft. A 1 cm × 2 cm piece of cartilage is implanted subcutaneously 1.5–2 cm lateral to the lateral end of the flap; these measurements depended on the size of the defect (Fig. 2.26).

3. Stage 2 begins after 4 weeks. A thin rubber tube is looped around the bridge of the skin between the lateral ends of the flap and medial to the cartilage implant and thereby, blood supply is occluded partially. The strangulation is gradually increased (Fig. 2.27). 4. A week after stage 2 and 5 weeks after stage 1, the bridge of the skin in the loop is cut and a free bipedicled flap is produced with implanted cartilage at the lateral end (Fig. 2.28). 5. After another 3  weeks (8  weeks after stage 1), the flap with the inserted cartilage is viable and ready to be transferred to the recipient site. The skin over the nasal-tip defect and columella is refashioned. The distal end of the flap is detached and inserted into the columella and nasaltip defect (Fig. 2.29a, b). 6. Four weeks later, the pedicle is divided and discarded. The donor site heals with minimal scaring. Preoperative defect (Fig. 2.30a) and postoperative appearance after 6 months (Fig. 2.30b).

2.5  Schmid–Meyer Frontotemporal Flap

91

B

A

2.25

Site of cartilage implantation

2.26

92

2  External Nasal Defects Repair

2.27

2.28

2.5  Schmid–Meyer Frontotemporal Flap

93

2.29a

2.29b

94

2  External Nasal Defects Repair

2.30a

2.30b

2.5  Schmid–Meyer Frontotemporal Flap

2.5.2 Potential Problems 1. Wrong placement of the rubber tube at stage 2 and complete strangulation of the lateral end of flap. 2. Complete strangulation of the lateral end of the flap.

95

3. Always do a blanching response of the flap tissue to finger pressure. It should disappear within 3 seconds. Delay the transfer of flap when the blanching response disappears after 3 seconds. References to Operative Procedure

2.5.3 Suggested Solutions 1. Remember that the thin rubber tube should loop around the bridge of the skin between the lateral end of the flap and medial to the cartilage implant, and thereby partially occluding the blood supply. 2. Gradually increase the strangulation over a week.

1. Schmid E (1952) A new method of plastic surgery of the nose (in German). Bruns’ Beitr Klin Chir 184:385–412 2. Schmid E (1961) Partial and total rhinoplasty (in German). Fortschr Kiefer Gesichts-Chir 7:80–88 3. Meyer R (1960) Partial rhinoplasty with frontal and frontotemporal flap (in Italian). Minerva Chir 15:1

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2.6

2  External Nasal Defects Repair

 otal Nose Reconstruction T with Anterior Scalping Flap

2.6.1 Operative Steps Siba P. Dubey and Charles P. Molumi 1. The skin incision is marked out on the forehead, head and temporal region; the midline forehead flap to line the upper two-thirds of the nose, and the lower third to be lined to the level of the nasal valve by infolding the distal end of the scalping forehead flap (Fig. 2.31). 2. The skin of the forehead is incised and elevated over the frontalis. After reaching the upper limit of the frontalis and as the flap elevation approaches the site where the ramifying temporal artery enters the scalp, the dissection is done at the supraperiosteal plane and the anterior scalp flap is completely elevated (Fig. 2.32). 3. The flap elevation is continued to the contralateral forehead to provide adequate mobility (Fig. 2.33).

4. The flap is directed to the defect, and further elevation is continued till the flap reaches the defect without tension (Fig. 2.34). 5. By infolding the forehead flap, the septal columella and the undersurface of the nasal vestibule are created (Fig. 2.35). 6. The recipient site is refreshened (Fig. 2.36a) and the nasal columella created from the anterior scalping flap is sutured to the remaining columella on its side (Fig. 2.36b). 7. The ala is recreated and the rest of the nasal defect is closed by infolding the forehead skin. The donor site is covered with split skin graft (Fig. 2.37). 8. After 3 weeks, the flap is ready to be divided. Note that the flap is designed in such a way that the non-hair-­bearing area of the flap forms the nasal dorsum (Fig. 2.38). 9. The flap is divided and returned to the forehead (Fig. 2.39). 10. The flap heals with patent nostril and the donor site heals with minimal scaring over time. A satisfactory external nasal profile with patent nasal cavities is achieved (Fig. 2.40).

2.6  Total Nose Reconstruction with Anterior Scalping Flap

97

2.31

2.32

98

2  External Nasal Defects Repair

2.33

2.34

2.6  Total Nose Reconstruction with Anterior Scalping Flap

99

Infolded flap to form septal columella

Flap to form nasal vestibular skin

2.35

2.36a

2.36b

100

2  External Nasal Defects Repair

Skin graft

2.37

2.38

2.6  Total Nose Reconstruction with Anterior Scalping Flap

101

2.39

2.40

102

2.6.2 Potential Problems 1 . Narrow distal part of the flap. 2. Insufficient length and height of the flap. 3. Flap failure when the main blood supply from the contralateral superficial temporal artery is injured. 4. Excessive budging of distal flap during folding. 5. Hair-bearing skin of the nasal dorsum causing unpleasant outcome. 6. Shortage of intranasal lining.

2  External Nasal Defects Repair

3. Ensure that the scalp incision is carried within 3–4 cm of the superior helical rim of the opposite ear. 4. During elevation of the forehead skin, the forehead muscles are left on the frontal bone to reduce flap thickness. 5. When shaving the hair, always leave some hair on the frontal hairline to determine the length of the flap. In doing so, apply the rule, the overall width of the distal end of the forehead flap above the eyebrow is 8–9 cm and the length of the columella is 2.5 cm. 6. Curve the columella tip rather than angled at its junction with the lateral flap margin.

2.6.3 Suggested Solutions

References to Operative Procedure

1. Always practice on a sterile towel by cutting out the flap and making trial folds, bearing in mind that the flap itself must be designed slightly larger than the model because the skin is fuller and more difficult to fold. 2. A general rule to have in mind: the more distal the extent of the nasal defect, the closer the lower forehead flap incision to the eyebrow. During flap elevation, as the flap elevation approaches the site where the temporal artery enters the scalp flap, raise the flap by bluntly dissecting it off the temporalis muscle fascia using finger.

1. Converse JM (1959) Reconstruction of the nose by the scalping flap technique. Surg Clin N Am 39:335–365 2. Converse JM (1969) Clinical applications of the scalping flap in the reconstruction of the nose. Plast Reconstr Surg 43:247–259 3. Converse JM, McCarthy JG (1981) The scalping forehead flap revisited. Clin Plast Surg 8: 413–434 4. Yoshihiro S, Kenichi N, Toshiaki N (2011) Reconstruction of larger nasal defect together with the nasal lining and the upper lip using the split-scalping forehead flap: a new technique. J Plast Reconstr Aesthet Surg 64:1108–1110

3

Free Flap in Head and Neck Reconstruction

3.1

Anterolateral Thigh (ALT) Free Flap

Emeka Nkenke, Eleftherios Vairaktaris, and Christos Perisanidis

3.1.1 Operative Steps 1. When raising the anterolateral thigh flap, it is recommended to identify the perforator vessels by a Doppler examination preoperatively. The individual flap design depends on the location of the perforator vessels. Nevertheless, for gross orientation, a line is drawn along the skin of the upper leg that connects the anterior superior iliac spine and the lateral aspect of the patella (Fig. 3.1). Around the middle of this line, a circle with a diameter of 15 cm approx. is drawn. Typically, this area does include perforator vessels. 2. After palpation of the intramuscular septum between rectus femoris muscle and vastus lateralis muscle the vertical incision is made down to the fascia (Fig. 3.2). After opening the fascia in the cranial aspect, the rectus femoris muscle is lifted up to allow accessing the vascular pedicle.

3. After completion of the incision of the intramuscular septum, the rectus femoris muscle is undermined bluntly (Fig.  3.3). The muscle can now be retracted, medially, which leads to an immediate exposure of the vascular pedicle. This step has to be performed carefully, because already at this stage septocutaneous perforator vessels are exposed. 4. Distally, the vascular pedicle is transected and ligated in order to facilitate the further steps of flap raising (Fig. 3.4). 5. Subsequently, the fascia is opened up along the pedicle in a cranial direction (Fig. 3.5). 6. In the cranial aspect, several vessels and nerves become visible (Fig. 3.6). The dissection is stopped once the lateral circumflex femoral artery is reached. 7. At this stage, the skin paddle can be circumcised starting from the distal to the cranial aspect along the lateral border (Figs.  3.7 and 3.8). Depending on the needs of the defect to be covered, a portion of the vastus lateralis muscle can be included in the flap. 8. Closure of the donor area is performed primarily (Fig. 3.9). The use of a suction drain is recommended. 9. Postoperative appearance of the flap over the left lower alveolus and adjoining gingivolabial and gingivolingual sulci (Fig. 3.10).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_3

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3.1.2 Potential Problems 1 . Pronounced thickness of the subcutaneous fatty tissue. 2. Poor perfusion of the included muscle portion. 3. Impossible primary wound closure after harvesting of flaps with diameters over 10 cm.

3.1.3 Suggested Solutions 1. Immediate thinning of the flap to a thickness of the subcutaneous fatty tissue to no less than 5 mm without damaging the cutaneous vessels. Note that the regions around the perforator vessels have to be spared. 2. When designing the flap, distally extended muscle portions should be avoided. 3. Covering of the remaining defect with split skin grafts.

References to Operative Procedure 1. Wolf KD, Grundmann A (1992) The free vastus lateralis flap: an anatomic study with case reports. Plast Reconstr Surg 89:469–475

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2. Malata CM, Tehrani H, Kumiponjera D, Hardy DG, Moffat DA (2006) Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction. Ann Plast Surg 57:169–175 3. Łuczewski Ł, Machczyński P, Marszałek S, Szewczyk M, Golusiński P, Pieńkowski P, Szybiak B, Weselik L, Majchrzak E, Hauke J, Golusiński W (2019) Colour Doppler sonography in the preoperative assessment of the vascular pedicle from the anterolateral thigh flap: proposal for a mathematical formula to predict pedicle length. Eur Arch Otorhinolaryngol 276:815–819 4. Hung KS, Chen SH, Chen WC, Tseng WL, Lee YC (2018) Surgical algorithmic approach to facilitate primary closure of the anterolateral thigh flap donor site in head and neck reconstruction. Ann Plast Surg 82: S33–S38 5. Oranges CM, Ling B, Tremp M, Wettstein R, Kalbermatten DF, Schaefer DJ (2018) Comparison of anterolateral thigh and radial forearm free flaps in head and neck reconstruction. In Vivo 32:893–897

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Maxillary Reconstruction with Parascapular Free Flap

Emeka Nkenke, Florian Katauczek, Eleftherios Vairaktaris, Konstantinos Mitsimponas, Konstantin Zauza, and Christos Perisanidis

3.2.1 Operative Steps 1. A 32-year-old male patient was referred to our outpatient clinic with a painless mild swelling in the region of the left posterior maxilla. On panoramic X-ray, a unilocular well-circumscribed radiolucent lesion in the left posterior maxilla (white arrow), surrounded by smooth sclerotic margins (red arrows), was discovered (Fig. 3.11). 2. Axial and coronal facial computed tomography scans showed a hypodense lesion in the left maxillary bone (green arrow) and maxillary sinus (white arrows) with resorption of the anterior wall of the left maxillary sinus (red arrows) (Fig. 3.12). 3. An open biopsy was performed. An incision was made intraorally along the free gingival margins of the posterior maxillary teeth and the mucoperiosteal flap was raised from caudal to cranial. The lesion (white arrow) lied within the left maxillary sinus, had destructed the anterior wall of the maxillary sinus, and extended to surrounding soft tissues. The histopathological examination revealed an odontogenic keratocyst (OKC). The treatment plan included segmental resection of the left maxilla with synchronous free scapula flap reconstruction of the maxillary defect. Buccal fat pad (BFP), upper molar (UM), upper central incisor (UCI) (Fig. 3.13). 4. Under general anesthesia, the Weber Ferguson approach was used to gain access to the left maxillary region. The incision was made through the vermillion and the philtrum of the upper lip, around the base of the nose and along the nasal groove. The incision was then extended intraorally along the mucobuccal fold up to the maxillary tuberosity. 5. A full-thickness upper lip and cheek flap was reflected. The labial artery was coagulated. A supraperiosteal dissection plane in the subcutaneous tissues was chosen over the anterolateral maxillary wall in order to keep a safe distance to the OKC. A segmental resection of the left maxilla was performed. Medial pterygoid muscle (MPM), buccal fat pad (BFP), upper central incisor (UCI) (Fig. 3.14). 6. Resected specimen of the left maxilla including the upper alveolar process from the upper canine (UC) to the second upper molar (UM), the zygomatic process, and the maxillary sinus with the odontogenic keratocyst (OKC) (Fig. 3.15). 7. A left osteocutaneous parascapular free flap was chosen for maxillary reconstruction. For flap harvesting, the patient was brought in a lateral decubitus position. The

angle and the lateral and medial borders of the scapula were palpated and outlined (dotted lines). The skin paddle of the parascapular flap was outlined (continuous lines) along the descending branch of the circumflex scapular artery and above the triangular space after palpation of the muscular groove created by the teres major muscle, the teres minor muscle, and the long head of the triceps muscle (Fig. 3.16). 8. The lateral edge of the skin paddle was incised through skin and subcutaneous tissue to the deep fascia overlying the latissimus dorsi muscle, the teres major muscle, the teres minor muscle, and the infraspinatus muscle (Fig. 3.17). 9. The teres major muscle was separated from the latissimus dorsi muscle and transected 3  cm parallel to the lateral scapular bone in order to improve access to the circumflex scapular vessels. A muscle cuff of teres major muscle was left attached to the lateral border of the scapula (Fig. 3.18). 10. The circumflex scapular (CS) vessels became visible in the fascial space between the teres major and teres minor muscles (Fig. 3.19). 11. The circumflex scapular (CS) artery and the two concomitant veins were traced from the lateral scapular rim to the subscapular vessels. The thoracodorsal (TD) vessels were identified after retracting the latissimus dorsi muscle and traced proximally to the bifurcation of the subscapular vessels. The teres minor muscle was transected to gain access to the lateral rim of the scapular bone. The skin paddle was incised along its medial edge (Fig. 3.20). 12. The first osteotomy was carried out 2 cm below the glenohumeral joint under protection of the vascular pedicle. The second osteotomy was performed 3 cm parallel to the lateral scapular rim and the third osteotomy 2  cm above the scapular angle (Fig. 3.21). 13. The subscapular muscle was transected from the undersurface of the scapula. The circumflex scapular (CS) artery and the two concomitant veins were ligated and the parascapular flap was ready for microvascular transfer (Fig. 3.22). 14. Lengthening of the vascular pedicle was performed by limited periosteal stripping (Fig. 3.23). 15. Two suction drains were inserted into the surgical wound and metal staples were used for skin closure (Fig. 3.24). 16. The osteocutaneous parascapular flap was used to cover bone and soft tissue defects of the left maxillary region. Microvascular arterial and venous anastomoses were performed to achieve flap perfusion. Excellent bone and soft tissue healing was observed in the early as well as late postoperative period (Fig. 3.25). 17. Panoramic X-ray following the insertion of four dental implants in the scapular bone 7 months after microvascular reconstruction of the left maxillary defect (Fig. 3.26). 18. Excellent facial contour of the left midface following dental implant-supported prosthetic restoration 12 months after microvascular reconstruction of the left maxillary defect (Fig. 3.27).

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3.2.2 Potential Problems

References to Operative Procedure

1 . Inadequate length of the vascular pedicle. 2. Pronounced thickness of the subcutaneous fatty tissue. 3. Insufficient bony union to pristine bone.

1. Mitsimponas KT, Iliopoulos C, Stockmann P, Bumiller L, Nkenke E, Neukam FW, Schlegel KA (2014) The free scapular/parascapular flap as a reliable method of ­reconstruction in the head and neck region: a retrospective analysis of 130 reconstructions performed over a period of 5 years in a single department. J Craniomaxillofac Surg 42:536–543 2. Nkenke E, Vairaktaris E, Stelzle F, Neukam FW, Stockmann P, Linke R (2009) Osteocutaneous free flap including medial and lateral scapular crests: technical aspects, viability, and donor site morbidity. J Reconstr Microsurg 25:545–553 3. Miles BA, Gilbert RW (2011) Maxillary reconstruction with the scapular angle osteomyogenous free flap. Arch Otolaryngol Head Neck Surg 137:1130–1135

3.2.3 Suggested Solutions 1. Inclusion of thoracodorsal artery and concomitant veins in the vascular pedicle; if venous valves prevent retrograde perfusion, the respective part of the venous pedicle has to be transected and reanastomosed at the opposite ends to allow orthograde perfusion. 2. Excessive fatty tissue can be excised starting from 10 days after surgery. 3. If there is no bony fusion to the pristine bone 3 months after the reconstruction, interpositional bone grafting is done with nonvascularized grafts from the iliac crest.

3.3 Osteocutaneous Vascularized Fibula Free Flap

3.3

Osteocutaneous Vascularized Fibula Free Flap

Emeka Nkenke, Florian Katauczek, Eleftherios Vairaktaris, Konstantin Zauza, Josef Freudenthaler, Konstantinos Mitsimponas, and Christos Perisanidis

3.3.1 Operative Steps 1. Clinical appearance of a 25-year-old female patient with a diffuse swelling in the left mandible (Fig.  3.28a). Tumor growth outside the mandibular cortical bone was observed during diagnostic biopsy. The histopathological examination revealed a mandibular osteosarcoma (Fig.  3.28b). CT scan showed tumor infiltration in the left mandible (white arrow) with destruction of the buccal and lingual cortical bone (Fig. 3.28c). The treatment plan included wide tumor resection with primary free fibula flap reconstruction of the mandibular defect and postoperative chemotherapy. 2. Preoperative three-dimensional computed tomography of the mandible and computer-assisted patient-specific virtual surgical planning. During an online web meeting, the surgeons presented the desired surgical plan and the engineers from DePuy Synthes® and Materialise® enabled visualization of that plan in a virtual environment (using the ProPlan CMF software, DePuy Synthes®, Materialise®). Digital planning started with a virtual simulation of the mandibular resection (red color). The resection was virtually planned from just anteriorly of the right mandibular lateral incisor to a line connecting the left mandibular sigmoid notch (SN) with the anterior part of the left mandibular angle (MA) (Fig. 3.29a, b) The remaining part of the mandible is shown in blue color. Notice the preoperative anterior open bite on the three-dimensional computed-­tomography (Fig. 3.29b). 3. Virtual design of the customized mandible resection guides. Fixation holes (black arrows) are intended for temporary guide fixation. Cylindrical holes (blue arrows) correspond to the defined screw-hole positions (red arrows) on the patient-specific reconstruction plate (Fig. 3.30a, b). Virtual planning of mandibular resection is shown in red color and the remaining part of the mandible is shown in blue color (Fig. 3.30a, b). 4. Virtual simulation of the mandibular reconstruction with a double-barrel, 4-segment right fibula vascularized free flap and a patient-specific reconstruction plate containing individually defined screw hole positions (red arrows) (Fig. 3.31). 5. Digital planning of the customized, 4-segment (S1-S4) right fibula graft (Fig. 3.32).

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6. Virtual design of the customized cutting guide for harvesting the fibula segments. Cylindrical holes correspond to the defined screw hole positions on the patient-specific reconstruction plate (blue arrow) and virtually defined fixation holes (black arrow) (Fig. 3.33). 7. Access to the mandible was gained through a cervical incision and subplatysmal flap elevation. Dissection to the inferior border of the mandible was carried out through the deep cervical fascia while preserving the marginal mandibular branch (MMB) of the facial nerve (Fig. 3.34a, b). Right mandible cutting guide was fixed on the inferior border of the mandibular symphysis (Fig. 3.34a). Left mandible cutting guide was fixed on left mandibular angle and ramus (Fig. 3.34b). Platysma muscle (PM), deep cervical fascia (DCF), sternocleidomastoid muscle (SCM), external jugular vein (EJV), great auricular nerve (GAN). 8. Tumor specimen including the left mandible (Fig. 3.35a). Defect resulting after tumor resection (Fig.  3.35b). Mandibular symphysis (MS), mandibular angle (MA), sternocleidomastoid muscle (SCM). 9. Osteocutaneous fibula flap is harvested (Fig.  3.36). Longus peroneus muscle (LP), anterior intermuscular septum (AIS), posterior intermuscular septum (PIS). 10. Guided osteotomy of the fibula with the aid of the surgical cutting guide (Fig. 3.37). 11. Fibular osteotomies completed. Fixation of the patient-­ specific reconstruction plate while the fibula flap is still perfused by its vascular pedicle (Fig. 3.38). 12. Insertion of the fibula flap in the mandibular defect and fixation with the patient-specific computer-aided design/ computer-aided manufacturing (CAD/CAM) reconstruction plate to the remaining mandibular ramus on the left site and mandibular symphysis/parasymphysis on the right site (Fig.  3.39a, b). Mandibular angle (MA), posterior belly of digastric muscle (PBD), sternocleidomastoid muscle (SCM). 13. The cranial fibular bone segments are positioned in place to increase bone high (double-barrel technique) and are fixed with two mini plates. Microvascular arterial anastomosis (AA) and two venous anastomoses (VA) were performed to achieve flap perfusion (Fig. 3.40). 14. Panoramic X-ray in the immediate postoperative period (Fig. 3.41). 15. Panoramic X-ray showing insertion of three dental implants 6 months after tumor surgery (Fig. 3.42). 16. Postoperative orthodontic treatment is completed to restore the occlusion (Fig. 3.43a, b). 17. Favorable soft tissue healing around titanium abutments after using split-thickness skin graft for creation of keratinized tissue (Fig. 3.44a, b). 18. Prosthodontic restoration is completed (Fig. 3.45a, b).

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3.3.2 Potential Problems

References to Operative Procedure

1. Lack of adequate collateral circulation may lead to variety of ischemic manifestations, namely cellulitis, cold intolerance, and edema. 2. Injury to peroneal nerve may lead to great toe dorsiflexion, pain, numbness, ankle instability, and weakness during ambulation. 3. Loss of skin paddle. 4. Occasionally, hematoma may form in the donor area due oozing from the exposed bone ends.

1. Hidalgo DA (1995) A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 96:585–596 2. Deleyiannis FWB, Rogers C, Ferris RL, Lai SY, Kim S, Johnson J (2008) Reconstruction of through-and-through anterior mandibulectomy defect: indication and limitations of the double-skin paddle fibular free flap. Laryngoscope 118:1329–1334 3. Chaine A, Pitak-Arnopp P, Hivelin M, Dhannuthai K, Bertrand J-C, Bertolus C (2009) Postoperative complications of fibular free flaps in mandibular reconstruction: an analysis of 25 consecutive cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 108:488–495 4. Nkenke E, Vairaktaris E, Schlittenbauer T, Eitner S (2016) Masticatory rehabilitation of a patient with cleft lip and palate malformation using a maxillary full-arch reconstruction with a prefabricated fibula flap. Cleft Palate Craniofac J 53:736–740 5. Nkenke E, Agaimy A, Vairaktaris E, Lell M, von Wilmowsky C, Eitner S (2016) Case history report: immediate rehabilitation with a prefabricated fibula flap following removal of a locally aggressive maxillary tumor. Int J Prosthodont 29:53–58 6. Nkenke E, Eitner S (2014) Complex hemimaxillary rehabilitation with a prefabricated fibula flap and cast-based vacuum-formed surgical template. J Prosthetc Dent 111:521–524

3.3.3 Suggested Solutions 1. Preoperative assessment of the anterior or posterior tibial arteries by conventional angiography or magnetic resonance angiography. 2. Great care during dissection to avoid neural injury; early identification of the nerve during preparation of the flap. A segment of the bone be left attached to the knee. 3. 3.1 Prevention of perfusion problems by preoperative identification of perfusing vessels by Doppler sonography; the flap design should be chosen in a way that the perfusing vessels are situated in the middle of the skin paddle. 3.2 Debridement of the necrotic skin paddle. Alternative flap, namely scapular flap or second soft tissue flap should be considered in case of loss of skin paddle or wound dehiscence and bone exposure or osteoradionecrosis or flap failure.

3.4 Reconstruction of Oral Cavity and Oropharynx with Radial Forearm Free Flap

3.4

 econstruction of Oral Cavity R and Oropharynx with Radial Forearm Free Flap

Siba P. Dubey, Charles P. Molumi, and Herwig Swoboda

3.4.1 Operative Steps 1. The radial forearm flap is marked out with the cephalic vein and the palpable pulse of the radial artery (Fig. 3.46). 2. The dissection is begun distally after exsanguination of the forearm through the use of an elastic bandage and raising the pressure within the tourniquet to 250 mmHg. The distal skin incision is made to gain exposure of the radial artery and cephalic vein. The cephalic vein and radial artery are transected and ligated (Fig. 3.47). 3. The dissection is done from the lateral to medial. The skin flap is elevated with the deep fascia (Fig. 3.48).

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4. The dissection is continued along the intermuscular septum till the point where the brachioradialis and the flexor carpi radialis muscles overlap (Fig. 3.49). 5. The proximal radial artery and cephalic vein are exposed by separating the brachioradialis from the flexor carpi radialis muscles (Fig. 3.50). 6. The radial forearm free flap is ready; it is to be divided when the vessels of the recipient site are ready for anastomosis. The tourniquet is released (Fig. 3.51). 7. Postoperatively, skin graft is placed on the donor area (Fig. 3.52). 8. Six months postoperatively, appearance of the donor area (Fig. 3.53a); a radial forearm free flap into the postexcision defect in the tonsillar area, lateral pharyngeal wall, and soft palate (Fig. 3.53b). 9. The appearance of the donor and recipient areas following reconstruction with radial forearm free flap after posterior maxillectomy (Fig.  3.54a, b; photographs by Dr. Swoboda, Vienna).

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3.4.2 Possible Problems 1. The vascular insufficiency due to inherent vascular architecture of the donor arm. Vascular insufficiency can also occur secondary to tight closure of the forearm skin or from too tight dressing. 2. Infection of donor forearm. 3. Neurological problem can result. 4. Poor take of the skin graft over the tendons.

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3. Avoid injury to the superficial branches of the radial nerve and antebrachial cutaneous nerve. 4. Immobilization of the forearm postoperatively. The tourniquet is removed immediately after the procedure and the vascularity is checked. The skin graft is checked on the seventh postoperative day after removal of the dressing. An elastic stocking is used subsequently to reduce edema and to assist healing. References to Operative Procedure

3.4.3 Suggested Solutions 1. Allen’s test is the most important indicator of vascular sufficiency preoperatively. In doubtful situation, it must be performed more than once. In the operation theatre, Allen test can be performed with the help of pulse oximeter before the procedure is started. The donor arm should be covered with bandage to avoid accidental arterial or venipuncture preoperatively. Intra- and postoperatively, donor arm is observed to avoid excessive pressure from too tight closure or too tight dressing. 2. The operating fields of head and neck, the donor arm, and skin graft donor site must be separate from each other and separate set of instruments are used in each surgical field.

1. Muehlbauer W, Herndl E, Stock W (1982) The forearm flap. Plast Reconstr Surg 70:336–342 2. Soutar DE, McGregor IA (1986) The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 78:1–8 3. Bardsley AF, Soutar DS, Elliot S, Batchelor AG (1990) Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 86:287–292 4. Khaja SF, Rubin N, Bayon R (2017) Venous complications in one versus two vein anastomosis in head and neck free flap. Ann Otol Rhinol Laryngol 126:722–726

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Reconstruction of Total Laryngopharyngectomy Defect with a Tubed Radial Forearm Free Flap

Nicholas McIvor

3.5.1 Operative Steps 1. The operative defect is shown following total laryngopharyngectomy (Fig. 3.55a) and bilateral neck dissection (posterior surface) specimen (Fig. 3.55b). 2. Measuring the size of the flap is required The length of the defect determines the length of the required free flap. In this case, it measures 14  cm. The width of the flap is different at each end. The diameter of the upper lumen is approximately 4 cm, giving a circumference of approximately 12 cm, while the lower lumen has a diameter of 3 cm with circumference of 9 cm. A flap of 14 cm long with width 9 cm distally and 12 cm proximally is planned. 3. Preparing the Forearm The blood supply to the hand is first evaluated with an Allen’s test. Both ulnar and radial arteries are occluded manually while the patient squeezes the hand numerous times to exsanguinate it. The patient then relaxes his hand which should now appear pale while the arteries are occluded. The examiner now releases the pressure on the ulnar artery, while continuing to occlude the radial artery, thus simulating the postoperative result. If there is a prompt return of perfusion to the hand and in particular to the index finger, then it is safe to proceed with a radial forearm free flap. If the index remains pale, then raising a radial flap from this arm is contraindicated and the opposite upper limb should be evaluated. The radial artery and cephalic vein are marked at the wrist. The flap outline is drawn on the forearm and must include both vessels within its boundary. The arm is exsanguinated and a tourniquet is inflated up to 250  mmHg. The duration of tourniquet inflation must be timed and should not exceed 90 min with most flaps raised in under an hour. 4. Raising the Cephalic Border The lateral (cephalic) border is dissected first. The skin is incised to the subcutaneous fat. Continue flap elevation beneath the vein and on the medial aspect of the brachioradialis where the radial nerve will again be encountered. The distal end of the cephalic vein is ligated and divided. An incision is made up the arm and the vein is followed proximally until the desired flap pedicle length has been achieved. In this case, the vessels were to come off the upper end of the flap and have to be long enough to reach the neck vessels for anastomosis.

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8.

9.

Sensory branches of the radial nerve running on the brachioradialis are preserved. Continue dissection medially under the radial artery and on top of the flexor pollicis longus (Figs. 3.56, 3.57, and 3.58). There will be numerous vessels from the radial artery passing into this muscle and they must be individually ligated and divided. Raising the Ulnar Border The medial (ulnar) incision is made and the flap is elevated over the fascia of the flexor tendons toward the radial artery joining with the lateral dissection deep to the vessels (Fig. 3.59). Again, vessels running through flexor pollicis longus are divided. Releasing the Tourniquet and Flap Harvesting The tourniquet is deflated and bleeding from the flap (Fig.  3.60) and perfusion of the index finger are confirmed. There will be small bleeders that require ligation. With confirmation of good hand perfusion, the radial artery (with its paired venae comitantes) is ligated and divided, thus releasing the flap distally and leaving it solely pedicled on the feeding vessels (note: many surgeons divide the distal vessel ends early in flap elevation) (Fig. 3.61). While the flap is perfusing, the skin can be tubed and closed with interrupted sutures. It is often easier to achieve a watertight closure by suturing the tube with the skin externally (Fig. 3.62) and then turning the tube inside out so that the skin is on the inside (Figs. 3.63 and 3.64). Alternatively, it can be closed with inverting mattress sutures to achieve the same. The tubed flap ready for harvest must have the vessels and fascia outside and the skin inside. The flap is harvested (Fig.  3.65) and the forearm is closed. A split thickness skin graft is harvested from the ipsilateral thigh and applied to the defect. A suction drain is usually inserted to drain the arm wound. Insetting the Flap The flap is positioned with vessels coming off superiorly as planned and running down to the recipient neck vessels. The flap is then sewn in place with inverting individual mattress sutures above and below (Fig.  3.66). Often, a Montgomery salivary bypass tube is used as a stent. Watertight closure is necessary. A nasogastric tube may pass through the flap; alternatively, postoperative feeding may be achieved with a stomagastric tube. Microvascular Anastomosis The radial artery is anastomosed under magnification to a suitable neck artery and the cephalic vein anastomosed to a neck vein. In this case, the supraclavicular vessels were used. Closure Drains are inserted in such a way as to not compromise the feeding vessels to the flap. The skin flaps are closed.

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3.5.2 P  otential Problems and Suggested Solutions 1. Flap Failure The flap requires frequent and close monitoring, particularly over the first 2 days with prompt return to theatre if there is arterial or venous compromise. This is usually done with implantable Dopplers, but can be achieved by raising the flap with a separate island of vascularized skin on the flap vessels which is then included in the neck skin closure. This skin island can be easily monitored to ensure good perfusion and venous drainage. 2. Postoperative Pharyngocutaneous Fistula Ensure that the epithelium is inverted into the lumen during inset of the flap. The posterior wall at each end can be sewn with horizontal mattress sutures and the anterior walls with inverting mattress “Connell” sutures. Any sign of wound infection or fistula should be managed by returning the patient to theatre for washout, drainage, and repair of a leak if possible. 3. Pharyngeal Stenosis at the Inferior Repair Line This can occur due to excessive wide mattress sutures or poor flap planning. It can also occur after pharyngocutaneous fistula. Sewing over a Montgomery salivary bypass tube helps to prevent both.

3  Free Flap in Head and Neck Reconstruction

References to Operative Procedure 1. Muehlbauer W, Herndl E, Stock W (1982) The forearm flap. Plast Reconstr Surg 70:336–342 2. Bardsley AF, Soutar DS, Elliot S, Batchelor AG (1990) Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 86:287–292 3. Harri K, Ebihara S, Ono I, Saito S, Terui S, Takato T (1985) Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 75: 463–474 4. Disa JJ, Pusic AL, Hidalgo DA, Cordeiro PG (2003) Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases. Plast Reconstr Surg 111:652–660 5. Deschler DG, Herr MW, Kmiecik JR, Sethi R, Bunting G (2015) Tracheosphageal voice after total laryngopharygectomy reconstruction: jejunum versus radial forearm free flap. Laryngoscope 125:2715–2721

3.6 Reconstruction of Total Maxillectomy and Orbital Exenteration Defect with Vertical Rectus Abdominis Free Flap

3.6

 econstruction of Total Maxillectomy R and Orbital Exenteration Defect with Vertical Rectus Abdominis Free Flap

Nicholas McIvor

3.6.1 Operative Steps 3.6.1.1 Incision and Raising of Flap Following left total maxillectomy with orbital exenteration, the defect is measured (Figs. 3.67 and 3.68). The length of the flap required is determined by measuring from the top of the orbit down to the hard palate and then across to the buccal mucosa. The width is the distance between the Eustachian tube orifice posteriorly and the nasal spine anteriorly. The flap is raised as a vertical ellipse of abdominal skin perfused by vessels which arise from the inferior epigastric vessels and perforate the (left in this case) rectus muscle. A large segment of the left rectus muscle is therefore raised with the skin. The incision goes down directly to the rectus sheath (Fig. 3.69). The margins of the left anterior rectus sheath are then incised: superiorly at the upper incision margin, inferiorly at the lower incision margin, medially just inside the linea alba and laterally at the lateral border of the rectus muscle. Perforators may be encountered passing through the sheath and are included in the flap. The rectus muscle is then divided superiorly to expose the posterior rectus sheath. Vessels passing longitudinally within the muscle at the upper margin are ligated and divided (the blood supply is coming inferiorly). 3.6.1.2 Isolation of Vessels The rectus muscle is then elevated anteriorly and inferiorly to identify the inferior epigastric feeding vessels on the deep aspect of the flap and arising from iliac vessels deep to the inguinal ligament. Segmental vessels running into the flap from the lateral aspect will need to be ligated and divided. The flap vessels are followed inferiorly to achieve the desired pedicle length and vessels of approximately 2–3  mm diameter. The draining veins are paired vena commitantes and often join into a single vein of approximately 3–4 mm just above the inguinal ligament. With these vessels in view and protected, the rectus muscle is divided again inferiorly to achieve a free segment of rectus muscle of approximately 7 cm by 15 cm with an ellipse of overlying skin perfused by the inferior epigastric artery and draining into a common vena commitens (Figs. 3.70 and 3.71). 3.6.1.3 Harvesting of Flap and Closure of Rectus Sheath The flap is harvested by ligating and dividing the vessels (Fig. 3.72). The rectus sheath is repaired either with surgical mesh (Fig. 3.73) or by direct closure with 0 prolene sutures.

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3.6.1.4 Creation of Tunnel A tunnel is made from the maxillectomy defect into the neck for the flap vessels to pass through (Fig. 3.74). 3.6.1.5 Preparing Medial Canthus If the eyelids have been preserved as in this case, they are de-epithelialized on their deep surfaces. Best cosmesis will be obtained by restoring the medial canthus. A drill hole is made as near as possible to the original, but if bone is deficient, a miniplate is inserted and positioned to achieve the same anchoring point. In this case, there was sufficient bone to drill (Fig. 3.75). 3.6.1.6 De-epithelialization of Flap The most distal flap skin is positioned in the orbit and de-­ epithelialized, as it will be buried (Fig. 3.76). It is sutured to the drill hole at the medial canthus to prevent sagging (Fig. 3.77). Any other skin that will be buried (most) is also de-epithelialized. Do not leave skin to line the lateral wall of the nose internally, as it will simply crust and smell. The only flap skin that is retained is that planned to line the palatal defect. 3.6.1.7 Inset Medial Canthus The medial canthus is then sutured to the drill hole with permanent suture (Fig. 3.78). 3.6.1.8 Closure of Lateral Wall Nose Internally use either flap muscle or dermis to line the lateral wall of the nose. There should be no buried skin other than dermis. The external lateral wall of the nose is closed in layers. 3.6.1.9 Vessels Brought into Neck The flap vessels are brought into the neck (Fig. 3.79). 3.6.1.10 Closure Palate The palate is closed with flap muscle and rectus sheath (Fig.  3.80) or using flap skin. Any redundant flap tissue is resected while taking care to avoid the feeding vessels. 3.6.1.11 Microvascular Anastomosis The flap vessels are anastomosed to neck vessels. Drains are inserted taking care to not compromise these vessels. Neck wounds are closed (Fig. 3.81). 3.6.1.12 Postoperative Care Pre-resection tracheostomy is required to free the operative field. Also, there will be flap swelling in the mouth and blood oozing down the pharynx. It is removed when those issues are resolved. A nasogastric tube is also inserted at the start of the procedure. Oral feeding can occur after 7 days if the flap looks healthy and the palatal reconstruction secure.

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3.6.2 P  otential Problems and Suggested Solutions 1. The flap harvest is straightforward and akin to a pectoralis major flap harvest, as the vessels run on the deep surface of the muscle and perforate the muscle to supply the skin. Take care when dividing the rectus muscle inferiorly to have the vessels in view and protected as unlike a pectoralis flap, an island of free muscle is harvested. 2. The rectus sheath can be closed primarily from side to side with interrupted prolene sutures. Closure can be tight risking wound dehiscence and herniation. When incising the rectus sheath, leave sufficient sheath lateral and medial to allow good needle purchase. Close with interrupted figure 8 sutures and never with a continuous single suture, as dehiscence is more likely. Take care with suture placement to avoid penetrating the posterior rectus sheath and therefore risking bowel penetration and peritonitis. 3. The flap requires frequent and close monitoring particularly over the first 2 days with prompt return to theatre if there is arterial or venous compromise.

3  Free Flap in Head and Neck Reconstruction

References to Operative Procedure 1. Jones NF, Sekhar LN, Schramm VL (1986) Reconstruction of middle and posterior cranial base. Plast Reconstr Surg 78:471–477 2. Urken ML, Turk JB, Weinberg H, Vickery C, Biller HF (1991) The rectus abdominis free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 117:857–866 3. Browne JD, Burke AJC (1999) Benefits of routine maxillectomy and orbital reconstruction with the rectus abdominis free flap. Otolaryngol Head Neck Surg 121:203–209 4. Cordeiro PG, Santamaria E (2000) A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 105:2331–2346 5. Bianchi B, Bertolini F, Ferrari S, Sesenna E (2006) Maxillary reconstruction using rectus abdominis free flap and bone grafts. Br J Maxillofac Surg 44:526–530 6. Cappiello J, Piazza C, Taglietti V, Nicolai P (2012) Deep inferior epigastric artery perforated rectus abdominis free flap for head and neck reconstruction. Eur Arch Otorhinolaryngol 269:1219–1224

4

Harvesting of Free Grafts for Head and Neck Surgery

4.1

Abdominal Fat

Siba P. Dubey and Charles P. Molumi

4.1.1 Operative Steps 1. The abdomen area in males is shaved and an incision is marked out 2–3 cm above the umbilicus from 3 o’clock to 9 o’clock position (Fig. 4.1).

2. The incision is made through the skin to the subcutaneous tissue to expose the fat. The dissection of the fat is continued till the rectus abdominis muscle fascia is reached. The fat is dissected superficial to the rectus abdominis muscle fascia. The overlying skin is undermined to isolate the required amount of fat (Fig. 4.2). 3. The free fat flap is harvested and trimmed to the required size (Fig. 4.3).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_4

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4.1.2 Potential Problems 1. Peritoneal perforation 2. Small amount of fat graft than required 3. Wound dehiscence causing cosmetic deformity

4  Harvesting of Free Grafts for Head and Neck Surgery

3. Ensure that the dissection of the fat graft is done superficial to the rectus abdominis muscle. The dissecting scissors or diathery must be hold horizontal to the rectus abdominis muscle. References to Operative Procedure

4.1.3 Suggested Solutions 1. To allow for shrinkage, the fat graft must be 30% more than the required. 2. Always leave 3–5  mm of fat layer in the subcutaneous tissue to prevent wound dehiscence.

1. Conger BT, Gourin CG (2008) Free abdominal fat transfer for reconstruction of the total parotidectomy defect. Laryngoscope 118:1186–1190 2. Davis RE, Guida RA, Cook TA (1995) Autologous free dermal fat graft: reconstruction of facial contour defects. Arch Otolalaryngol Head Neck Surg 121:95–100

4.2 Fascia Lata

4.2

Fascia Lata

Herwig Swoboda

4.2.1 Operative Steps 1. The patient is made to lie on his side or in supine position and the knee is extended. The size of the graft usually determines the type incision required. Antiseptic preparation was done on the lateral aspect of the thigh from its upper end down to the knee. A line was drawn from the anterior superior iliac crest to the head of the fibula. A transverse or straight line incision is made in the lower part of this line a few centimeters above the knee when a smaller graft around 5 cm in length is needed (Fig. 4.4).

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For much bigger graft, a longer ‘S’-shaped incision is preferred. The skin, subcutaneous tissue, and fat are cut and separated above and below using a small sponge on a long forceps (Fig. 4.5). 2. The fascia lata is identified as glistening white sheet of avascular tissue with fibers running parallel to the axis of the leg; it was exposed and was defined clearly (Fig. 4.6). 3. The required dimension of fascia lata is cut with knife and blunt-tipped scissors to avoid injury to the muscle underneath (Fig. 4.7). 4. The fascial lata is separated from the underlying vastus lateralis muscle (Fig. 4.8). 5. The fascia is removed and placed separately wrapped in wet cloth before use (Fig. 4.9). 6. The fascial gap is closed by interrupted sutures over the vastus lateralis muscle (Fig. 4.10).

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4.2.2 Potential Problems

References to Operative Procedure

1. Tensor fascia lata muscle will be entered by a proximal incision while a more medial incision might miss the fascia entirely. 2. Various complications have been mentioned, namely local pain, joint problem, injury to lateral cutaneous nerve of the thigh, reduction of muscle power, muscle herniation, and cosmetic concern.

1. Drever JM (1972) A simple method for obtaining fascia lata grafts. Plast Reconstr Surg 50:196–197 2. Wheatcroft SM, Vardy SJ, Tyers AG (1997) Complication of fascia lata harvesting for ptosis surgery. Br J Ophthalmol 81:581–583 3. Amir A, Gatot A, Zucker G, Sagi A, Fliss DM (2000) Harvesting large fascia lata sheaths: a rational approach. Skull Base Surgery 10: 29–34 4. Bleyen I, Hardy I, Codere F (2009) Muscle prolapse after harvesting autogenous fascia lata used for frontalis suspension in children. Ophthalmic Plast Reconstr Surg 25:359–360

4.2.3 Suggested Solutions 1. A distal incision on the lateral aspect of the thigh is the optimal site of harvesting the fascia lata. 2. Use of small incision and Crawford stripper for a bigger graft used to reduce the long-standing complication in most patients.

4.3 Sural Nerve Graft

4.3

Sural Nerve Graft

Siba P. Dubey and Charles P. Molumi

4.3.1 Operative Steps 1. A vertical incision marking is made out approximately 1 cm posterior and 1 cm superior to the lateral malleolus. The incision marking is extended in either direction for a

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variable distance depending on the required length of the nerve graft (Fig. 4.11). 2. The skin is incised to the subcutaneous tissue. The sural nerve is identified medial to the short saphenous vein within the subcutaneous tissue. The nerve is isolated from the surrounding tissues (Fig. 4.12). 3. Measure the required length of the nerve graft and transect the nerve inferiorly and superiorly (Fig.  4.13). Caudally, the nerve divides into branches which may be included in the graft according to necessity.

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4.11

Sural nerve

Short saphenous vein

4.12

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4.3.2 Potential Problems

References to Operative Procedure

1. Nerve injury

1. Ducic Y (2000) A new technique of sural nerve harvest. J Otolaryngol 29:386–388 2. Hill HL, Vasconez LO, Jerkiewicz MJ (1978) Method of obtaining sural nerve graft. Plast Reconstr Surg 61:177–179

4.3.3 Suggested Solutions 1. Avoid excessive stretching during isolation of the nerve.

5

Laser Microsurgery for Glottic Cancer

5.1

Transoral Approach

Mohssen Ansarin, Augusto Cattaneo, and Francesco Chu

5.1.1 Operative Steps Under general anesthesia, after oro-tracheal intubation with a specific double-cuffed endotracheal tube (Laser-Flex Mallinckrodt, Athlone, Ireland or Laser Shield II, Xomed, Jacksonville, Florida), the larynx is exposed and suspension is obtained (Figs.  5.1a, b). A bedside assistant exercises external counterpressure on the larynx in order to expose the anterior commissure region. Before starting transoral laser microsurgery (TLM), it is mandatory to intraoperatively explore the larynx with angle rigid endoscopes (we suggest 30°and 70°), examining both vocal cords, ventricles, and subglottis. The surgeon might use an endoscopic rigid forceps to assess the consistency of the tumor at the level of its margins, raising the false vocal fold to evaluate tumor’s extension into the ventricle (Fig. 5.2). The laryngeal endoscopic surgical set consists of rigid laryngoscopes, light source and smoke suction, suction with integrated electrocautery function, cotton gauzes in different sizes, and endoscopic forceps with different tip angles (Fig. 5.2).

5.1.1.1 Subepithelial Cordectomy (Type I) Sub-epithelial cordectomy is performed for cases of vocal fold lesions suspected for premalignant or malignant transformations; it includes the resection of the vocal fold epithelium, passing through the superficial layer of the lamina propria, sparing the deeper layers and thus, the vocal ligament. Preoperative squamous cell carcinoma in situ of the left vocal fold (Fig. 5.3a) and the same patient after type 1 cordectomy (Fig. 5.3b).

5.1.1.2 Subligamental Cordectomy (Type II) Subligamental cordectomy, performed by cutting between the vocal ligament and the vocal muscle, is the resection of the epithelium, Reinke’s space, and the vocal ligament. The vocalis muscle is preserved as much as possible. The resection may extend from the vocal process to the anterior commissure. Squamous cell carcinoma (T1a) of the right vocal fold before (Fig.  5.4a) and after type II cordectomy (Fig. 5.4b). The vocal ligament is removed with exposure of the thyroarytenoid muscle. This procedure is indicated when a lesion shows clinical signs of neoplastic transformation and stroboscopic examination indicates a deeper infiltration, or “vibratory silence.” 5.1.1.3 Transmuscular Cordectomy (Type III) Transmuscular cordectomy is performed by cutting through the vocalis muscle. The resection may extend from the vocal process to the anterior commissure and encompass the epithelium, lamina propria, and part of the vocalis muscle, with or without partial resection of the ventricular fold (vestibulectomy). Squamous cell carcinoma of the right vocal fold before (Fig. 5.5a) and after Type III cordectomy (Fig. 5.5b). Type III cordectomy is indicated for superficial cancer of the mobile vocal fold, where cancer reaches the vocalis muscle without deep infiltration. 5.1.1.4 Total or Complete Cordectomy (Type IV) Complete cordectomy extends from the vocal process to the anterior commissure and reaches the internal perichondrium of the thyroid ala, sometimes included with the resection. Squamous cell carcinoma of the right vocal fold and ventricular fold before (Fig. 5.6a) and after type IV cordectomy (Fig. 5.6b). The neoplasia reaches out the anterior commissure without infiltrating it. The vocalis muscle is removed, and the ventricular fold is sacrificed.

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_5

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This cordectomy is indicated for cases where cancer infiltrates the vocal fold and is diagnosed prior to surgery. Resection can be extended to remove partially or totally the ipsilateral ventricular fold in order to ensure complete resection of the vocal fold. Extension of a neoplasm may spread as far as the anterior commissure, but without involving it.

5.1.1.5 Extended Cordectomy (Type V) Four types of extended cordectomies (type V) are described. Type Va: the resection includes a hemilarynx, the anterior commissure, and a portion of the contralateral vocal fold. The resection of the petiole of the epiglottis is sometimes necessary to ensure sufficient visualization. In some cases, the incision is continued toward the subglottis. Type Vb: this cordectomy is indicated for vocal fold carcinoma involving posteriorly the vocal process but sparing the arytenoid. The cartilage is partially or totally resected and the posterior arytenoid mucosa is preserved. Type Vc: total cordectomy can be extended to the ventricular fold. This procedure is indicated for ventricular or

5  Laser Microsurgery for Glottic Cancer

transglottic cancers that spread from the vocal fold to the ventricle. The specimen encompasses the ventricular fold and Morgani’s ventricle. Squamous cell carcinoma of the right ventricular fold before (Fig.  5.7a) and after (Fig.  5.7b, c) type Vc cordectomy extended to the ventricular fold. Type Vd: If necessary, resection can be continued as deep as 1 cm under the glottis in order to expose the cricoid cartilage.

5.1.1.6 Anterior Commissurectomy or Type VI Cordectomy Type VI cordectomy is indicated for cancer originating in the anterior commissure extended or not to one or both vocal folds, without infiltration of the thyroid cartilage. Squamous cell carcinoma of the anterior commissure before (Fig. 5.8a) and after (Fig. 5.8b, c) Type VI cordectomy. Resection of the anterior commissure includes the subglottic mucosa and the cricothyroid membrane. This is an anterior commissurectomy with bilateral anterior cordectomy.

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5.8c

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5.1.2 Potential Problems 1 . Dental fractures (i.e. upper incisor teeth). 2. Traumatic laceration of the anterior pillar of the tonsil. 3. Impairment of the lingual / hypoglossal nerve function due to lingual compression. 4. Laryngeal obstruction by foreign body (i.e. gauges, sponges)

5.1.3 Suggested Solutions 1 . Use of Gum shield 2. Careful and delicate inspection of the oral cavity and oropharynx before laryngeal exposure, and use of waterbased lubricant 3. In case of procedural delays (for more than two hours), it is recommended to schedule one or more breaks to relieve

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the pressure on the tongue (i.e. laryngoscope extraction or tension release) 4. Sponge / gauge count should be done before laryngeal exposure and before laryngoscope removal. References to Operative Procedure 1. Remacle M, Eckel HE, Antonelli A, et  al (2000) Endoscopic cordectomy:a proposal for a classification by the Working Committee, European Laryngological Society. Eur Arch Otorhinolaryngol 257:227–231 2. Remacle M, Van Haverbeke C, Eckel H, et  al (2007) Proposal for revision of the European Laryngological Society classification of endoscopic cordectomies. Eur Arch Otorhinolaryngol 264:499–504

6

Lips and Facial Defects Repair

6.1

 bbe–Estlander Flap for Repair of Lip A Defect

Siba P. Dubey and Charles P. Molumi

6.1.1 Operative Steps 1. The line of excision of the upper lip flap is marked out to close a lower lip defect from human bite. The flap is marked out such that width of the base of the triangular flap is half that of the width of the base of the triangular surgical defect (Fig. 6.1). 2. The margins of the defect are refashioned. The mucosal edges and muscle of the lip are incised (Fig. 6.2). 3. The skin incision of the flap is begun on the lateral aspect of the upper lip. The incision is carried through both the muscle and mucosa, and the superior labial artery running between the muscle and mucosa along the inferior margin of the upper lip close to the wet line is identified and ligated (Fig. 6.3). 4. The incision on the medial margin of the flap is done carefully not to injure the labial artery. The knife is carried to the subcutaneous tissue beginning at the vermilion border. The muscle is slowly separated and the labial artery is identified and preserved. Under direct vision, the

muscles around the labial artery are incised keeping the mucosa of the vermilion intact. The pedicle of the flap contains the labial artery and accompanying vein, muscle, and mucosa of the vermilion border. The mucosa on the medial aspect of the flap is divided. The Estlander flap is rotated to fill the defect in the lower lip (Fig. 6.4). 5. The vermilion edges of the flap and the lower lip are accurately approximated and anchored with nylon sutures and retracted to ensure that the flap is placed accurately (Fig. 6.5). 6. The defect is closed by first suturing the muscular layer of the flap and the lower lip. The mucosal layer is closed followed by the closure of the skin. A bridged pedicle between the upper and lower lips allows the flap to be attached to the upper lip. The accurate approximation of the vermilion border of the upper lip is not possible due to the attachment of the flap to the upper lip by the bridge pedicle (Fig.  6.6). The skin sutures are removed after 7 days (Fig. 6.7). 7. When a lesion of the upper lip is excised (Fig.  6.8), an Abbe flap is used. The flap is elevated from the lower lip based on the inferior labial artery to close the upper lip defect (Figs.  6.9, 6.10 and 6.11). Despite microstomia, symmetry and function of the lip are maintained (Fig. 6.12a, b).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_6

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6.2

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189

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6.3

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6.4

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Abbe’s flap

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6.1.2 Potential Problems

References to Operative Procedure

1 . Notching deformity at the site of repair. 2. Flap failure.

1. Estlander JA (1968) A method of reconstructing loss of substance in one lip from the other lip (translated and reprinted from Archiv fur Klinische Chirurgie, 14: 622, 1872). Plastic Reconstr Surg 42:360–366 2. Abbe R (1968) A new plastic operation for the relief of deformity due to double harelip (reprinted from Medical Record, 53: 477, 1898). Plastic Reconstr Surg 42:480–482 3. Genc S, Ugur SS, Arslan IB, Tuhanioglu B, Demir A, Selcuk A (2012) Lower lip reconstruction with Abbe-­ Estlander flap modification: preserving the same side vascular pedicle. Eur Arch Otorhinolaryngol 269:2593–2594 4. Templer J, Renner G, Davis WE, Thomas JR (1981) “How I do it”—plastic surgery. Practical suggestions on facial plastic surgery. A modification of the Abbe-­ Estlander flap for defects of the lower lip. Laryngoscope 91:153–156

6.1.3 Suggested Solutions 1. While mobilizing the specimen, do not grasp and pull too hard, as the stretch will pull the lower lip muscle and be excised. The resulting loss of muscle of the lower lip will result in the upper lip flap thicker than the donor site, resulting in notching deformity. 2. The labial artery when injured at the medial margin of the upper lip flap leads to flap failure. To have a visualized course of the artery, the incision is begun at the lateral margin of the of the upper lip flap, the artery identified and ligated. The surgeon is guided when doing incision of the medial side of the flap. Take extreme care when placing sutures between the edge of the flap and muscles of the lower lip near the commissure to avoid injury to the labial artery in the pedicle of the flap.

6.2  Bilobed Flap for Repair of Cheek Defect

6.2

 ilobed Flap for Repair of Cheek B Defect

Siba P. Dubey and Charles P. Molumi

6.2.1 Operative Steps 1. The defect is closed by the first lobe which is same size as the defect. The secondary lobe closes the donor site and the donor site is closed primarily. The planned procedure in this case is 3 cm × 3 cm basal cell carcinoma of the cheek skin (Fig. 6.13). 2. The donor site is marked out such that the height of the first lobe corresponds to the second arch. The height of

195

the second lobe is twice that of the first lobe. The width of the first lobe corresponds to that of the defect while that of the second lobe is slightly smaller than the first (Fig. 6.14). 3. Incise the skin such that the depth corresponds to the depth of the defect and elevate the flap at this level. Continue elevation till the flap can be rotated to the defect (Fig. 6.15). 4. Any extra tissue is excised so the donor best fits the defect (Fig.  6.16). The donor lobe, the secondary lobe, and donor site are closed primarily (Fig. 6.17). 5. The appearance of the operated site 3 months postoperatively (Fig. 6.18).

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6  Lips and Facial Defects Repair

6.13

Ala of nose

6.14

6.2  Bilobed Flap for Repair of Cheek Defect

197

Right Ear lobule

6.15

Ala of nose

6.16

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Ala of nose

6.17

6.18

6.2  Bilobed Flap for Repair of Cheek Defect

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6.2.2 Potential Problem

References to Operative Procedure

Irregular shape of the defect leading to harvesting of mismatched donor

1. McGregor JC, Soutar DS (1981) A critical assessment of bilobed flap. Br J Plastic Surg 34:197–205 2. Zitelli JA (1989) The bilobed flap for nasal reconstruction. Arch Dermatol 125:957–959 3. Cook JL (2005) Reconstructive utility of the bilobed flap: lessons from flap successes and failures. Dermatol Surg 31(8 Pt 2):1024–1033 4. Chu EA, Byrne PJ (2009) Local flaps I: bilobed, rhombic, and cervicifacial. Facial Plast Surg Clin N Am 17:349–360

6.2.3 Suggested Solution The borders of the defect must be well defined and regular before harvesting the donor site. If the borders of the defect are not well defined and/or the shape is too irregular, incise the edges of the defect so a well-contoured circular shape defect is created whenever possible. After this is done, measure the defect and ensure a donor fits to the defect.

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6.3

6  Lips and Facial Defects Repair

Cervicofacial Rotation-Advancement Flap

Siba P. Dubey and Charles P. Molumi

6.3.1 Operative Steps 1. The incision is marked for the excision of neurofibroma involving midface and adjoining external nose, and repair of the defect with deep-plane cervicofacial advancement flap (Fig. 6.19). 2. The neurofibroma is excised; a large defect is created in the midface, medial canthus, and adjoining bridge of the nose (Fig. 6.20). 3. A posteriorly based deep-plane cervicofacial flap is raised with incision along the right nasolabial crease; the plane

of dissection is kept superficial to the facial muscles and deep to superficial musculoaponeurotic system (Fig.  6.21). During the elevation of the flap, the frontal and mandibular branch of the facial nerve is protected. Subsequently, the incision is extended to the upper part of the neck at a plane deep to the platysma muscle (Fig. 6.21). The anterior part of the flap is supplied by submental and perforating branches of the facial artery while the posterior part of the flap is supplied by the perforating branches of the superficial temporal artery. 4. The advancement flap covers most of the raw area except in the medial canthus and adjoining nasal dorsum (Fig. 6.22). 5. An appropriate size island forehead flap (described in Chap. 2) is used to cover the medial canthal and adjoining nasal dorsal defect (Fig. 6.23).

6.3  Cervicofacial Rotation-Advancement Flap

201

6.19

6.20

202

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6.21

6.22

6.3  Cervicofacial Rotation-Advancement Flap

203

Island forehead flap

6.23

204

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6.3.2 Potential Problems

References to Operative Procedure

1. The distal edge of the flap may develop ischemic necrosis when a large flap is stitched with tension. 2. Possible injury to the peripheral branches of the facial nerves at the anterior margin of the gland where the branches are not protected by parotid tissue. 3. Ectropion of the lower eyelid.

1. Kroll SS, Reece GP, Robb G, Black J (1994) Deep-plane cervicifacial rotation-advancement flap for reconstruction of large cheek defect. Plast Reconstr Surg 94:88–93 2. Tan ST, MacKinnon CA (2006) Deep plane cervicofacial flap: a useful and versatile technique in head and neck surgery. Head Neck 28:46–55 3. Hivelin M, Wolkenstein P, Lepage C, Valeyrie-Allanore L, Meningaud JP, Lantieri L (2010) Facial aesthetic unit remodeling procedure for neurofibromatosis type I hemifacial hypertrophy: result on 33 consecutive adult patients. Plastic Reconstr Surg 125:1197–1207 4. Boyette JR, Vural E (2011) Cervicofacial advancement-­ rotation flap in midface reconstruction: forward or reverse? Otolaryngol Head Neck Surg 144:196–200

6.3.3 Suggested Solutions 1. Appropriate deep-plane dissection results in improved flap mobilization and blood supply; it reduces the chance of the necrosis of the distal most part of the flap. 2. Blunt dissection with hemostat held perpendicular to the skin is safe and effective to avoid injury to facial nerve branches; compulsory use of bipolar forceps for hemostasis is also helpful. 3. Ectropion of the lower eyelid is prevented by anchoring the flap above the lateral canthus and tightening the lower eyelid.

6.4  Lip Shaving

6.4

Lip Shaving

Siba P. Dubey and Charles P. Molumi

6.4.1 Operative Steps 1. The incision is marked out to excise the vermilion surface of the lip to excise the hyperkeratotic superficial infiltrating squamous cell carcinoma of the lower lip (Fig. 6.24). 2. The vermilion border is shaved off with adequate margins (Fig. 6.25).

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3 . The surgical defect after excision (Fig. 6.26). 4. The entire labial mucosa of the lower lip is mobilized to the gingivolabial sulcus. The mucosal edges are anchored with sutures and the labial mucosa is approximated to the cutaneous margin of the surgical defect (Fig. 6.27). 5. The labial mucosa is sutured to the cutaneous margin to close the defect (Fig. 6.28). 6. The lip maintains normal function and appearance (Fig. 6.29).

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6.24

6.25

6.4  Lip Shaving

207

6.26

6.27

208

6  Lips and Facial Defects Repair

6.28

6.29

6.4  Lip Shaving

209

6.4.2 Potential Problems

References to Operative Procedure

1 . Inadequate resection margin 2. Disfiguration of lip

1. Kolhe PS, Leonard AG (1988) Reconstruction of the vermilion after “lip-shave.” Br J Plast Surg 41:68–73 2. McGregor IA (1983) Reconstruction of the lower lip. Br J Plast Surg 36:40–47 3. Birt BD (1977) The “lip shave” operation for pre-­ malignant conditions and micro-invasive carcinoma of the lower lip. J Otolaryngol 6:407–411

6.4.3 Suggested Solutions 1 . Always do frozen section of the surgical margins. 2. Accurate alignment of the cutaneous margin to the remaining vermilion border is very important.

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6.5

6  Lips and Facial Defects Repair

Lip Shaving with “V” Excision

Siba P. Dubey and Charles P. Molumi

6.5.1 Operative Steps 1. The vermilion cutaneous incision is marked from one commissure to the other (Fig.  6.30a). Anteriorly, it is marked on the lip skin (white roll) and posteriorly to the inner lip mucosa or the wet line (Fig. 6.30b). The vermilionectomy incision is communicated with the “V” incision of the vermilion. 2. The incision is begun on both commissure and carried to the midline to the edge of the proposed “V” incision on both sides (Fig. 6.31). The incision is carried superficial to the muscle bed. The “V” incision of the vermilion is begun anteriorly at the skin and through-and-through excising of the muscle and the mucosa posteriorly is carried. The incision is done with the lip “pinched” between

the thumb and index fingers of the assistant to compress the inferior labial artery. 3. The specimen is removed; bleeding is controlled by slowly releasing the compression of the lower lip and bipolar coagulation (Fig. 6.32). The wound margins and excised specimen are examined for tumor clearance. 4. The closure of the superficial defect is begun by placing sutures through the vermillion edge of the skin of the “V”-shaped defect. Tension is applied to the ends of the skin suture which allows both sides of the surgical defect to collapse to permit accurate closure of the muscle sutures (Fig. 6.33). 5. The “V” is closed beginning with the muscle, mucosa, and skin. The mucosa is undermined in a plane such that some minor salivary gland tissue remains on the mucosal flap while the muscle remains intact. The mucosa is advanced adequately to meet the vermilion skin without inversion of the lip. The mucosa is sutured to the vermilion skin (Fig. 6.34). 6. The appearance after 5 days postoperatively (Fig. 6.35).

6.5  Lip Shaving with “V” Excision

211

6.30a

6.30b

6.31

212

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6.32

Minor salivary gland

6.33

6.5  Lip Shaving with “V” Excision

213

6.34

6.35

214

6.5.2 Potential Problems 1 . Anatomical disfigurement of lip 2. Functional incompetence of the lower lip 3. Tension of the advancement flap 4. Inadequate vermilion in females to apply lipstick and irritation to upper lip from ingrown air in male patients

6.5.3 Suggested Solutions 1. Accurate alignment of the mucosa to the remaining vermilion border is very vital to restore the anatomical configuration of the reconstructed lower lip. 2. Always ensure that the excision is done superficial to the orbicularis oris muscle to maintain the function of the lip. At the “V” incision, ensure that the muscle layer is approximated perfectly and sutured. 3. Advancement flap is done 2–3 cm adjacent to the defect on both sides. If it is found to be tense after undermining, do a relaxing incision in the gingivolabial sulcus incision from one commissure to the other.

6  Lips and Facial Defects Repair

4. Always discuss unavoidable insignificant complications like dissatisfaction of loss of vermilion in female patients and hair growth along the edge of the mucosa and skin in male patients. References to Operative Procedure 1. Kolhe PS, Leonard AG (1988) Reconstruction of the vermilion after “lip-shave.” Br J Plast Surg 41:68–73 2. Birt BD (1977) The “lip shave” operation for pre-­ malignant conditions and micro-invasive carcinoma of the lower lip. J Otolaryngol 6:407–411 3. Barton M, Spira M, Hardy SB (1964) An improved method for “V” excision of the lip combined with vermilionectomy. Plast Reconstr Surg 33:471–473 4. Spira M, Hardy SB (1964) Vermilionectomy: review of cases with variations in technique. Plast Reconstr Surg 33:39–46 5. Kurth MB (1957) Lip shave or vermilionectomy; indications and technique. Br J Plast Surg 10:156–162

6.6  Medial Canthal and Eyelid Defect Repair with Split Forehead Flap

6.6

 edial Canthal and Eyelid Defect M Repair with Split Forehead Flap

Siba P. Dubey and Charles P. Molumi

6.6.1 Operative Steps 1. The squamous cell carcinoma involving the medial canthus and adjoining upper and lower eyelids (Fig. 6.36); the

215

excision margin around the lesion and the forehead flap are marked out (Fig. 6.37). 2. The postexcision defect involved medial canthus and both upper and lower eyelids (Fig. 6.38). The forehead flap is elevated and its tip is split into two in the midline. The split flap is rotated to cover the defect. The donor area in the forehead is closed directly in layers. 3. The donor and recipient sites heal well within 8  weeks (Fig. 6.39).

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6  Lips and Facial Defects Repair

6.36

6.37

6.6  Medial Canthal and Eyelid Defect Repair with Split Forehead Flap

217

6.38

6.39

218

6  Lips and Facial Defects Repair

6.6.2 Potential Problems

References to Operative Procedure

1. Multiple structures have to be reconstructed for successful cosmetic and functional result in the postoperative period. These are conjunctiva, tarsal plate, orbicularis muscle, canthal ligaments, and skin and lacrimal drainage system. 2. Squamous cell carcinoma may require additional anticancer therapy.

1. Sakai S, Soeda S, Matsukawa A (1989) Refinement of the island median forehead flap for reconstruction of the medial canthus area. J Dermatol Surg Oncol 15:524–530 2. Chiarelli A, Forcignano R, Boatto D, Zuliani F, Bisazza S (2001) Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases. Br J Plast Surg 54:248–252 3. Kim JH, Kim JM, Park JW, Hwang JH, Kim KS, Lee SY (2013) Reconstruction of the medial canthus using an ipsilateral paramedian forehead flap. Arch Plast Surg 40:742–747 4. Parker AM, Richardson MA, Jordan JR (2014) Functional reconstruction of large medial canthal defects. Facial Plast Surg 30:656–660 5. Onishi K, Maruyama Y, Okada E, et  al (2007) Medial canthal reconstruction with glabellar combined Rintala flaps. Plast Reconstr Surg 119:537–541

6.6.3 Suggested Solutions 1. The skin and the muscle of the forehead flap replaced the respective excised tissues. Oral mucosa of the lower lip replaces excised palpebral conjunctiva. Nasal septal cartilage and mucosa are used to reconstruct the tarsus. 2. Dacryocystorhinostomy or conjunctivorhinostomy is performed to provide lacrimal drainage. 3. Telecanthus should preferably be corrected in second-­ stage epicanthoplasty as immediate repair surgery could affect flap survival.

6.7  Near-Total Lip Defect Repair by Karapandzic Flap

6.7

 ear-Total Lip Defect Repair by N Karapandzic Flap

Siba P. Dubey and Charles P. Molumi

6.7.1 Operative Steps 1. Full thickness of the lower lip is involved by exophytic squamous cell carcinoma; incisions are marked out (Fig. 6.40). 2. The tumor is excised creating a near-total lower lip defect (Fig.  6.41). Crescentic skin incisions parallel to lip

219

margins and along the nasolabial and mentolabial creases around the oral commissures and ending into or near the lower lip defects are made. Incision is deepened and subcutaneous tissues are divided. At this stage, blunt dissection is made in radial fashion parallel with the muscular and neurovascular structures; labial artery pedicles are preserved (Fig. 6.42). The muscles attached at the lateral margin of the orbicularis oris muscle are also preserved as much as possible (Figs. 6.43 and 6.44). 3. Closure started with muscle-to-muscle suturing; the vermilion border is aligned. The rest of the skin and mucosa are also closed (Fig. 6.45). The oral sphincter function is maintained and moderate degree microstoma results in the postoperative period (Fig. 6.46).

220

6  Lips and Facial Defects Repair

6.40

6.41

6.7  Near-Total Lip Defect Repair by Karapandzic Flap

221

Left zygomaticus major muscle

Left superior labial artery

6.42

Right zygomaticus major muscle

6.43

222

6  Lips and Facial Defects Repair

Right depressor angular oris muscle

6.44

6.45

6.7  Near-Total Lip Defect Repair by Karapandzic Flap

223

6.46

224

6.7.2 Potential Problems 1. Functional outcomes of preservation of lip competence, sensation, and facial expression may vary. 2. Less successful results are obtained in the defect near the angle of the mouth because it is difficult to obtain symmetry of the lips. 3. Bigger the extent of lip excision, bigger is the microstoma.

6.7.3 Suggested Solutions 1. Functional results improve greatly by keeping the concentric fibers of the orbicularis oris, the radial fibers attached with it intact and preserving the neurovascular structures. 2. The best result is obtained in midline defect of the lower and upper lips.

6  Lips and Facial Defects Repair

3. Mucosal incisions in the vestibule are required only adjacent to the margin of the defect to enable closure. References to Operative Procedure 1. Karapandzic M (1974) Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 27:93–97 2. Teemul TA, Telfer A, Singh RP, Telfer MR (2017) The versatility of the Karapandzic flap: a review of 65 cases with patient-reported outcomes. J Cranio-Maxillo-Fac Surg 45:325–329 3. Ethunandan M, Macpherson DW, Santhanam V (2007) Karapandzic flap for reconstruction of lip defects. J Oral Maxillofac Surg 65:2512–2517 4. Hanasono MM, Langstein HN (2011) Extended Karapandzic flaps for near-total and total lower lip defects. Plast Reconstr Surg 127:1199–1205

6.8  Temporalis Muscle Flap Transposition for Paralyzed Face

6.8

 emporalis Muscle Flap Transposition T for Paralyzed Face

225

before anesthesia and compared with the normal side. Alternatively, it is ascertained by elevating the paralyzed angle of the mouth with fingers. The incision is deepened Siba P. Dubey and Charles P. Molumi down to the orbicularis oris muscle. A subcutaneous tunnel is created from the temporal fossa to the face by blunt dissection with forceps and fingers (Fig.  6.50). In 6.8.1 Operative Steps the temporal fossa, the tunnel lies superficial to the superficial musculoaponeurotic system (SMAS). In the 1. The patient had 3-year-old posttraumatic facial paralysis face, it lies between the fat and facial muscles layer. The (Fig. 6.47). middle and index fingers are passed through the tunnel to 2. The incision for the temporalis muscle flap is marked out create adequate diameter for the muscle to pass through. as a curved incision from the back of the ipsilateral pinna The attached periosteum and temporalis muscle in the and followed to the superior temporal line anteriorly. The flap are stitched with the fibrous tissue and orbicularis patient also needed mastoid exploration as a consequence respectively with 3-0 proline sutures. Overcorrection of of the trauma. Additional markings of incisions are made the nasolabial fold is made in such a way as to expose the lateral to the oral commissure, lateral and medial canthus ipsilateral upper second or third molar tooth. of the eye, as well as middle of the upper and lower 5. The anterior third of the muscle is brought out through the eyelids (Fig. 6.48). incision at the lateral canthus. The anterior third of the 3. The middle third of the muscle (roughly 4 cm or two finsplit muscle is now negotiated through the tunnels in such gers breadth wide) is raised with a 2-cm strip of periosa way that the posterior part occupied the lower lid and teum (P) by which the muscle belly is pulled through to the anterior one in the upper lid. The cranial part of the the incision lateral to the oral commissure. The periosmuscle lies at the medial canthus. The canthal and lid teum at the tip of the muscle is split in the middle incisions helped in this process of adjustment. The lower (Fig. 6.49). The temporalis muscle is not elevated beyond ends of both the parts were stitched together at the lateral the zygomatic arch to protect the neurovascular supply to canthus (Fig.  6.51). The temporalis muscle strips are it. The anterior third of the temporalis is elevated. This stitched to the orbicularis oculi and tarsal plates through bulk of muscle is split into equal anterior and posterior the upper and lower lid incisions with the help of the fine parts or arms except for its cranial 2 cm. The anterior part absorbable sutures (Fig.  6.51). Likewise, the tip of the or arm is detached from its proximal attachment leading muscle strip is attached to the medial canthal ligament to the formation of the word “V” (Fig. 6.49). (Fig. 6.51). 4. A 3-cm-long incision is placed on the “smile fold” or lip-­ 6. All the incisions are closed and the suction drain is cheek crease of the paralyzed side. The location of this inserted (Fig. 6.52). line on the paralyzed side is determined during smile

226

6  Lips and Facial Defects Repair

6.47

Temporal incision

Upper eyelid incision Medial canthal incision

Lower eyelid incision Lateral canthal incision

Incision at lipcheek crease

6.48

6.8  Temporalis Muscle Flap Transposition for Paralyzed Face

227 Right pinna

Divided anterior third of temporalis muscle for upper and lower eyelids

Skin flap

Middle third of temporalis muscle

Musculoperiosteal flaps for lower and upper lip

To be frixed at medial canthus

6.49

Tips of hemostat in tunnel from temporal fossa to lip-cheek crease

6.50

228

6  Lips and Facial Defects Repair

Muscle at lateral canthus

Muscle at upper eyelid

Muscle at lower eyelid Muscle at medial canthus

6.51

6.52

6.8  Temporalis Muscle Flap Transposition for Paralyzed Face

6.8.2 Potential Problems 1 . Depressed temporal fossa. 2. Hematoma formation and facial swelling. 3. Hypertrophic scar at oral commissure. 4. Injury to the frontal branch of the facial nerve in case it is intact preoperatively. 5. Bulkiness over zygomatic arch by folded temporalis muscle.

6.8.3 Suggested Solutions 1. To obliterate the depression in the temporal fossa, the temporoparietal fascial flap with its vascular pedicle is rotated and fixed into the defect. 2. Pressure dressing to reduce swelling and hematoma formation. 3. Modified oral commissure incision. 4. The frontal branch used to be located 3 cm anterior the midsegment of the temporalis muscle. Working at a plane superficial to the SMAS also reduces the risk of frontal branch injury.

229

5. Making a wide tunnel which easily accommodates two fingers where folded temporalis muscle is laid in a flattened state. References to Operative Procedure 1. Baker DC, Conley J (1979) Regional muscle transposition for rehabilitation of the paralyzed face. Clin Plast Surg 6:317–331 2. May M (1984) Muscle transposition for facial reanimation: indications and results. Arch Otolaryngol 110:184–189 3. May M, Drucker C (1993) Temporalis muscle for facial reanimation: a 13-year experience with 224 procedures. Arch Otolaryngol Head Neck Surg 119:378–382 4. Cheney ML, McKenna MJ, Megerian CA, Ojemann RG (1995) Early temporalis muscle transposition for the management of facial paralysis. Laryngoscope 105:993–1000 5. Boahene KDO (2008) Dynamic muscle transfer in facial reanimation. Facial Plast Surg 24:204–210

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6.9

6  Lips and Facial Defects Repair

“V” Excision of Lower Lip

Siba P. Dubey and Charles P. Molumi

6.9.1 Operative Steps 1. A “V” excision of the lip is marked out on the skin and lip mucosa in a patient with squamous cell carcinoma (Fig. 6.53a, b).

2. A through-and-through V excision of the lower lip is done (Fig. 6.54). 3. The vermilion border is reapproximated by first aligning the mucocutaneous junction (Fig. 6.55). 4. The subcutaneous tissue is closed first followed by the mucosa and skin (Fig. 6.56).

6.9  “V” Excision of Lower Lip

231

6.53a

6.53b

232

6  Lips and Facial Defects Repair

6.54

6.55

6.9  “V” Excision of Lower Lip

233

6.56

234

6.9.2 Potential Problems 1 . Inferior Labial artery bleeding 2. Malalignment of the lip

6  Lips and Facial Defects Repair

vermilion edge. Apply traction on this suture and complete the rest of suturing from muscle, to skin and later, the mucosa. References to Operative Procedure

6.9.3 Suggested Solutions 1. Compress the lip between the index finger and the thumb when doing the through-and-through incision of the lip. Release slowly, identify the inferior labial artery bleeding, and ligate. 2. Place a 5-0 nylon suture initially at the mucocutaneous junction of the vermilion border accurately aligning the

1. Barton M, Spira M, Hardy SB (1964) An improved method for “V” excision of the lip combined with vermilionectomy. Plast Reconstr Surg 33: 471–473 2. Spira M, Hardy SB (1964) Vermilionectomy: review of cases with variations in technique. Plast Reconstr Surg 33:39–46 3. Kurth MB (1957) Lip shave or vermilionectomy: indications and technique. Br J Plast Surg 10:156–162

6.10  V-Y Advancement Flap for Cheek and Alar Defect

6.10 V  -Y Advancement Flap for Cheek and Alar Defect Siba P. Dubey and Charles P. Molumi

6.10.1 Operative Steps 1. The location of the flap is critical in designing a V to Y advancement flap. In this case basal cell carcinoma involved the nasolabial groove and lateral nasal wall is excised (Fig. 6.57). 2. The skin incision around the lesion to be excised and the V to Y advancement flap are marked out (Fig. 6.58). 3. The lesion is excised creating a defect in the nasolabial groove and over the lateral nasal wall. The nasal ala is intact (Fig. 6.59).

235

4. The flap is elevated by carrying the skin incision deep to the dermis and into the subcutaneous fat. At the same subcutaneous fat level, the adjacent tissues on both sides of the V are undermined. Undermining continued inferiorly to the point along the V (Fig. 6.60). 5. Undermining continued until the desired mobility is achieved to a point where the flap is easily mobilized to cover the defect site. Edges of the flap are trimmed to fit the shape of the defect. The donor site is closed. The amount of advancement is noted by the area from the tip of the V at its new location compared to its location at the time of incision. The difference between these two points is the amount of advancement achieved with the flap advancement (Fig. 6.61). 6. Appearance of the patient 9 months after operation (Fig. 6.62).

236

6  Lips and Facial Defects Repair

6.57

6.58

6.10  V-Y Advancement Flap for Cheek and Alar Defect

237

6.59

6.60

238

6  Lips and Facial Defects Repair

6.61

6.62

6.10  V-Y Advancement Flap for Cheek and Alar Defect

6.10.2 Potential Problems 1. Flap failure 2. Wrong choice of flap causing distortion and inability of the flap to reach defect 3. Poor esthetic outcome

239

donor site should take into account where the final scar will be placed and whether the movement will cause distortion of the surrounding tissues or structures. 3. The V to Y advancement flap is suitable for reconstruction of superficial defects of the upper lip skin. References to Operative Procedure

6.10.3 Suggested Solutions 1. The survivability of the flap is dependent on the maintenance of the perforating vessels from the underlying tissues. The reliance on the perfusion from the perforators requires a broad subcutaneous bed under the cutaneous portion of the flap to be transposed. Therefore, undermine the flap in the subcutaneous plane. 2. Understand the potential movement of the skin in a V-Y advancement in relation to the defect and an understanding of the pliability of the skin over its underlying tissue bed is essential in the design of the flap. The location of the

1. Herbert DC (1978) A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg 31:79–92 2. Zook EG, Van Beek AL, Russell RC, Moore JB (1980) V–Y advancement flap for facial defects. Plast Reconstr Surg 65:786–797 3. Doermann A, Hauter D, Zook EG, Russell RC (1989) V–Y advancement flaps for closure of nasal defects. Plast Reconstr Surg 84:916–920 4. Pribaz JJ, Chester CH, Barrall DT (1992) The extended V–Y flap. Plast Reconstr Surg 90:275–280

7

Maxillofacial Surgery

7.1

Bilateral Sagittal Split Osteotomy

Emeka Nkenke, Florian Katauczek, Eleftherios Vairaktaris, Konstantinos Mitsimponas, and Christos Perisanidis

7.1.1 Operative Steps 1. In a patient, a bilateral sagittal split osteotomy is planned to improve the dental occlusion (Fig. 7.1). 2. The ascending ramus is approached through the oral cavity. The incision is made directly on the ascending ramus (Fig. 7.2). 3. Buccally and lingually, mucoperiosteal flaps are elevated to expose the ascending ramus (Fig. 7.3). 4. A curved raspatory is used to completely detach the masseter and medial pterygoid muscle from the bony surface (Fig. 7.4). 5. A blunt hook is used to identify the mandibular foramen (Figs. 7.5 and 7.6). 6. A bur is used to create a notch above the mandibular foramen. The aim is to give enough overview to surely preserve the mandibular nerve during the following osteotomy (Figs. 7.7 and 7.8).

7. The osteotomy is performed with the piezotome along the ascending ramus in a vertical fashion (Fig. 7.9). 8. At the caudal end of the vertical osteotomy, a horizontal osteotomy is carried out. At its distal end, this osteotomy is performed bicortically (Fig. 7.10). 9. In order to complete the osteotomy, an osteotome is used (Fig. 7.11). 10. After completion of the osteotomy, the inferior alveolar nerve can be identified (Fig. 7.12). 11. A plastic splint is used to bring the mandibular corpus in the intended position (Fig. 7.13). 12. Mandibulomaxillary fixation is achieved with elastics (Fig. 7.14). 13. Osteosynthesis in the new position is performed with an adjustable osteosynthesis plate with a 70-degree angle (Fig. 7.15). 14. The holes for the osteosynthesis screws are drilled with an angled screwdriver (Fig. 7.16). 15. The osteosynthesis plate can be fixed without a transbuccal approach (Fig. 7.17). 16. After completion of the healing period, the dental occlusion is improved significantly (Fig. 7.18).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_7

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Gap between the opposing teeth as a sign of the unbalanced dental occlusion

Orthodontic appliance

7.1

Upper dentition

Outline of the incision line along´the ascending ramus

Lower dentition

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7.1 Bilateral Sagittal Split Osteotomy

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Upper dentition

Ascending ramus

Lower dentition

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Upper dentition

Curved raspatory

Lower dentition

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Retractor

Ascending ramus Upper dentition

Blunt hook Lower dentition

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Retractor

Ascending ramus

Upper dentition

Blunt hook Lower dentition

The buccal aspect is packed with gauze in order to reduce bleeding

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Ascending ramus

Upper dentition Bur

Lower dentition

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Retractor

Ascending ramus

Notch

The buccal aspect is packed with gauze in order to reduce bleeding Lower dentition

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7.1 Bilateral Sagittal Split Osteotomy

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Ascending ramus

Piezotome

The buccal aspect is packed with gauze in order to reduce bleeding

7.9

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Vertical osteotomy

Horizontal osteotomy

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7.1 Bilateral Sagittal Split Osteotomy

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Ascending ramus Retractor

7.11

Lower dentition

Osteotome

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Ascending ramus

Retractor

Inferior alveolar nerve

Lower dentition

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Occlusal splint

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Elastics

Occlusal splint

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7.1 Bilateral Sagittal Split Osteotomy

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Ascending ramus

Elastics

Angled screwdriver

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Ascending ramus Osteosynthesis plate

Elastics

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7.1 Bilateral Sagittal Split Osteotomy

7.1.2 Potential Problems 1 . Bad split at the level of the condyle 2. Neurosensory disturbance (innervation area of the mental nerve) 3. Sagittal relapse following mandibular advancement

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3. 3.1 Intraoperative check of stable achievement of the intended position of the mandible after osteosynthesis by dorsal pressure to the chin; in case of immediate relapse, as the consequence of this maneuver, reosteosynthesis is indicated. 3.2 If immediate relapse is detected only postoperatively, revision surgery for reosteosynthesis is necessary.

7.1.3 Suggested Solutions

References to Operative Procedure 

1. 1.1 Adoption of piezosurgery for the osteotomy allowing complete osteotomy with reduced risk of nerve damage. 1.2 If fracture has occurred, internal fixation of the fracture should be performed. If the access to the fracture is difficult, the removal of the coronoid process can be considered. 2. 2.1 Adoption of piezosurgery for reducing the risk of direct nerve damage. 2.2 Short osteotomy limited to the ascending ramus should be considered to reduce the risk of neurosensory disturbance 2.3 In case of an intraoperative transection of the inferior alveolar nerve, apposition and suturing of the nerve ends is needed.

1. Nkenke E, Vairaktaris E, Bauersachs A, Hertrich K, Stelzle F, Scheller K (2012) Superficial skin sensitivity impairment and skeletal stability after sagittal split ramus osteotomy. J Craniofac Surg 23:1900–1905 2. Nkenke E, Kessler P, Wiltfang J, Neukam FW, Weisbach V (2005) Hemoglobin value reduction and necessity of transfusion in bimaxillary orthognathic surgery. J Oral Maxillofac Surg 63:623–628 3. Nkenke E, Zachow S, Benz M, Maier T, Veit K, Kramer M, Benz S, Häusler G, Neukam FW, Lell M (2004) Fusion of computed tomography data and optical 3D images of the dentition for streak artefact correction in the simulation of orthognathic surgery. Dentomaxillofac Radiol 33:226–232

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Le Fort I Osteotomy

Emeka Nkenke, Florian Katauczek, Eleftherios Vairaktaris, Konstantinos Mitsimponas, and Christos Perisanidis

7.2.1 Operative Steps 1. A male patient was suffering from a fibromatosis of the nasal cavity and maxillary sinuses (Fig. 7.19).The diagnosis had been made by an incision biopsy. It was decided to approach the tumor through the oral cavity by a Le Fort I osteotomy. 2. A semilunar incision is planned in the mucobuccal fold (Fig. 7.20). 3. The incision is brought down directly to the bony maxilla and a mucoperiosteal flap is raised (Fig. 7.21). The ventral aspect of the bony maxilla and the zygomaticomaxillary buttress are exposed. 4. The piriform aperture is exposed (Fig. 7.22). In a dorsal direction, the notch between the pterygoid process and the maxilla is identified. The osteotomy line is outlined in a horizontal fashion approx. 5 mm above the deepest point of the piriform aperture to the middle of the zygomaticomaxillary buttress. In order to reduce

bleeding to a minimum, the nasal cavity and the retromaxillary space are packed with gauze. The gauze is fixed to a cord for the ease of removal. 5. A curved osteotome is positioned behind the zygomaticomaxillary buttress in order to separate the pterygoid process from the maxilla (Fig. 7.23). 6. Before the horizontal osteotomy is performed, L-shaped osteosynthesis plates are fixed to the maxilla with self-­ tapping screws. The aim is to reposition the maxilla in its initial position following the removal of the tumor (Fig. 7.24). For the osteotomy, a piezotome is used. 7. The piezotome creates a fine osteotomy gap (Fig. 7.25). After removal of the plates, the osteotomy can be completed. 8. A semilunar osteotome with blunt tips is used to separate the nasal septum from the maxilla (Fig. 7.26). 9. After all osteotomies have been performed bilaterally, the down fracture of the maxilla is performed with a sharp hook (Fig. 7.27). Its tip is positioned just behind the nasal spine and pulled downward. 10. The tumor can now be easily removed (Fig. 7.28). 11. After the tumor removal, the nasal conchae become visible (Fig. 7.29). 12. The maxilla is repositioned and the osteosynthesis is completed (Fig. 7.30).

7.2 Le Fort I Osteotomy

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1 Region of the on a coronal MRI scan slice 2 Remainder of nasal cavity 3 Maxillary sinus 4 Chonca nasalis

5

5 Nasal septum

4 3

6 Palate

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7 Tongue 2 6 7

7.19

Bleeding points arising from the injection of local anesthetic Semilunar outline of the incision line

Tongue retractor Laryngotracheal tube

7.20

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Zygomaticomaxillary buttress

Tongue retractor

7.21

Laryngotracheal tube

Cord that is fixed to a gauze which packs the nasal cavity in order to reduce bleeding

Outline of the course of the LeFort I osteotomy

Piriform aperture

Buccal fat pad Zygomaticomaxillary buttress

7.22

7.2 Le Fort I Osteotomy

261 Cord that is fixed to a gauze which packs the nasal cavity in order to reduce bleeding

Outline of the course of the LeFort I osteotomy Zygomaticomaxillary buttress Curved osteotome

Tongue retractor

7.23

Cord that is fixed to a gauze which packs the nasal cavity in order to reduce bleeding Osteosynthesis plates provisionally fixed with osteosynthesis screws

Buccal fat pad Piezotome Zygomaticomaxillary buttress

Laryngotracheal tube

7.24

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7  Maxillofacial Surgery Cord that is fixed to a gauze which packs the nasal cavity in order to reduce bleeding Osteosynthesis plates provisionally fixed with osteosynthesis screws

Piriform aperture

Osteotmy line Buccal fat pad Zygomaticomaxillary buttress

7.25

Laryngotracheal tube

Cord that is fixed to a gauze which packs the nasal cavity in order to reduce bleeding Osteotome for the nasal septum Piriform aperture Nasal spine

Tongue retractor

Osteosynthesis plates provisionally fixed with osteosynthesis screws

7.26

7.2 Le Fort I Osteotomy

263

Tumor mass

Maxillary sinus

Piriform aperture Nasal spine

Sharp hook for downfracture

Laryngotracheal tube

7.27

Tumor mass (fibromatosis)

7.28

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Choncha

Choncha

Maxillary sinus

Piriform aperture

Sharp hook for downfracture

Osteosynthesis plates fixed to the bone with 4 screws after repositioning of the maxilla

7.29

Laryngotracheal tube

Piriform aperture Nasal spine

Osteotomy line

Laryngotracheal tube

7.30

7.2 Le Fort I Osteotomy

265

7.2.2 Potential Problems

References to Operative Procedure

1 . Bleeding following downfracture 2. Incorrect occlusion between maxilla and mandible following osteosynthesis 3. Postoperative maxillary sinusitis

1. Singh R, Hazarika P, Nayak DR, Balakrishnan R, Pillai S, Hazarika M (2011) Role of Le Fort type I osteotomy approach in juvenile nasopharyngeal angiofibroma. Int J Oral Maxillofac Surg 40:1271–1274 2. Zijderveld SA, Smeele LE, Kostense PJ, Tuinzing DB (1999) Preoperative antibiotic prophylaxis in orthognathic surgery: a randomized, double-blind, and placebo-­ controlled clinical study. J Oral Maxillofac Surg 57:1403–1406 3. De Lange J, Baas EM, Horsthuis RB, Booij A (2008) The effect of nasal application of cocaine/adrenaline on blood loss in Le Fort I osteotomies. Int J Oral Maxillofac Surg 37:21–24

7.2.3 Suggested Solutions 1. 1.1. Prevention of bleeding by osteotomy piezosurgery 1.2. Electrocoagulation of palatal vessels 2. Maxillomandibular fixation before osteosynthesis 3. Conservative treatment of the sinusitis

by

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7.3

7  Maxillofacial Surgery

Le Fort III Osteotomy

Emeka Nkenke, Florian Katauczek, Eleftherios Vairaktaris, Konstantinos Mitsimponas, and Christos Perisanidis

7.3.1 Operative Steps 1. Some syndromes like Crouzon syndrome go along with a hypoplastic midface as a consequence of insufficient growth. The result is a concave facial appearance (Fig.  7.31). Typically, these patients suffer from sleep apnea and recurrent airway infections. 2. The treatment approach requires advancement of the midface on a Le Fort III level. The adoption of distraction osteogenesis is a well-established treatment approach. Precise planning of the intervention can be performed based on 3D data of the facial skeleton (Fig. 7.32). The relevant structures are segmented and represented by different colors. 3. The virtual planning of surgery includes the introduction of osteotomy planes and the advancement of the midface to the intended position (Fig. 7.33). 4. The appropriate distraction devices are selected and aligned in a way that they move the midface to the intended position (Fig.  7.34). Also, the holes of the osteosynthesis plates that will receive osteosynthesis screws can be preselected. 5. The planning phase also includes the fabrication of a physical model of the skull. It is used to prebend the osteosynthesis plates of the distraction devices (Fig. 7.35). 6. Based on the vertical planning, drilling and cutting guides are fabricated (Fig.  7.36). They allow transferring the planning with a high precision to the patient situation. 7. A coronal incision is performed to allow approaching the root of the nose and the lateral aspects of the orbits

(Fig. 7.37). The osteotomies are performed with a piezo-­ electric device, preferably. 8. The zygomatic bone is exposed and the cutting and drilling guide is positioned on it (Fig. 7.38). Subsequently, the screw holes are drilled and the osteotomies are performed. 9. Mobilization of the midface also requires an osteotomy of the orbital floor (Fig.  7.39). A transconjunctival postseptal approach is chosen. The infraorbital rim shows a typical knife-shaped contour. 10. The osteotomy of the orbital floor is performed with a piezoelectric device (Fig. 7.40). 11. After completion of the different osteotomies, there is some mobility of the midface (Fig. 7.41). 12. The distraction devices are fixed to the parietal bone and the latero-orbital rim (Fig. 7.42). In order to check if the advancement of the midface is possible, the distraction devices are activated. Afterward, they are brought back to the initial position. 13. Also, the root of the nose (Fig. 7.43) and the orbital floor (Fig.  7.44) are checked for adequate advancement during the intraoperative activation of the distraction devices. 14. After wound closure, only the most distal part of the distraction device penetrates the parietal skin (Fig.  7.45). The activation is performed by a 360-degree turn twice per day at a 12-hour interval until the intended position of the midface has been reached (Fig.  7.46). After a consolidation period of 3 months, the distraction devices are removed. 15. In cases of severe concavity of the midface, Le Fort II and Le Fort III osteotomies can be combined (Fig. 7.47). Again, the distraction is planned virtually (Fig.  7.48). The first step of surgery is to advance the Le Fort II segment. Subsequently, it is fixed to the zygomatic segments. Later on, this 3-piece segment is advanced by distraction. The improved skeletal situation is reflected by an improved contour of the malar region and the significantly increased malar projection (Fig. 7.49).

7.3 Le Fort III Osteotomy

267

7.31

268

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7.32

Cranial horizontal osteotomy plane

Dorsal vertical osteotomy plane

7.33

7.3 Le Fort III Osteotomy

269

Acoustic canal

Distraction device

Osteosynthesis plate for the fixation of the distraction device

7.34

7.35

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Cutting and drilling guide

7.36

Supraorbital rim

Lateroorbital rim

Root of the nose

Piezoelectric device

7.37

7.3 Le Fort III Osteotomy

271 Temporalis muscle

Lateroorbital rim Orbit

Drill

Cutting and drilling guide

Piezoelectric device

7.38

272

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Conjunctival mucosa

Transconjunctival approach

Knife-shaped infraorbital rim

7.39

7.3 Le Fort III Osteotomy

273

Piezoelectric device

Osteotomy line

7.40

Temporalis muscle

Osteotomy lines through the lateroorbital rim and the lateral orbital wall

7.41

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Distraction device

Orbital content

Advanced lateroorbital rim

7.42

7.43

Periorbital fat Orbital content Gap at the root of the nose created by the activation of the distraction devices

7.3 Le Fort III Osteotomy

275

7.44 Infraorbital nerve

Distal end of the distraction device penetrating the skin in the parietal area

Gap at the root of the nose created by the activation of the distraction devices

7.45 Ear lobe

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7.46

7.47

7.3 Le Fort III Osteotomy

277 Zygomatic bone

LeFort II segment

Virtually advanced LeFort II segment

Distraction device

7.48

7.49

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7.3.2 Potential Problems 1. Fracture of the maxilla during mobilization of the midface in patients suffering from a cleft alveolus and palate 2. Loosening of fixation screws at the transport segment because of forces generated by the convergence of the distraction vectors of the devices 3. Chronic infection around the region of penetration of the distraction device through the skin of the scalp

7  Maxillofacial Surgery

References to Operative Procedure

1. Balaji SM, Balaji P (2018) Comparison of midface advancement by external and internal craniofacial distraction osteogenesis. Ann Maxillofac Surg 8:200–205 2. Glover CD, Fernandez AM, Huang H, Derderian C, Binstock W, Reid R, Dalesio NM, Zhong J, Stricker PA (2018) Pediatric Craniofacial Collaborative Group. Perioperative outcomes and management in midface advancement surgery: a multicenter observational descriptive study from the Pediatric Craniofacial 7.3.3 Suggested Solutions Collaborative Group. Paediatr Anaesth 28:710–718 3. Gibson TL, Grayson BH, McCarthy JG, Shetye PR 1. Splinting of the maxilla with a rigid cast-based vacuum-­ (2018) Proptosis correction in pre-adolescent patients formed resin plate during the mobilization procedure. with syndromic craniosynostosis by Le Fort III distrac 2. Virtual planning with parallelization of the distraction tion osteogenesis. J Craniofac Surg 29:1535–1541 vectors of the devices. 3. Daily cleaning of the penetration areas of the distraction devices until the removal of the distraction devices can be scheduled once bony consolidation of the transport segment is confirmed radiologically.

7.4  Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome

7.4

Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome

Emeka Nkenke and Eleftherios Vairaktaris

7.4.1 Operative Steps 1. A female patient is scheduled for maxillomandibular advancement because of an obstructive sleep apnea syndrome (Figs. 7.50 and 7.51). Besides, the patient is suffering from a “gummy smile” which is an esthetic problem. As a consequence of a mandibular retrognathia, there is a pronounced supramental fold which also reduces esthetics. 2. The aim of the maxillomandibular advancement is the increase of the posterior airway space (PAS). The posterior airway space is well depicted on a lateral skull radiograph (Fig. 7.52). 3. The panoramic radiograph gives an overview of the dentition and allows identifying the mandibular canal and the

279

metal foramen (Fig. 7.53). The temporomandibular joints (TMJ) show signs of arthrosis bilaterally. 4. The maxillomandibular advancement requires a Le Fort I osteotomy for the maxilla and a bilateral sagittal split osteotomy for the mandible (Fig.  7.54). The osteotomy sites are approached through the oral cavity. 5. The postoperative lateral skull radiograph shows the increase of the posterior airway space (PAS) (Fig. 7.55). Note that an anticlockwise rotation of the maxilla has been performed. 6. The postoperative panoramic radiograph shows the new position of the joint-bearing parts of the ascending ramus and the osteosynthesis plates fixed to maxilla and mandible (Fig. 7.56). 7. As a side effect, the maxillomandibular advancement creates a more youthful facial appearance (Fig.  7.57). The advancement of the maxilla was combined with an impaction in order to eliminate the gummy smile. 8. The mandibular advancement reduces the depth of the supramental fold and again improves facial esthetics (Fig.  7.58). The maxillary advancement improves the projection of the tip of the nose.

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Gummy smile

Orthodontic appliance

7.50

7.4  Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome

281

Pronounced supramental fold

7.51

7

Posterior airway space 6 5 4

3

1

2

8

7.52

1

Epiglottis

2

Hyoidal bone

3

Base of tongue

4

Soft palate

5

Hard palate

6

Maxillary sinus

7

Frontal sinus

8

Soft tissue contour

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3

3

1 4 1 5 4 6 2

2

7.53 1 Mandibular canal 2 Mental foramen 3 Temporomandibular joint (TMJ) 4 Orthodontic appliances 5 Tooth restorations 6 Tooth with incomplete root canal filling and periapical pathology

Cranial

1 Ascending ramus of the mandible 2 Situation after the sagittal split osteotomy 3 Angles osteosynthesis plate

1

4

Buccal 2

3

7.54

4 Orthodontic appliances

7.4  Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome

283

Posterior airway space 1

Epiglottis

2

Hyoidal bone

3

Base of tongue

4

Soft palate

5

Hard palate

6

Maxillary sinus

7

Frontal sinus

8

Soft tissue contour

9

Mandibular osteosynthesis plates

7

10 6 5 4

9 3

10

Maxillary osteosynthesis plates

8 1

2

7.55

3

8

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8

1

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7

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6 2

5

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7.56 1 Mandibular canal 2 Mental foramen 3 Temporomandibular joint (TMJ) 4 Orthodontic appliances 5 Tooth restorations 6 Tooth with incomplete root canal filling and periapical pathology 7 Mandibular osteosynthesis plates 8 Maxillary osteosynthesis plates

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7.57

7.4  Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome

285

Improved contour of the supramental fold

7.58

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7.4.2 Potential Problems

References to Operative Procedure

1. Pronounced (esthetically favorable) changes of the facial appearance with potential postoperative psychological problems 2. Pronounced postoperative soft tissue swelling 3. Inadequate postoperative occlusion between upper and lower dentition in patients with mandibular micrognathia

1. Vigneron A, Tamisier R, Orset E, Pepin JL, Bettega G (2017) Maxillomandibular advancement for obstructive sleep apnea syndrome treatment: long-term results. J Craniomaxillofac Surg 45:183–191 2. Nkenke E, Kessler P, Wiltfang J, Neukam FW, Weisbach V (2005) Hemoglobin value reduction and necessity of transfusion in bimaxillary orthognathic surgery. J Oral Maxillofac Surg 63:623–628 3. Cohen-Levy J, Petelle B, Vieille E, Dumitrache M, Fleury B (2013) Changes in facial profile after maxillomandibular advancement surgery for obstructive sleep apnea syndrome. Int Orthodont 11:71–92

7.4.3 Suggested Solutions 1 . Preoperative psychological assessment 2. CPAP ventilation during the immediate postoperative phase for prevention of hypooxygenation 3. Postoperative orthodontic treatment

7.5  Surgery for Hemifacial Microsomia

7.5

Surgery for Hemifacial Microsomia

Emeka Nkenke, Florian Katauczek, Eleftherios Vairaktaris, Konstantinos Mitsimponas, and Christos Perisanidis

7.5.1 Operative Steps 1. A patient with hemifacial microsomia was followed up from birth onward (Fig. 7.59). 2. Facial asymmetry with deviation of the chin to the affected side was accompanied by a pronounced microtia (Fig. 7.60). 3. A panoramic radiograph taken at the age of 9  years shows an intermediate hypoplasia of the right ascending ramus of the mandible. The condyle of the right temporomandibular joint is present, but also being hypoplastic. The right glenoid fossa is absent (Fig. 7.61). 4. At the age of 16 years, facial asymmetry is present with unchanged severity (Fig. 7.62). 5. Although being treated with fixed orthodontic appliances in maxilla and mandible, the dental occlusion is unbalanced (Fig. 7.63). 6. The panoramic radiograph taken at the age of 16 shows the hypoplastic ascending mandibular ramus and the hypoplastic condyle of the right temporomandibular joint (Fig.  7.64). The glenoid fossa again cannot be identified. 7. Lengthening of the right ascending ramus was performed by distraction osteogenesis (Fig. 7.65). The dis-

287

traction device was fixed to the right ascending ramus via an intraoral approach. A horizontal osteotomy was made with a piezotome. 8. The distraction device was activated for some extent to make sure that the osteotomy was carried out correctly (Fig. 7.66). 9. A postoperative panoramic radiograph shows the distraction device fixed to the right ascending ramus and the horizontal osteotomy (Fig. 7.67). 10. Activation of the distraction device was performed 0.4 mm twice daily until the maximum distraction distance was reached (Fig. 7.68). While the activation handle was removed, the distraction device was left in place until bony consolidation of the distraction gap was reached. 11. A CT scan taken 2  months after the last action of the distraction device shows the bridging of the distraction gap by newly formed bone (Figs. 7.69 and 7.70). 12. Following an additional bimaxillary intervention including Le Fort I osteotomy and bilateral sagittal split osteotomy, a significantly improved dental occlusion and facial symmetry could be achieved (Figs. 7.71 and 7.72). However, there was still a lack of soft tissue on the affected facial half. 13. Stable soft tissue augmentation can be achieved with a vascularized free soft tissue graft (Figs. 7.73, 7.74, 7.75, and 7.76). The skin is undermined and a soft tissue graft (parascapular flap) is used for the augmentation procedure. A small skin island of the flap is placed in the preauricular region in order to monitor the flap vascularity.

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7.59

7.5  Surgery for Hemifacial Microsomia

289

7.60

2

1

3

7.61 1 Hypoplastic ascending ramus of the right mandible 2 Hypoplastic condyle of the right temporomandibular joint 3 Mixed dentition with germs of permanent teeth, fully erupted permanent teeth and deciduous teeth

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7  Maxillofacial Surgery

7.62

Fixed orthodontic appliance

7.63

7.5  Surgery for Hemifacial Microsomia

291

2 1

7.64 1

Hypoplastic ascending ramus of the right mandible

2

Hypoplastic condyle of the right temporomandibular joint

3

2

1

7.65 1 Ascending ramus of the right mandible 2 Distraction device fixed with osteosynthesis screws to the ascending ramus 3 Horizontal osteotomy line

292

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2 4 3

1

7.66 1 Ascending ramus of the right mandible 2 Distraction device fixed with osteosynthesis screws to the ascending ramus 3 Gap caused by the activiation of the distraction device 4 Inferior alveolar nerve

2

3

1

4

5

1 Hypoplastic ascending ramus of the right mandible 2 Hypoplastic condyle of the right temporomandibular joint 3 Osteotomy line 4 Distraction device 5 Activation handle of the distraction device that penetrates the skin

7.67

7.5  Surgery for Hemifacial Microsomia

293

2 3

1

4 5

7.68 1 Hypoplastic ascending ramus of the right mandible 2 Hypoplastic condyle of the right temporomandibular joint 3 Distraction gap 4 Distraction device 5 Activation handle has been removed after the completion of the activation period

2

3

4

1

5

7.69 1 Coronal CT scan of the caudal aspect of the ascending ramus of the right mandible 2 Hypoplastic condyle of the right temporomandibular joint 3 New bone formation in the former osteotomy gap 4 Distraction device 5 Contralateral ascending ramus

294

7  Maxillofacial Surgery

2

1

3

7.70 1 Axial CT scan of new bone formation in the former osteotomy gap 2 Distraction device 3 Contralateral ascending ramus

7.71

7.5  Surgery for Hemifacial Microsomia

295

7.72 *

Scar formation where the activation handle of the distraction device pepetrated the skin

296

7  Maxillofacial Surgery

7.73 * Soft tissue deficiency

7.5  Surgery for Hemifacial Microsomia

297

7.74 * Vascular pedicle of the parascapular flap that is mostly deepithelialized

298

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1

2

7.75 1 Monitoring flap 2 Drain

7.5  Surgery for Hemifacial Microsomia

299

7.76

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7.5.2 Potential Problems

References to Operative Procedure

1 . Inadequate length of the distraction device 2. Unintentional transection of the inferior alveolar nerve during horizontal osteotomy 3. Fracture of the distraction device during the activation period or consolidation period

1. Zhang RS, Lin LO, Hoppe IC, Swanson JW, Taylor JA, Bartlett SP (2018) Early mandibular distraction in craniofacial microsomia and need for orthognathic correction at skeletal maturity: a comparative long-term follow-up study. Plast Reconstr Surg 142:1285–1293 2. Ko EW, Chen PK, Lo LJ (2017) Comparison of the adult three-dimensional craniofacial features of patients with unilateral craniofacial macrosomia with and without early mandible distraction. Int J Oral Maxillofac Surg 46:811–818 3. Neiva C, Dakpe S, Davrou J, Dîner PA, Devauchelle B, Vazquez MP, Picard A, Kadlub N (2015) Anatomical study of the course of the inferior alveolar nerve in craniofacial macrosomia using three-dimensional computed tomography: correlation with the Pruzansky classification. Br J Oral Maxillofac Surg 53:426–429

7.5.3 Suggested Solutions 1. By virtual planning of the distraction procedure, the choice of the adequate distraction device can be facilitated. 2. Performing the horizontal osteotomy using piezosurgery reduces the risk of nerve damage. 3. Preoperative perfect adaptation of the osteosynthesis plates of the distraction device to the surface of a 3D model of the mandible might reduce the risk of a fatigue fracture during the postoperative course.

7.6  Temporary Mandibulotomy

7.6

Temporary Mandibulotomy

Emeka Nkenke, Florian Katauczek, Eleftherios Vairaktaris, Konstantinos Mitsimponas, and Christos Perisanidis

7.6.1 Operative Steps 1. A female patient suffers from a recurrence of a pleomorphic adenoma in the left parapharyngeal region (Fig. 7.77). 2. In order to guarantee a maximum exposure of the parapharyngeal region, lip split was planned (Fig. 7.78). 3. The vermillion is incised in the midline in a V-shaped fashion for the ease of the later wound closure (Fig. 7.79). A vertical through-and-through incision is brought down to the deepest point of the supramental fold. 4. The chin is circumcised in a semilunar fashion down to the bone (Fig. 7.80). The incision is extended to the submandibular region. A horizontal skin crease incision is made at the level of the hyoid bone. The submandibular gland and the anterior belly of the digastric muscle are identified. The capsule of the submandibular gland is incised. In this plane, the dissection is continued in a cranial direction in order to expose the lower border of the mandible.

301

5. A stair-step osteotomy is performed with a piezotome anterior to the mental nerve (Fig. 7.81). The craniovertical osteotomy limb has to be positioned in way that dental injuries do not occur. Before completion of the osteotomy, osteosynthesis plates are fixed provisionally to the bone with screws. 6. The lingual gingiva is released from the mandibular bone and the osteotomy is completed (Fig. 7.82). 7. Now, the proximal segment of the left mandible can be rotated, laterally, to give access to the parapharyngeal space (Fig. 7.83). Whenever possible, the lingual nerve is spared during tumor resection. 8. In the present case, the parapharyngeal defect is filled with a vascularized free radial forearm flap. The mandibular segments are repositioned and the osteosynthesis is completed (Fig. 7.84). 9. After reduction of the initial swelling, the radial forearm flap forms an adequate intraoral soft tissue lining (Fig. 7.85). 10. Extraorally, some scar formation remains visible as a consequence of the lip splitting (Fig. 7.86). 11. If the aim is to avoid scars to the lip and chin region, there is the option to approach the mandible from a submandibular approach and to introduce a second mandibular osteotomy situated cranially to the mandibular foramen (Fig. 7.87). 12. The mandibular body is rotated cranially to give wide access to the parapharyngeal space (Figs. 7.88 and 7.89).

302

7  Maxillofacial Surgery

1 Region of recurrence of the pleomorphic adenoma on a coronal MRI scan slice 2 Tongue

5

3 Submandibular gland

1

4

4 Masseter muscle

6

5 Pterygoid muscle 2

6 Mandible 3

7.77

7.78

7.6  Temporary Mandibulotomy

303

1

2

7.79 1 V-shaped incision to the vermillion 2 Vertical incision down to the deepest point of the supramental fold

3

2 1

7.80 1 Left submandibular gland 2 Anterior belly of the digastric muscle 3 Mental nerve

304

7  Maxillofacial Surgery

3

4

2

1

7.81 1 2 3 4

Left submandibular gland Anterior belly of the digastric muscle Mental nerve Stair-step osteotomy

1 Left submandibular gland 2 Anterior belly of the digastric muscle

7

3 Mental nerve 5

4 Left sublingual gland 3

5 Lingual gingiva

4

6 Sharp hook 6 2

7 Tongue retractor

1

7.82

7.6  Temporary Mandibulotomy

305

7

5

4 3 2 6

1

7.83 1 2 3 4 5 6 7

Left sublingual gland Lingual nerve Internal carotid artery Buccal fat pad Mandibular nerve Laryngotracheal tube Left submandibular gland

306

7  Maxillofacial Surgery

3

1 2

7.84 1 Osteosynthesis plates 2 Mental nerve 3 Osteotomy line

7.6  Temporary Mandibulotomy

307

1

7.85 1 Reconstructed soft tissue lining (radial forearm flap)

1

7.86 1 Scar formation as a consequence of lip splitting

308

7  Maxillofacial Surgery

6 3 2

5

1 4

7.87 1 Mandibular body 2 Ascending ramus 3 Mental nerve 4 Submandibular gland 5 Anterior stair-step osteotomy 6 Horizontal osteotomy situated cranially to the mandibular foramen

6

1 Mandibular body 3

1

2 Submandibular gland 3 Medial pterygoid muscle

2

5

4 Gauze 5 Chin 6 Ear lobe

4

7.88

7.6  Temporary Mandibulotomy

309

5 4 1

3

1 Mandibular body 2 Submandibular gland

1 3 Osteosynthesis plate

2

4 Mental nerve 5 Chin

6

6 Digastric muscle

7.89

310

7  Maxillofacial Surgery

7.6.2 Potential Problems

References to Operative Procedure

1. Damage of adjacent teeth during osteotomy of the mandible 2. Incorrect occlusion between upper and lower teeth after osteosynthesis 3. Pseudoarthrosis of the osteotomy gap

1. Ong HS, Gokavarapu S, Tian Z, Li J, Cao W, Zhang CP (2018) Does a mandibular access osteotomy improve survival in pT2 oral tongue cancers? Retrospective study at a single institution. Int J Oral Maxillofac Surg 47:289–295 2. Kamalpathey K, Sahoo MGNK, Chattopadhyay CPK, Issar MY (2017) Access osteotomy in the maxillofacial skeleton. Ann Maxillofac Surg 7:98–103 3. Schlieve T, Carlson ER, Freeman M, Buckley R, Arnold J (2017) The Double mandibular osteotomy for vascular and tumor surgery of the parapharyngeal space. J Oral Maxillofac Surg 75:1046–1061

7.6.3 Suggested Solutions 1 . Proper planning of the osteotomy using a CT scan 2. Adoption of a piezosurgery device with a thin blade 3. Precise adaption of the osteosynthesis plates before osteotomy 4. Overbending of osteosynthesis plates during adaption for compression of the osteotomy sites

8

Neck Dissections

8.1

Supraomohyoid Neck Dissection

Siba P. Dubey and Charles P. Molumi

8.1.1 Operative Steps 1. Incision: The skin incision is marked along the skin crease from the anterior border of sternocleidomastoid muscle to the midline of the neck just below the level of the hyoid at least two finger breaths below the angle of the mandible (Fig. 8.1). 2. Elevation of skin flap: The skin incision is carried through the platysma. The upper skin flap is elevated remaining very close to the platysma to the level of the angle of mandible. Elevation of the flap is continued posteriorly, and the external jugular vein and greater auricular nerve overlying the sternocleidomastoid muscle are identified and preserved. The inferior skin flap is raised below the level of the cricoid till the omohyoid muscle is seen. The upper skin flap and lower skin flaps are anchored with “0” silk (Fig. 8.2). 3. Identification of the mandibular division of the facial nerve: The facial artery and vein are identified by blunt dissection with a fine hemostat at the mandibular notch where the facial vessels cross the lower border of the mandible. The marginal nerve is located as it is crossing superficial to the facial vessels. After identification of the nerve, the facial vein is divided inferior to the nerve and slung upward to protect the marginal mandibular nerve during the dissection (Fig. 8.3). 4. Level I Dissection: (a) Dissection is continued in the lower border of the body of the mandible to the attachment of the anterior belly of digastric muscle. The facial artery is ligated (Fig. 8.4).

(b) The anterior belly of digastric muscle is retracted forward and the fibrofatty tissues anterior to the submandibular gland between the anterior belly of digastric and mylohyoid muscle are dissected. The submental triangles with the anterior bellies of the digastric forming the lateral borders of the triangles and the mylohyoid muscle forming the floor of the triangles are exposed. The submandibular salivary gland is mobilized from its bed by traction with a hemostat (Fig. 8.5). (c) The lateral border of the mylohyoid muscle is retracted to expose the secretomotor fibers to the submandibular salivary gland coming off the lingual nerve and the Wharton’s duct (Fig. 8.6). (d) The secretomotor fibers to the submandibular gland are divided and the gland is now attached to the Wharton’s duct (Fig. 8.7). (e) The Wharton’s duct is divided and the distal stump is ligated. The submandibular gland is retracted posteroinferiorly and the proximal portion of the facial artery is exposed by dissecting the loose areolar tissue between the posterior belly of digastric muscle and submandibular gland as it enters the submandibular gland. The facial artery is ligated and the entire contents of the submandibular triangle are retracted inferiorly (Fig. 8.8). 5 . Level II a and b Dissection: (a) The tissues at the region of the tail of the parotid and the anterior part of the anterior border of the sternocleidomastoid muscle are dissected. The fascia over the anterior border of sternocleidomastoid muscle is incised and grasped with several Allis forceps. The fascia over the anterior border of the sternocleidomastoid muscle is cleared off (Fig. 8.9). (b) The accessory nerve is identified at the apex of the posterior triangle. The lymph nodes (Level II b) posterolateral to the nerve are dissected and passed

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_8

311

312

them anteriorly under the nerve. Dissection of the lymph nodes continued anterior to the accessory nerve (Level II a) to remain in continuity with rest of specimen (Fig. 8.10). 6 . Level III Dissection: (a) Dissection is continued medially to expose the carotid sheath, the roots of the cervical plexus, and the phrenic nerve. The fascia of the carotid sheath is separated from the vagus nerve, common carotid artery, and internal jugular vein. This dissection is continued superiorly up to the upper end internal jugular vein as it enters the jugular foramen and inferiorly to the level of anterior belly of omohyoid muscle (Fig. 8.11). (b) The fascia enclosing the internal jugular vein containing the upper deep jugular and jugulodigastric

8  Neck Dissections

lymph nodes is dissected. The entire jugular vein from posterior belly of digastric muscle superiorly to the inferior belly of omohyoid below is exposed (Fig. 8.12). (c) Dissection is continued medially to the junction where the superior belly of omohyoid crosses the sternocleidomastoid muscle. The superior thyroid vein is ligated. The final attachment of the specimen around the thyrohyoid membrane and tissues around the inserting of strep muscles over the hyoid bone is divided. The specimen is removed containing level 1 nodes with submandibular salivary gland, level II a and level II b nodes, and Level III lymph nodes. Facial vessels are preserved for further free flap reconstruction, if required (Fig. 8.13).

8.1  Supraomohyoid Neck Dissection

313

8.1

Superior skin flap

Left external jugular vein

8.2

314

8  Neck Dissections Left marginal mandibular branch of facial nerve

Left facial artery

Left facial vein

Submandibular

8.3

salivary gland

Facial vessels sutures

Left external jugular vein

8.4

8.1  Supraomohyoid Neck Dissection

315

Anterior belly of digastric muscle

Dissected level I tissues including submandibular salivary gland

8.5

Anterior belly of digastric muscle

Lingual nerve

Submandibular salivary gland

8.6

316

8  Neck Dissections

Anterior belly of digastric muscle

Left submandibular duct

Left submandibular salivary gland

8.7

Anterior belly of digastric muscle Intermediate tendon of digastric muscle

Level I dissected tissues Ligated submandibular duct

8.8

8.1  Supraomohyoid Neck Dissection

317

Sternocleidomastoid muscle

Fascia covering sternocleidomastoid muscle

8.9

Left spinal accessary nerve

Dissected tissues

Sternocleidomastoid muscle

8.10

318

8  Neck Dissections Dissected tissues

Internal jugular vein

Vagus nerve

Internal carotid artery

Brachial plexus– upper trunk

Spinal accessary nerve

8.11

Attached dissected tissues

Superior belly of omohyoid

Internal jugular vein Phrenic nerve

Spinal accessary nerve

Brachial plexus– upper trunk

8.12

8.1  Supraomohyoid Neck Dissection

319

Internal carotid artery

Superior belly of omohyoid Bellies of digastric muscle

Facial vessels

Internal jugular vein Spinal accessary nerve

8.13

320

8.2

8  Neck Dissections

Modified Radical Neck Dissection

Siba P. Dubey and Charles P. Molumi

8.2.1 Operative Steps 1. The transverse incision is made two finger breaths below the angle of the mandible with “S”-shaped vertical limb beginning at a point posterior to the carotid artery (Fig. 8.14). 2. The skin and the platysma muscle are incised. The skin and platysma flap are raised in the subplatysmal plane by following the deep surface of the platysma. The inferior border of the mandible superiorly, the clavicle inferiorly, the anterior border of the trapezius posteriorly, and the midline of the neck anteriorly are exposed (Fig. 8.15). 3. The spinal accessory nerve is identified as it enters the trapezius muscle and is traced it to the posterior border of the sternocleidomastoid muscle (Fig. 8.16). 4. The lymph nodes and fibrofatty tissue in the posterior triangle and upper neck over the posterior compartment muscles are dissected (Fig. 8.17). 5. The upper end of the sternocleidomastoid muscle is incised from its attachment at the mastoid process. The sternocleidomastoid muscle is split up to the level of the digastric muscle and the accessory nerve is dissected away from the muscle, exposing it from its entry to the jugular foramen superiorly and into the trapezius muscle inferiorly (Fig. 8.18). 6. The dissected contents of the posterior triangle in the specimen are retracted medially under the accessory

nerve and dissected along the levator scapulae and scalene muscles. The roots of the cervical plexus supplying scalene muscles, fibers contributing to phrenic nerve and the cutaneous branches are exposed. The cutaneous branches are transected and the dissection is continued (Fig. 8.19). 7. The internal jugular vein is exposed from the inferior belly of omohyoid muscle inferiorly to the digastric muscle superiorly. The specimen reflected further anterosuperiorly to expose the insertion of the sternocleidomastoid muscle to the clavicle and sternum (Fig. 8.20). 8. The sternal and clavicular head of the sternocleidomastoid muscle is cut. The lower end of the internal jugular vein is dissected circumferentially, and ligatures are passed (Fig. 8.21). 9. The carotid sheath is dissected, the common carotid artery and vagus nerve are preserved, and the lower end of the internal jugular vein is ligated by two silk sutures with a through-and-through knot in-between (Fig. 8.22). 10. The dissection is continued to the level of the digastric muscle. The nodes of level I to level III are dissected as described in supraomohyoid neck dissection. Middle thyroid vein is identified and to be ligated (Fig. 8.23). 11. The entire dissected tissues are retracted posteriorly. The hypoglossal nerve is identified as it crosses over the external carotid artery and is preserved (Fig. 8.24). 12. Ligate the upper end of the internal jugular vein which is the only structure holding the entire specimen. Hemostasis of the surgical field is made (Fig. 8.25). A suction drain inserted. Incision is closed in layers. 13. The lymph nodes in the specimen are sent for histopathological examination (Fig. 8.26).

8.2  Modified Radical Neck Dissection

321

8.14

Posterior skin flap

Superior skin flap

Anterior skin flap

8.15

322

8  Neck Dissections

Sternocleidomastoid muscle

Right spinal accessary nerve

Trapezius muscle

Spinal accessary nerve

Trapezius muscle

External jugular vein

8.16

Dissected tissues

Dissected tissue

8.17

8.2  Modified Radical Neck Dissection

323

Transected sternocleidomastoid muscle

Trapezius muscle

Spinal accessary nerve

Dissected tissues

8.18

324

8  Neck Dissections

Spinal accessary nerve

Levator scapulae muscle

Scalenus medius muscle

Muscular branch of cervical plexus Phrenic nerve

Brachial plexus– upper trunk

Scalenus anterior muscle

Omohyoid muscle

8.19

8.2  Modified Radical Neck Dissection

325

Spinal accessary nerve

Anteriorly retracted dissected tissues

Brachial plexus– upper trunk

Sternocleidomastoid muscle

Phrenic nerve

Omohyoid muscle

Internal jugular vein

8.20

326

8  Neck Dissections

Spinal accessary nerve

Dissected and retracted tissues

Lower cut end of sternocleidomastoid muscle

Brachial plexus –upper trunk Ligature around internal jugular vein

8.21

8.2  Modified Radical Neck Dissection

327

Spinal accessary nerve

Proximal ligatures of lower cut end of internal jugular vein

Vagus nerve

Ansa supplying strap muscles

Common carotid artery

Brachial plexus– upper trunk Phrenic nerve on scalenus anterior muscle

Distal ligatures of lower cut end of internal jugular vein

8.22

328

8  Neck Dissections

Anterior belly of digastric muscle

Strap muscles of neck

Middle thyroid vein

8.23

8.2  Modified Radical Neck Dissection

329

Posterior belly of digastric and stylohyoid muscles Spinal accessary nerve over internal jugular vein

Hypoglossal nerve over external carotid artery

Internal laryngeal nerve

Dissected tissues

8.24

330

8  Neck Dissections

Descendens hypoglossai nerve

Intermediate tendon of digastric muscles

Hypoglossal nerve

Spinal accessary nerve

Common carotid artery

Strap muscles of neck

Brachial plexus– upper trunk

Omohyoid muscle Phrenic nerve on scalenus anterior muscle

8.25

8.26

8.2  Modified Radical Neck Dissection

8.2.2 Potential Problems 1. Difficulty raising subplatysmal flap due to tumor involvement 2. Injury to mandibular division of facial nerve 3. Injury to spinal accessary, hypoglossal, vagus nerve and sympathetic trunk; upper trunk of brachial plexus and phrenic nerve. 4. Injury to internal jugular vein at its junction with its tributaries. 5. Injury to thoracic duct

8.2.3 Suggested Solutions 1. If a subplatysmal plane cannot be raised because of tumor adherence to the platysma, then the overlying skin is removed. This is because we feel that the platysma, being part of the panniculus carnosus, is a muscle of the skin and involvement of platysma would suggest involvement of the skin and therefore overlying skin is to be resected. The resulting skin defects can be reconstructed using either a deltopectoral flap or a pectoralis major myocutaneous flap or free flap as required. 2. Elevate the fascia over the submandibular gland and suture to the platysma flap. This protects the marginal mandibular division of the facial nerve which lies in a plane deep to platysma and superficial to the superficial layer of investing cervical fascia overlying the submandibular gland. The marginal mandibular division of the facial nerve can be identified crossing superficial to facial vein where the vein crosses the inferior border of the body of the mandible to enter the face. 3. The spinal accessary is identified in the posterior triangle at the posterior border of the sternocleidomastoid muscle 1 cm cranial to the great auricular point (nerve). The accessary nerve passes 1 cm superior and parallel to the sternomastoid branch of the occipital artery in the superior part of the anterior triangle. Alternatively, the nerve passes over the transverse process of the atlas between the tip of the mastoid process and the ramus of the mandible; dissection with a scissors parallel to the course of the nerve will make the nerve visible without injuring it. 4. The injury to sympathetic trunk lead to Bernard-Horner’s syndrome. The sympathetic trunk lies deeply posterior and medial to the carotid artery, between the prevertebral fascia and the carotid sheath. A careful surgical technique of prevention of stretching or inadvertent traction avoid this complication. 5. The hypoglossal nerve and descendens hypoglossai are located below the posterior belly of the digastric muscle.

331

The nerve is also accompanied by two large veins on either side. Any bleeding from them must be dealt with great care and with direct vision. Unintentional sectioning of the nerve should be managed by nerve anastomosis. 6. The nerve can be injured by thermal injury in addition to the mechanical one. Lower power bipolar diathermy and bipolar diathermy with simultaneous spraying of water near by any neural structure also greatly reduces thermal damage to any nerves during neck dissection. 7. Overstretching of any direct tributaries of the internal jugular vein may lead to injury to the jugular vein itself. It can be avoided by ligaturing the tributaries in advance. 8. It is possible to detect the injury to the thoracic duct intraoperatively by putting pressure on the abdomen when leakage starts; in this situation the duct is ligated with or without operating microscope. Other procedures to stop leakage includes, thoracic duct embolization, thoracic duct ligation by open thoracotomy or thoracoscopy, placement of myofascial flaps, namely, pectoralis major or clavicular head of sternocleidomastoid, nutritional therapy (low fat diet) and somatostatin analog therapy. References to Operative Procedure 1. Patel A, Clune J, Ariyan S (2016) Functional neck dissection: the operative technique series. Plast Reconstr Surg 138:1084–1088 2. Pai SI, Tufano RP (2008) Central compartment neck dissection for thyroid cancer. ORL 70:292–297 3. Campisi CC, Boccardo F, Piazza C, Campisi C (2013) Evolution of chylous fistula management after neck dissection. Curr Opin Otolaryngol Head Neck Surg 21:150 –156 4. Prim MP, De Diego JI, Verdaguer JM, Sastre N, Rabanal I (2006) Neurological complications following functional neck dissection. Eur Arch Otorhinolaryngol 263:473–476 5. Rafferty MA, Goldstein DP, Brown DH, Irish JC (2005) The sternomastoid branch of the occipital artery: a surgical landmark for spinal accessory nerve in selective neck dissections. Otolaryngol Head Neck Surg 133:874–876 6. Leung MKS, Dieu T, Cleland H (2004) Surgical approach to the accessary nerve in the posterior triangle of the neck. Plast Reconstr Surg 113:2067–2070 7. Woods JE, Yugueros P (1999) A safe and rapid technique for modified neck dissection. Ann Plast Surg 43:90–95 8. Robbins KT, Oppenheimer RW (1994) How I do it: incisions for neck dissection modifications: rationale for and application of non-trifurcate patterns. Laryngoscope 104:1041–1044 9. Spiro JD, Spiro RH, Strong EW (1990) The management of chyle fistula. Laryngoscope 100:771–774

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10. Medina JE, Byers RM (1989) Supraomohyoid neck dissection: rationale, indications and surgical technique. Head Neck 11:111–122 11. De langen ZJ, Vermey A (1988) Posterolateral neck dissection. Head Neck 10:252–256 12. O’Brien CJ, Urist MM, Maddox WA (1987) Modified radical neck dissection: terminology, technique, and indications. Am J Surg 153:310–316 13. Goepfert H, Jesse RH, Ballantyne AJ (1980) Posterolateral neck dissection. Arch Otolaryngol 106:618–621 14. Bocca E, Pignataro O, Sasaki CT (1980) Functional neck dissection: a description of operative technique. Arch Otolaryngol 106:524–527 15. Becker GD, Parrel GJ (1979) Technique of preserving the spinal accessary nerve during radical neck dissection. Laryngoscope 89:827–831

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16. Conley J (1978) Radical neck dissection. Ann Plast Surg 1:19–26 17. Bakamjian VY, Miller SH, Poole AG (1977) A technique for radical dissection of the neck. Surg Gynecol Obstet 144:419–424 18. Beahrs OH (1977) Surgical anatomy and technique of radical neck dissection. Surg Clin N Am 57:663–700 19.  Bocca E (1975) Conservative neck dissection. Laryngoscope 85:1511–1515 20. Conley J (1973) Radical neck dissection. Laryngoscope 85:1344–1352 21. Baker HW (1964) Surgical anatomy of the neck. Surg Clin N Am 44:1151–1160 22. MacFee WF (1960) Transverse incisions for neck dissection. Ann Surg 151:279–284

8.3  Central Compartment Neck and Superior Mediastinal Dissection

8.3

 entral Compartment Neck C and Superior Mediastinal Dissection

Siba P. Dubey and Charles P. Molumi

8.3.1 Operative Steps 1. Skin incision, flap elevation, exposure of thyroid gland, and identification of recurrent laryngeal nerve are similar to those described in thyroidectomy. The fascia over the lateral border of the thyroid gland is incised and elevated. The parathyroid gland is identified, and the inferior thyroid artery is ligated distal to the parathyroid glands and dissected off the thyroid gland. The recurrent laryngeal nerve is identified as described in total thyroidectomy (Fig. 8.27). 2. The carotid sheath is dissected from the level of the thyroid cartilage down to the level of the clavicle. The fibrofatty tissue and lymph nodes in the area bounded by common carotid artery laterally and innominate artery inferiorly are dissected to communicate with the dissected tissue. The right recurrent laryngeal nerve is dissected from all fibro-tissue containing lymph nodes in the tracheoesophageal groove to the level of the inferior thyroid artery superiorly and to the innominate artery inferiorly. The dissected tissues are taken medially under the right recurrent laryngeal nerve to keep it attached to the

333

main tumor mass (Fig.  8.28). The same procedure is repeated on the left side. 3. The prelaryngeal lymph nodes anterior to the cricothyroid membrane are dissected during dissection of the isthmus and pyramidal lobe (if present), and the pretracheal lymph nodes are dissected during dissection of the thyroid gland off the surface of the trachea (Fig. 8.29). 4. Both superior mediastinal dissection and central compartmental neck dissection are done at the same sitting, if indicated. It can be performed either craniocaudally or vice versa. The manubriotomy is done and Delphi retractor applied. The dissection started by elevating the tissues covering the brachiocephalic artery and vein at their junction (Fig. 8.30a). The dissected tissues are elevated cranially from the surrounding vascular and neural tissues at the root of the neck, which are ventral to the manubrium. During this process, the recurrent laryngeal nerves are also identified. The tissues dissected in the superior mediastinum are made continuous with the tissues at the central compartment neck dissection, which was started earlier; and both are removed in continuity (Fig.  8.30b). Alternatively, superior mediastinal dissection started first and continued upward as central compartment neck dissection with the recurrent laryngeal nerves are in direct view. This technique is useful while dealing with a large tumor involving neck and extending into superior mediastinum.

334

8  Neck Dissections

Thyroid tumor Ligated right inferior thyroid artery

Right recurrent laryngeal nerve

Right inferior parathyroid gland

8.27

Common carotid artery

Dissected tissues

Tumor

Right recurrent laryngeal nerve

8.28

8.3  Central Compartment Neck and Superior Mediastinal Dissection

335

Right internal jugular vein

Right Common carotid artery

Trachea

Right Vagus nerve

Right recurrent laryngeal nerve

8.29

336

8  Neck Dissections

Dissected tissues

Brachiocephalic artery

Ascending and arch of aorta

Left brachiocephalic vein

8.30a

8.3  Central Compartment Neck and Superior Mediastinal Dissection

337

Left common carotid artery

Right recurrent laryngeal nerve

Trachea

Subclavian artery and thyrocervical trunk

Left internal jugular vein

Right common Carotid artery

Brachiocephalic artery

Arch of aorta

Left brachiocephalic vein

8.30b

338

References to Operative Procedure 1. Pai SI, Tufano RP (2008) Central compartment neck dissection for thyroid cancer: technical considerations. ORL J Otorhinolaryngol Relat Spec 70:292–297

8  Neck Dissections

2. Pai SI, Tufano RP (2009) Central compartment neck dissection. Oper Tech Otolaryngol 20:39–43

8.4  Posterior Lateral Neck Dissection

8.4

Posterior Lateral Neck Dissection

Siba P. Dubey and Charles P. Molumi

8.4.1 Operative Steps 1. A hockey stick-type incision with posterior extension at the upper end to expose the occipital region is marked out (Fig. 8.31). 2. The skin flaps are elevated exposing the trapezius muscle (Fig. 8.32).

339

3. The occipital nodes are dissected free from the surrounding muscles. The muscles are reflected posteriorly, while the occipital nodes are reflected anteriorly (Fig. 8.33). 4. Suboccipital nodes and lymph nodes deep to the trapezius muscle are dissected and reflected anteriorly to remain in continuity with lymph nodes of the posterior triangle of the neck. These nodes are dissected forward in continuity with level II, level III, level IV, and level V nodes as described in modified radical neck dissection and removed (Fig. 8.34).

340

8  Neck Dissections

8.31

Sternocleidomastoid muscle Great auricular nerve

External jugular vein

Trapezius muscle

8.32

8.4  Posterior Lateral Neck Dissection

341

Level III neck nodes to be dissected

Splenius capitis muscle

Dissected suboccipital tissues and lymph nodes

Semispinalis capitis muscle

Trapezius muscle

Superior thyroid artery

8.33

Common carotid artery

Vagus nerve Phrenic nerve

Hypoglossal nerve

Splenius capitis Semispinalis capitis muscle

Brachial plexus– upper trunk Trapezius muscle

8.34

342

References to Operative Procedure 1. Wander JV, Chaudhuri PK (1976) Dissection of the posterior part of the neck. Surg Gynecol Obstet 143:97–100 2. Goepfert H, Jesse RH, Ballantyne AJ (1980) Posterolateral neck dissection. Arch Otolaryngol 106:618–621

8  Neck Dissections

3. Fisher SR, Cole TB, Seigler HF (1983) Application of posterior neck dissection in treating malignant melanoma of the posterior scalp. Laryngoscope 93: 760–765 4. de Langen ZJ, Vermey A (1988) Posterolateral neck dissection. Head Neck 10:252–256

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Nose and Paranasal Sinuses Surgery

9.1

Lateral Rhinotomy

Siba P. Dubey and Charles P. Molumi

9.1.1 Operative Steps 1. Moure’s incision began below the medial aspect of the eyebrow and curved downward and forward midway between the nasal dorsum and medial canthus. The incision is extended to the nasofacial junction along the nasal alar rim and ending within the nostril (Fig. 9.1). 2. The incision is deepened in layers to the periosteum. The angular vessels are encountered at the medial canthus and ligated or coagulated (Fig. 9.2). 3. The periosteum along the face of the maxilla and its frontal process is incised and raised till the infraorbital foramen with its neurovascular bundle is reached. This marks the lateral limit of the dissection (Fig. 9.3). 4. The nasal ala is detached by dividing the vestibular lining and retracted medially exposing the frontal process of the maxilla (Fig. 9.4). The elevation of the periosteum is continued to the medial aspect of the orbit. The medial canthal ligament is detached from the anterior and posterior crests of the lacrimal fossa. The lacrimal sac is carefully displaced from the lacrimal fossa and retracted laterally. The periosteum over the inferior orbital margin is elevated, and the globe is retracted laterally with a malleable retractor exposing the frontoethmoidal suture and anterior and posterior ethmoidal vessels. The anterior ethmoidal artery is coagulated. This marks the posterior limit of the dissection. The osteotomy sites are exposed and marked out with a diathermy.

5. Osteotomies are performed at five places: (1) first osteotomy is done at the nasal pyramid along the frontal process of the maxilla, (2) the second osteotomy is done across the pyriform rim at the level of the floor of the maxillary sinus and into the inferior meatus of the nose, (3) the third osteotomy is done medial to the inferior orbital foramen and across the infraorbital rim, (4) the fourth osteotomy is performed within the orbit by a superior cut made along the frontoethmoidal suture line. Anteriorly, the remaining portion of the frontal process of the maxilla is sectioned above the lacrimal fossa, and (5) the fifth osteotomy is performed at the frontoethmoidal suture line downward and forward at the level of the posterior ethmoidal artery toward the infraorbital rim to connect the third osteotomy. The medial wall of the maxilla is now free of all bony attachments (Fig. 9.5). 6. The bony medial wall of the maxilla is detached from the soft-tissue attachments and preserved in saline. This exposes the lateral nasal wall, the tumor, and the maxillary sinus (Fig. 9.6). 7. The origin and extension of the tumor at the lateral nasal wall, maxillary sinus, and ethmoid labyrinth is assessed, and it is removed (Fig. 9.7). 8. After hemostasis, the nasal cavity is packed with paraffin gauze and the bone placed back and fixed with miniplate with screws (Fig.  9.8). The trochlea is reinserted in its fossa and sutured with 3/0 nylon to the adjacent periosteum of the frontonasal bone; it is done to avoid “telecanthus.” 9. Nasal cavity is packed with paraffin gauze. The nasal ala is returned to its position, and the skin is closed with interrupted sutures (Fig. 9.9). The pack is removed after 3 days.

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_9

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Tumor

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9.2

9.1 Lateral Rhinotomy

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Tumor

9.3

Tumor

9.4

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9.6

9.1 Lateral Rhinotomy

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9.7

9.8

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9.9

9.1 Lateral Rhinotomy

9.1.2 Potential Problems 1. Danger of injuring orbital structures while incising close to the eye 2. Potential danger of entering the cranial cavity 3. Failure to reattach medial canthal ligament and lacrimal sac transected 4. Injury to the optic nerve 5. Fragmentation of the bone flap during removal due to incomplete osteotomies 6. Bone flap osteitis in the postoperative period

9.1.3 Suggested Solutions

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4. If posterior exposure is required, posterior ethmoidal artery will need to be ligated which lies 1 cm posterior the anterior ethmoidal artery in the same plane. Always remember that the optic nerve is 5–6 mm further posterior to the posterior ethmoidal artery and is at risk of injury. 5. The oblique osteotomy passing from the inferior orbital rim along the floor of the orbit should meet the superior osteotomy at the level of the ethmoid roof. If they fail to meet, they can be easily connected by making a small vertical fracture through the lamina papyracea with a Howarth’s elevator. 6. When performing osteotomy with saw or drill, always irrigate with saline to prevent burning of the bone. References to Operative Procedure

1. When curving the incision laterally beneath the eyebrow, stay on the bone to avoid entering into the orbit. Keep the incision at the eyebrow to the bone through the periosteum and medial to the attachment of the medial canthal ligament which is preserved intact on the periosteum when the periosteum is elevated. To retract the orbit, use a broad flat blade retractor or a smooth copper malleable retractor to avoid injury to the orbital fascia and prevent pressure on the orbital contents. 2. When performing osteotomy of the frontoethmoidal suture line, angle the chisel downward slightly to avoid entering the anterior cranial fossa or injuring the cribriform plate. 3. Attaching a silk suture to the detached medial canthal ligament allows its identification after the procedure.

1. Schramm VL, Myers EN (1978) Lateral rhinotomy. Laryngoscope 88:1042–1045 2. Mertz JS, Pearson BW, Kerr EB (1983) Lateral rhinotomy-­ indications, technique and review of 226 patients. Arch Otolaryngol 109:235–239 3. Sessions RB, Humphreys DH (1983) Technical modifications of the medial maxillectomy. Arch Otolaryngol 109:575–577 4. Sessions RB, Larson DL (1977) En bloc ethmoidectomy and medial maxillectomy. Arch Otolaryngol 103:195–202 5. Benard PJ, Lawson W, Biller HF, LeBerger J (1989) Complications following rhinotomy-review of 148 patients. Ann Otol Rhinol Laryngol 98:684–692

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9.2

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Midfacial Degloving

Siba P. Dubey and Charles P. Molumi

9.2.1 Operative Steps 1. The procedure is begun first with the sublabial incision. The incision is carried from the sublabial mucosa down to the bone from one maxillary tuberosity to the other tuberosity (Fig. 9.10). 2. The transfixation incision is begun by passing a knife at the septocolumellar junction and carried to the nasal floor to communicate with the sublabial incision (Figs.  9.11 and 9.12). 3. Through the sublabial incision, the upper lip and the columella are elevated exposing the caudal end of the septal cartilage. The intercartilaginous incisions are made. The

intercartilaginous incisions are joined to the sublabial incision laterally and to the superior end of the transfixation incision medially (Figs. 9.13 and 9.14). 4. Dissection is continued through the intercartilaginous incision exposing the nasal dorsum over the upper lateral cartilages and then to the nasal bones. The periosteum is incised with a curved Joseph knife, and the soft tissue is separated from the nasal bones. The elevation is continued laterally to the nasomaxillary suture line and superiorly to the glabella. Soft tissue over the anterior maxilla is elevated with a periosteal elevator in the subperiosteal plane to the zygoma and the infraorbital rim. The neurovascular bundle in the infraorbital foramen is carefully preserved (Fig. 9.15). 5. Resection depends on the extension of the tumor (Fig. 9.16). Sometime, medial maxillectomy is performed as described in lateral rhinotomy. The maxillary sinus is packed, and the end of the pack is placed in the nasal cavity; it is removed in the third postoperative day.

9.2 Midfacial Degloving

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9.10

9.11

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9.12

Intercartilaginous incisions

Caudal end of upper lateral cartilage

Caudal end of septal cartilage

Continuous sublabial and intercartilaginous incisions

9.13

9.2 Midfacial Degloving

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Continuous intercartilaginous and transfixation incisions

9.14

Dissection pathway over nasal dorsum

Infraorbital foramen

9.15

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9.16

9.2 Midfacial Degloving

9.2.2 Potential Problems 1. Cosmetic concerns arise when care is not taken during incisions and closing of the incisions. 2. Difficulty in closing sublabial incision. 3. Injury to infraorbital nerve. 4. Facial swelling and subconjunctival hemorrhage in the postoperative period. 5. Surgeon must be prepared to expose further when need arises.

9.2.3 Suggested Solutions 1. Reposition the frenulum in the midline first when closing the sublabial incision. Excessive removal of the cartilaginous septum and frontal process of maxilla results in nasal deformity. Attaching a silk suture to the detached medial canthal ligament allows its identification after the procedure. 2. Incise the buccal mucosa 2 cm superior to the buccal line to spare adequate mucosa for closure.

355

3. Care must be taken not to stretch and injure the infraorbital nerve. 4. Encasing the nose with plaster-of-Paris helps to reduce bleeding and facial edema. 5. Removal of the lateral wall of the nose including perpendicular plate of the palatine bone allows access to the nasopharynx, ethmoid, and sphenoid sinus. Further ­exposure of the infratemporal fossa can be achieved by drilling the anterior and posterior wall of the maxillary sinus and ligation of the maxillary artery. References to Operative Procedure 1. Casson PR, Bonano PC, Converse JM (1974) The midface degloving procedure. Plast Reconstr Surg 53: 102–103 2. Maniglia AJ (1986) Indications and techniques of midfacial degloving: a 15-year experience. Arch Otolaryngol Head Neck Surg 112:750–752 3. Howard DJ, Lund VJ (1992) The midfacial degloving approach to sinonasal disease. J Laryngol Otol 106: 1059–1062

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9.3

9  Nose and Paranasal Sinuses Surgery

 ranspalatal Approach by Palatal T Osteomucoperiosteal (POMP) Flap

Siba P. Dubey and Charles P. Molumi

9.3.1 Operative Steps 1. A 5-cm sublabial incision is made, and it is made bone deep. The nasal mucoperiosteal floor is elevated from the piriform aperture to the posterior end of the hard palate and side to side as much as possible. With a heavy scissors, the junction of the maxillary crest and septum is cut all the way from its anterior end to the posterior end. A space is created between the bony and soft tissues of the nasal floor where a malleable copper retractor is placed (Fig. 9.17). This is done to prevent injury to the nasal floor mucoperiosteum during subsequent osteotomy of the hard palate. 2. The palatal incision is marked on the hard palate from the last molar tooth of the pathological side to the junction between the contralateral canine and first premolar tooth. It is made where the palatal mucoperiosteum meets the teeth (Fig. 9.18). 3. The surgeon moves to the head end. The mouth is opened with a Boyle Davis mouth retractor. The palatal incision is made bone deep. The palatal mucoperiosteum is elevated just medial to the greater palatine canal posteriorly and posterior to the incisive foramen anteriorly. The greater and lesser palatine arteries are coagulated. This exposes the osteotomy site from the oral side (Fig. 9.19). 4. An inverted “J”-shaped cut is made on the exposed hard palate. The cut started just medial to the greater palatine canal using a mastoid drill with a small cutting burr. The cut is made through and through the bony nasal floor. The inverted “J” is placed at the junction of the horizontal and vertical part of the hard palate. The summit of the

inverted “J” is located almost 2 cm posterior to the base of the central incisor tooth. By this way, the very thick palatal bone is avoided (Fig. 9.20). The bony palatal cut with the drill extended to the junc­tion between the contralateral canine and first premolar tooth. 5. The rest of the contralateral palatal cut is made through the midline sublabial incision. A through-and-through osteotomy is done without injuring the palatal mucoperiosteum using a Joseph lateral osteotome which is used in rhinoplasty—the right one for the left palatal half and vice versa. The knob at the tip of the osteotome is felt through the palatal mucoperiosteum to prevent accidental injury or buttonhole of the palatal mucoperiosteum (Fig. 9.21). 6. Pressure is applied with a periosteal elevator from the nasal side toward the oral side; it opens up the palatal osteomucoperiosteal (POMP) flap in the oral cavity like the lid of a box. The flap is pedicled on the mucoperiosteum of the normal side from the premolar to last molar tooth with intact greater palatine artery. This exposes the nasal floor mucoperiosteum. The POMP flap is retracted with a retractor or sutured and anchored with a weight at the nonpathological side (Fig. 9.22). 7. The nasal floor mucoperiosteum of the pathological side is cut open to expose the tumor (Fig. 9.23). 8. The tumor is removed; the postnasal space and nasopharynx are exposed. The incised edges of the nasal floor mucoperiosteum are delineated (Fig. 9.24). 9. The nasal floor mucoperiosteum is sutured together to close off the nasal and nasopharyngeal cavities (Fig. 9.25). 10. The POMP flap is placed back. Three to four sutures are placed between the elevated palatal mucoperiosteum with mucoperiosteum of the gingivolabial sulci across spaces between the teeth (Fig. 9.26). The sublabial incision is closed in two layers. A light nasal packing is done with paraffin gauze and kept for 3–4 days. 11. The palate heals within 6 weeks (Fig. 9.27).

9.3 Transpalatal Approach by Palatal Osteomucoperiosteal (POMP) Flap

357

Endotracheal tube

Oral cavity

Tunnel under nasal floor

Malleable retractor

9.17

Head end

Incision line

9.18

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Elevated palatal mucoperiosteum

Hard palate

Tongue Greater palatine vessels and nerves in its canal

Endotracheal tube

9.19

Elevated palatal mucoperiosteum Endotracheal tube

Drill cut of hard palate

Tongue

9.20

9.3 Transpalatal Approach by Palatal Osteomucoperiosteal (POMP) Flap

359

Oral cavity Tongue

Tunnel under nasal floor

Joseph osteotome

Malleable retractor Head end

9.21

Nasal floor mucoperiosteum Elevated palatal osteomucoperiosteal flap

Greater palatine canal

Tongue

9.22

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Palatal osteomucoperiosteal flap

Tumor

Tongue

9.23

Elevated palatal mucoperiosteum

Right nasal cavity

Elevated palatal bone Cut ends of right nasal floor mucoperiosteum

9.24

9.3 Transpalatal Approach by Palatal Osteomucoperiosteal (POMP) Flap

361

Elevated palatal osteomucoperiosteal flap

Sutured right nasal floor mucoperiosteum

9.25

Suture line

Palate

9.26

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Healed palate

9.27

9.3 Transpalatal Approach by Palatal Osteomucoperiosteal (POMP) Flap

9.3.2 Potential Problems 1. Creation of buttonhole on the contralateral palatal mucoperiosteum 2. Fragmentation of hard palate bone due to incomplete osteotomy 3. Tear of nasal floor mucoperiosteum 4. Cutting through the tumor causing bleeding when incising nasal floor mucoperiosteum

9.3.3 Suggested Solutions 1. Feel the knob at the tip of the osteotome through the palatal mucoperiosteum to prevent accidental injury or buttonhole on the contralateral palatal mucoperiosteum. 2. A feeling of “give-in” and the drill hitting onto the malleable retractor indicates through-and-through osteotomy. The summit of the osteotomy close to the incisive foramen is done approximately 2 cm posterior to the base of the central incisor tooth. The drill should be visible from

363

the nasal side, which indicates complete through-and-­ through osteotomy. Place the Josephs osteotomy at the end of the hard palate osteotomy done from the oral side, and gently, hammer it to do the osteotomy of the hard palate of the normal side. 3. Ensure that the malleable copper retractor is in place between the nasal floor mucoperiosteum and hard palate bone before the osteotomy is done. 4. Pass a perichondrium elevator from the nose between the nasal floor and tumor before cutting the nasal floor mucoperiosteum to avoid injury to the tumor causing bleeding. References to Operative Procedure 1. Dubey SP, Molumi CP (2011) Transpalatal approach with pedicled palatal osteo-muco-periosteal flap. ANZ J Surg 82:439–442 2. Dubey SP, Molumi CP (2017) Modified transpalatal approach. In: Dubey SP, Schick B (eds) Juvenile angiofibroma. Springer International Publishing, Cham, p 173–185

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9  Nose and Paranasal Sinuses Surgery

 otal Maxillary Swing (TMS) Approach T for Excision of Large Juvenile Angiofibroma

7. Osteotomies are made at the frontal process of maxilla and maxillozygomatic suture with an oscillating saw, and the maxilloethmoidal junction is separated with a small thin straight osteotome. A straight osteotome is Siba P. Dubey and Charles P. Molumi placed between the arms of the small V-shaped notch located on the anterior nasal spine in the midline at the inferior margin of the piriform aperture. It is gently 9.4.1 Operative Steps hammered in both anterior and posterior directions, and the palatal halves open up in the line of fusion 1. The Weber–Fergusson incision with palatal and without (Fig. 9.34). sublabial component is marked out as described in total 8. A curved osteotome is placed at the pterygomaxillary maxillectomy in this chapter (Fig.  9.28). After orotrasuture behind the last molar tooth and gently hammered cheal intubation, the patient is placed in the head-­ to disarticulate the maxilla from the pterygoid processes extended position. The palatal incision is marked on the (Fig. 9.35). pathological side from the last molar tooth to the central 9. A curved osteotome is used to separate the palatal halves incisor where palatal mucoperiosteum meet the teeth. and the entire maxilla with attached cheek tissue, and 2. The mouth opened and the palatal mucoperiosteum on skin are reflected outward as in the opening of a swing the involved side reflected just proximal to the level of door thereby exposing the entire surgical field and the the hard and soft palate junction posteriorly and just tumor (Fig. 9.36). beyond the midline medially; the greater and lesser pala- 10. Any bleeding vessels are coagulated or ligated, and the tine arteries are coagulated in the process (Fig. 9.29). tumor is removed completely. Residual tumor in the 3. In larger tumors, the anterior and posterior faucial pillars pterygoid base, basisphenoid, and sphenoid sinus is incised and soft palate reflected together with the hard removed. Tumor extensions into the orbital apex and palatal mucoperiosteum exposing the oropharyngeal middle cranial fossa are removed by gentle traction extension of the tumor as in POMP flap (Fig. 9.30). downward (Fig. 9.37a, b). 4. The facial incision deepened to the bone. The nasal ala 11. After satisfactory removal of the tumor and hemostasis, incised at the level of the bone and the ala reflected the orbit is lifted by placing a malleable retractor at its medially and anchored with sutures, thereby exposing inferior aspect, and the maxilla is placed back as in closthe nasal extension of the tumor. The periosteum over ing of a swing door. The maxilla is fixed with miniplate the orbital floor elevated (Fig. 9.31a, b). and screws at the maxillozygomatic suture, the frontal 5. The lacrimal sac is transected and anchored with sutures process of the maxilla, and the intermaxillary suture at (Fig. 9.32). the inferior margin of the piriform aperture. In patients 6. The orbital floor is elevated, and the infraorbital nerve is less than 18 years of age, absorbable miniplates and sectioned as it enters the infraorbital foramen on the screws are used (Fig. 9.38). orbital floor. The periosteum of the orbital floor is ele- 12. The facial and palatal wound heals up without scaring vated as far as the orbital apex (Fig. 9.33). (Fig. 9.39).

9.4 Total Maxillary Swing (TMS) Approach for Excision of Large Juvenile Angiofibroma

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9.28

Elevated palatal mucoperiosteum

9.29

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Undersurface of reflected palatal flap

Oropharyngeal extension of tumor

Tongue

9.30

Orbital floor periosteum

Infraorbital nerve

Nasal extension of tumor

9.31a

9.4 Total Maxillary Swing (TMS) Approach for Excision of Large Juvenile Angiofibroma

367

9.31b

Transected and anchored lacrimal sac

Nasal part of tumor

Oral endotracheal tube

9.32

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Orbital floor

9.33

9.34

9.4 Total Maxillary Swing (TMS) Approach for Excision of Large Juvenile Angiofibroma

369

9.35

Lateral nasal wall mucosa

Nasal extension of tumor

Reflected maxilla with cheek skin Cheek fat

Oropharyngeal extension of tumor

9.36

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9.37a

9.37b

9.4 Total Maxillary Swing (TMS) Approach for Excision of Large Juvenile Angiofibroma

371

Absorbable miniplate and screws at maxillary – zygomatic osteotomy site

9.38

9.39

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9.4.2 Potential Problems

References to Operative Procedure

1 . Removal of minimal middle fossa extension of tumor 2. Cavernous sinus bleeding 3. Residual tumor leading to recurrence

1. Dubey SP, Molumi CP (2007) Critical look at the surgical approaches of nasopharyngeal angiofibroma excision and ‘total maxillary swing’ as a possible alternative. Ann Otol Rhinol Laryngol 116:723–730 2. Dubey SP, Molumi CP (2012) Transpalatal approach with pedicled palatal osteo-muco-periosteal flap. ANZ J Surg 82:439–442 3. Dubey SP, Molumi CP, Apaio ML (2011) Total maxillary swing approach to the skull base for advanced intracranial and extracranial nasopharyngeal angiofibroma. J Craniof Surg 22:1671–1676 4. Dubey SP, Molumi CP (2017) Modified transpalatal approach. In: Dubey SP, Schick B (eds) Juvenile angiofibroma. Springer International Publishing, Cham, p 173–185

9.4.3 Suggested Solutions 1. Attach an artery force to the tumor at the orbital apex and excise the specimen for removal. Gently apply traction downward, which pulls down the intracranial extension of the tumor. Note that the tumor is extradural, and hence, chances of dural injury are minimal. 2. When cavernous sinus bleeding is encountered, pack with surgical wrapped with gelfoam and apply bone wax. 3. Note that residual tumor remains in the pterygoid base and basisphenoid. Always drill out the pterygoid base and basisphenoid under microscope.

9.5 Total Maxillectomy

9.5

Total Maxillectomy

Siba P. Dubey and Charles P. Molumi

9.5.1 Operative Steps 1. The Weber–Fergusson incision is marked out by starting at the midpoint of the lip (the philtrum) and going in a stepladder pattern to the columella. The incision extends into the floor of the nasal cavity for a few millimeters and then returns back outside the nasal cavity. It is then continued round the margin of the ala of the nose and up the lateral border of the nose in the nasofacial groove to the medial canthus. The marking is turned laterally in a suitable skin crease in the lower eyelid to a point just beyond the lateral canthus (Fig. 9.40). 2. The incision is begun at the upper lip; an assistant grasps the upper lip on each side of the midline between the thumb and index finger to compress the superior labial artery. The knife is carried right down to the bone taking the incision to the mouth in the gingivolabial sulcus as far as the tuberosity of the maxilla. The incision is carried straight to the base of the columella, curves through a right angle, and goes around the origin of the nasal ala. From there, the incision is curved up to the medial canthus. The incision is continued from the medial to the lateral canthus 3–5  mm below the eyelashes. The subciliary flap is raised superficial to the orbicularis oculi muscle to the inferior orbital margin periosteum (Fig. 9.41). 3. The medial palpebral ligament is divided, and the lacrimal sac is elevated from its fossa and transected as distally as possible with a scalpel. The periosteum over the infraorbital rim is cut and communicated with the medial canthal incision. The periosteum along the medial orbital rim is elevated, and the medial orbital wall is explored by blunt dissection with a periosteal elevator. The anterior and posterior ethmoidal arteries are coagulated, and the orbital contents retracted (Fig. 9.42). 4. When the medial aspect of the orbit is free, the floor of the orbit is explored by elevating the orbital floor periosteum laterally to the inferior orbital fissure. The soft tissues of the face are elevated exposing the entire anterolateral surface of the maxilla. The infraorbital nerve and vessels are transected as they exit the infraorbital foramen. The tissues are stripped all the way around the maxilla up to the pterygomaxillary fissure and the zygoma. The sublabial part of the incision is extended from the midline to the last molar tooth and around it. The gingival mucosa of the upper alveolus from the central incisor to the last molar of the involved side is reflected and elevated together with the cheek

373

flap. The cheek flap is elevated in the subperiosteal plane exposing the nasal bone medially and the zygoma and lateral border of the maxilla laterally. The soft tissue of the cheek is now separated from the facial skeleton and gingiva. The mobilized cheek flap is reflected laterally wrapped with a moist gauze and fixed (Fig. 9.43). 5. The nasal ala is retracted, and the lateral wall of the nasal vestibule is incised to expose the ipsilateral nasal cavity and inferior turbinate. The nasal vestibule flap is reflected medially exposing tumor in the nasal cavity if present. The anterior part of the nasal septum is dislocated from the anterior nasal spine to expose the V-shaped notch located on the anterior nasal spine. The soft tissues from the bone up to the anterior free margin of the nasal aperture are freed with diathermy (Fig. 9.44). 6. The mouth is opened with a Boyle Davis mouth gag. The palatal mucoperiosteum of the involved side (when hard palate is free of tumor) is elevated as described in “palatal osteomucoperiosteal flap” operation. The elevated gingivolabial mucosa is made continuous with the reflected palatal mucoperiosteum across to the last molar tooth on the involved side (Fig. 9.45). The maxilla is now free from soft-tissue attachments and ready for osteotomies to disarticulate it. 7. The first osteotomy is at the zygomaticomaxillary suture line to separate the zygoma from the maxilla. A curved artery forceps are passed under the zygoma from the inferior orbital fissure. Using an oscillating saw, the bony cut is made through and through at the zygomaticomaxillary suture line. The artery forceps in the inferior orbital fissure guide the osteotomy to pass over the inferior orbital fissure. The second osteotomy is at frontal process of the maxilla to separate the maxilla from the nasal bone. The third osteotomy is done through the lamina papyracea and anterior ethmoids along the medial orbital wall to separate the maxilla from the lacrimal bone. The orbital contents are retracted with a malleable copper retractor. A fine osteotome is used to carry the osteotomy just inferior to the fronto-ethmoidal suture anteriorly by gently tapping on the osteotome to enter the ethmoid air cell system. The osteotomy stops short of the posterior ethmoidal artery and then directed inferiorly toward the orbital floor so as to safeguard the optic nerve. The fourth osteotomy is done at the midline of the hard palate to separate the diseased maxilla from the contralateral side. A straight osteotome is placed between the V-shaped notch located on the anterior nasal spine and hammered in both anterior and posterior directions, thus opening the palatal halves in the midline thereby separating the maxillae. The osteotomy is observed from the oral side as it separates the two palatal halves (Fig. 9.46).

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8. The last osteotomy is performed to disarticulate the maxilla from the pterygoid processes. A curved osteotome is placed behind the last molar with the concavity of the blade facing upward and hammered to disarticulate the pterygomaxillary suture. The osteotomy ends in the pterygomaxillary fissure and pterygopalatine fossa. After the last osteotomy, the maxilla is held in position only by soft tissues (Fig. 9.47). 9. An osteotome is placed in the midline palatal osteotomy gap and another one in zygomaticomaxillary suture line osteotomy gap and levered on the remaining bones (remaining opposite palate and remaining end of zygoma), and the maxilla is mobilized. The maxilla with the nasal bone and ethmoid sinus with the specimen are removed after diathermy division of few soft-tissue attachments at the nasal floor and at the disarticulated pterygoid plates. Bleeding in the maxillary cavity is con-

9  Nose and Paranasal Sinuses Surgery

trolled with diathermy. The cavity is now ready to be closed (Fig. 9.48). The authors used temporalis muscle flap to close the defect. The harvesting of temporalis muscle to close the defect is described in the next operative procedure. The specimen is examined to determine the adequacy of the margins of resection (Fig. 9.49a, b). 10. The cavity is packed with medicated gauze. The gingivolabial mucoperiosteum and the palatal mucoperiosteum are sutured with the buccal fat in between, thereby separating the nasal cavity from the oral cavity (Fig. 9.50). The cheek flap is placed back, and the Weber–Fergusson incision is closed. The lacrimal sac is slit along its length and marsupialized by suturing its edges to the surrounding soft tissue with vicryl sutures. 11. The facial and palatal incisions heal with minimal scaring (Fig. 9.51a, b).

9.5 Total Maxillectomy

375

9.40

9.41

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Lacrimal sac

9.42

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9.5 Total Maxillectomy

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Retractor in nasal cavity

Notch on nasal spine

Upper jaw

Tongue

Left maxillary sinus with tumor

9.44

Elevated palatal mucoperiosteum

9.45

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Osteotomy at maxillary frontal process

Osteotomy at maxillary-zygomatic junction

Cheek flap Nasal vestibule

Midline palatal osteotomy

Tongue 9.46

Buccal fat

Cheek flap

3 rd molar tooth Curved osteotome at pterygomaxillary articulation

9.47

9.5 Total Maxillectomy

379

Nasal vestibule Post - total maxillectomy cavity Cheek flap

Tongue 9.48

Tumor

9.49a

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Tumor

9.49b

Temporalis muscle

Gingivolabial mucoperiosteum

Palatal mucoperiosteum

Buccal fat Tongue Contralateral central incisor not removed

9.50

9.5 Total Maxillectomy

381

9.51a

9.51b

382

9.5.2 Potential Problems 1. Optic nerve injury 2. Accidental entry into the anterior cranial fossa 3. Risk of inadequate tumor resection while trying to preserve the eye 4. Injury to the structure in the inferior orbital fissure 5. Uncontrollable internal maxillary artery bleeding in the pterygopalatine fossa 6. Scar contracture of the face 7. Malformation of the lower eye lid 8. Hyperlacrimation in the postoperative period 9. Lymphedema, dystopia, and diplopia in the postoperative period

9.5.3 Suggested Solutions 1. Be mindful of the optic nerve which lies 5 mm posterior to the posterior ethmoidal artery. 2. The level of the floor of the anterior cranial fossa (fovea ethmoidalis and cribriform plate) corresponds with anterior and posterior ethmoidal foramina located along the frontoethmoidal suture line. Take note of this when performing osteotomy along the medial orbital wall. 3. The decision whether to preserve the orbit is done when the anterior and posterior ethmoidal arteries are cauterized and the orbital contents are retracted. Remove the orbit if tumor is present along the medial orbital wall. 4. No vessels of surgical significance are encountered in the inferior orbital fissure. Hence, always pass an artery force without fear from the infratemporal fossa to the inferior orbital fissure when performing zygomaticomaxillary suture line osteotomy. 5. Avoid using sharp dissection beyond the pterygomaxillary fissure, which may transect the internal maxillary artery causing excessive bleeding. 6. Ensure that the Weber–Fergusson incision starting at the midpoint of the lip (the philtrum) is done in a stepladder pattern to the columella to avoid scar contracture in the postoperative period.

9  Nose and Paranasal Sinuses Surgery

7. The lower lid incision should be approximately 3–5 mm from the eyelashes. If the incision is too near the eyelid margin, the patient will develop ectropion, and if it is too far away from the eyelashes, the patient will develop lymphedema of the lower lid. 8. After elevating the lacrimal sac from its fossa, transect it as distally as possible with a scalpel so as to facilitate fashioning a dacryocystorhinostomy. Failure to do this will result in epiphoria in the postoperative period. 9. Take special care not to tear the periosteum at the inferior orbital margin at the attachment of the orbital septum and causing extrusion of orbital fat. Risk of postoperative lymphedema is high when the orbital fat is protruding. Risk of herniation of the orbital contents into the antral cavity resulting in enophthalmos, dystopia, and diplopia is high when the floor of the orbit is not reconstructed at the time of tumor resection. References to Operative Procedure 1. Pearson BW (1977) The surgical anatomy of maxillectomy. Surg Clin N Am 57:701–721 2. Lore JM (1976) Partial and radical maxillectomy. Otolaryngol Clin N Am 9:255–267 3. Som ML (1974) Surgical management of carcinoma of the maxilla. Arch Otolaryngol 99:270–273 4. Bakamjian VY, Souther SG (1975) Use temporal muscle flap for reconstruction after orbito-maxillary resections for cancer. Plast Reconstr Surg 56:171–177 5. Konno A, Togawa K, Lizuka K (1981) Primary reconstruction after total or extended total maxillectomy for maxillary cancer. Plast Reconstr Surg 67:440–448 6. Komisar A, Silken D (1991) Achieving better functional outcome after maxillectomy: surgical and prosthetic outcome. Laryngoscope 101:567–569 7. Wang C, Yang T, Ko J, Lou P (2007) Ligation of the internal maxillary artery to reduce intraoperative bleeding during total maxillectomy. Laryngoscope 117:1978–1981 8. Molumi CP, Dubey SP, Apaio ML (2012) Preservation of palatal mucoperiosteum for oronasal separation after total maxillectomy. Indian J Cancer 49:209–214

9.6 Extended Total Maxillectomy with Orbital Exenteration and with Frontotemporal Craniotomy

9.6

Extended Total Maxillectomy with Orbital Exenteration and with Frontotemporal Craniotomy

383

(Fig. 9.56); the erosion of the bony anterior wall of the middle cranial fossa is apparent (arrowhead). 6. The full length of the temporalis muscle is raised. The muscle is passed under the zygoma to the maxillary and Siba P. Dubey and Charles P. Molumi orbital cavity for oronasal separation (Fig. 9.57). 7. The temporalis muscle is sutured to the periosteum of the supraorbital rim and tissues of the medial canthus 9.6.1 Operative Steps and incised muscles of the nose (Fig.  9.58). The gingivolabial mucoperiosteum (blue arrow) and the pala 1. The Weber–Dieffenbach incision includes Weber– tal mucoperiosteum (white arrow) are sutured with the Fergusson incision as described in total maxillectomy combined buccal fat and the inferior end of the tempowith extension with subciliary and supraciliary comporalis muscle (black arrow) in between, thereby separatnents (arrows); the latter circumferentially encompasses ing the oral cavity from the nasal cavity (Fig. 9.58). The the palpebral fissure of the eye (Fig. 9.52). cheek flap is placed back, and the Weber–Dieffenbach 2. The cheek skin flap is elevated (Fig.  9.53); the palpebral incision is closed. skin flaps are elevated circumferentially superficial to the 8. The facial incision heals with acceptable scar during tarsal plates till the superior orbital rim is reached (Fig. 9.54). postoperative period (Fig. 9.59). 3. The attachment of the orbital periosteum to the supe- 9. In cases where the cheek skin is to be removed, the lip rior orbital rim is incised, and the orbital periosteum is split is avoided. The involved cheek skin, instead of separated all the way to the orbital apex. From there, the reflecting, is removed with the tumor (Fig.  9.60). The orbital contents are dissected and retracted down from specimen consists of the eye, cheek skin, and maxilla the roof of the orbit to the orbital floor. Osteotomies are (Fig. 9.61). done as described in total maxillectomy. The entire soft-­ 10. The cavity is obliterated with temporalis muscle as tissue content of the orbit including ophthalmic artery before. and optic nerve is grasped with a long, curved forceps 11. An appropriate axial or free flap with skin is raised and near bony orbital apex and cut distal to the forceps. The placed over the temporalis muscle flap to replace the lost orbital tissues proximal to the curved forceps are ligated. cheek skin. 4. The specimen contains the eyeball, the cheek extension 12. Malignancy spreads to the superior orbital fissure and of the tumor, and the maxilla (Fig. 9.55). anterior part of the middle cranial fossa (Fig.  9.62); a 5. The postoperative cavity up to the roof of the orbit combined transorbital and frontotemporal (Fig. 9.63a–c) is examined meticulously to detect tumor remnant approaches are used for tumor removal.

384

9  Nose and Paranasal Sinuses Surgery

9.52

9.53

9.6 Extended Total Maxillectomy with Orbital Exenteration and with Frontotemporal Craniotomy

385

9.54

9.55

386

9  Nose and Paranasal Sinuses Surgery

9.56

9.57

9.6 Extended Total Maxillectomy with Orbital Exenteration and with Frontotemporal Craniotomy

387

9.58

9.59

388

9  Nose and Paranasal Sinuses Surgery

9.60

9.61

9.6 Extended Total Maxillectomy with Orbital Exenteration and with Frontotemporal Craniotomy

389

Residual tumor at orbital apex External nose

Cavity after removal of eye and maxilla

9.62

Frontotemporal Craniotomy incision line

9.63a

390

9  Nose and Paranasal Sinuses Surgery

Frontotemporal craniotomy done and dura opened

9.63b

Bone flap replaced and fixed with miniplates and screws

9.63c

9.6 Extended Total Maxillectomy with Orbital Exenteration and with Frontotemporal Craniotomy

9.6.2 Potential Problems 1. See total maxillectomy 2. Injury to the superior orbital nerve during elevation of the orbital periosteum

9.6.3 Suggested Solutions 1. See total maxillectomy 2. Incise the orbital periosteum at the orbital margin to avoid injury to the superior orbital nerve References to Operative Procedure 1. Pearson BW (1977) The surgical anatomy of maxillectomy. Surg Clin N Am 57:701–721 2. Lore JM (1976) Partial and radical maxillectomy. Otolaryngol Clin N Am 9:255–267 3. Som ML (1974) Surgical management of carcinoma of the maxilla. Arch Otolaryngol 99:270–273

391

4. Bakamjian VY, Souther SG (1975) Use temporal muscle flap for reconstruction after orbito-maxillary resections for cancer. Plast Reconstr Surg 56:171–177 5. Konno A, Togawa K, Lizuka K (1981) Primary reconstruction after total or extended total maxillectomy for maxillary cancer. Plast Reconstr Surg 67:440–448 6. Komisar A, Silken D (1991) Achieving better functional outcome after maxillectomy: Surgical and prosthetic outcome. Laryngoscope 101:567–569 7. Wang C, Yang T, Ko J, Lou P (2007) Ligation of the internal maxillary artery to reduce intraoperative bleeding during total maxillectomy. Laryngoscope 117:1978–1981 8. Molumi CP, Dubey SP, Apaio ML (2012) Preservation of palatal mucoperiosteum for oronasal separation after total maxillectomy. Indian J Cancer 49:209–214 9. Conley J (1985) The risk to the orbit in head and neck cancer. Laryngoscope 95:515–522 10. Cantu G, Solero CL, Riccio S, Colombo S, Pompilio M, Aboh IV, Formillo P, Arana GH (2010) Surgery for malignant maxillary tumors involving the middle cranial fossa. Skull Base 20:55–60

10

Orbital Surgery

10.1 Inferior Transpalpebral Approach Stefano Sellari-Franceschini

10.1.1 Operative Steps 1. The incision (1) is made in a skin crease along the lower margin of the tarsus and includes skin and orbicularis muscle (Fig. 10.1). 2. The incision margin (1) is raised to complete muscle section (Fig. 10.2). 3. The tarsus covered by the skin (2) is pulled up and held with a stitch (1) (Fig. 10.3). 4. At this stage, the surgeon (1) moves to the head end of the patient and separates the musculocutaneous flap from the orbital tissue (2) with a scissors (Fig. 10.4). 5. The margin of the orbital floor (1) and the fat (2) of the lower compartment of the orbit are visible when the muscle-cutaneous flap is lifted (Fig. 10.5). 6. In the orbital decompression for Graves’ orbitopathy, removal of adipose tissue is performed before removing the bony floor. The medial fat pad is often subdivided into two smaller compartments by a septum in the region of the inferior oblique muscle. At this level, the adipose tissue (1) is raised and incised with scissors from lateral to the medial direction of the inferomedial orbital rim, along the course of inferior oblique muscle (Fig. 10.6). 7. The inferior oblique muscle is located (1) and freed from fibrous connections with the fat. The inferomedial fat (2) is pulled, cauterized, and gently released with scissors (Fig. 10.7). 8. Depending on the state of fibrosis and the necessity of the case, 0.5–1.5  cm3 of inferomedial orbital fat (2) is removed (Fig.  10.8); the inferolateral (1) orbital fat is also visible.

9. A malleable retractor protects the inferior rectus muscle, and the inferolateral fat (1) is visible (Fig. 10.9). The fat is blunty mobilized from the orbital wall along the periosteum (periorbita) up to the apex. 10. The inferolateral pad of fat is removed (Fig. 10.10). 11. At this point, the operator changes position again and returns to the classic position on the patient’s side. If orbital floor drilling is also planned, the removal of the periosteum is completed, and V2 (arrow) is detected (Fig.  10.11). It is always necessary to cauterize small vessels (1) running between the V2 canal and the periorbita; in some cases, these vessels are useful for locating the nerve. 12. The drilling is performed with a diamond burr. Drilling begins in the floor lateral to V2, including part of the zygomatic bone (Fig. 10.12). 13. The mucous membrane of the maxillary sinus (2) can be discovered or removed (Fig. 10.13); also visible are V2 (1) and zygomatic bone (3). 14. Subsequently, if indicated, the drilling of the floor medial to V2 is made, leaving a 2-cm medial strut of bone anteriorly (between the floor and the medial orbital wall) and the V2 bony canal; V2 (1), lateral part of maxillary sinus (2), medial part of the maxillary sinus (3), bone strut between the floor, and the medial orbital wall (4) are also visible (Fig. 10.14). 15. If surgeon wants to avoid a skin incision or needs a wider approach to the floor and lateral orbit, a swinging eyelid approach can be performed. An incision is made at the lateral canthus from a few millimeters to 2 cm laterally in relation to the amplitude of the necessary approach (Fig. 10.15). 16. The eyelid is rotated downward and the conjunctiva is incised near the tarsus (Fig. 10.16). 17. The conjunctiva is lifted and fixed with three 5/0 vicryl stitches to the upper eyelid to cover the cornea (Fig. 10.17); conjunctiva (1), the medial stitch (2), and

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_10

393

394

the second stitch (3) are also seen. The operation continues as described earlier. 18. In the case of a direct approach to the bony floor, the periosteum of the floor will be incised at the level of the bony frame and the periosteum is elevated (Fig. 10.18): V2 (1), lateral orbital floor (2), and medial orbital floor (3). 19. In the case of intraconal neoplasms, the periorbita will be opened in the area occupied by the neoplasm. This is

10  Orbital Surgery

a schwannoma between the floor and the optic nerve (Fig. 10.19). 20. It is removed with a swinging approach (Fig.  10.20); orbital floor (1), inferior rectus muscle (2), the tumor (3), malleable retractor (4), and elevator (5) are also seen. 21. At the end of the procedure, the cutaneous muscle flap is sutured continuously with a 4/0 nylon (Fig. 10.21).

10.1 Inferior Transpalpebral Approach

395

10.1

10.2

396

10  Orbital Surgery

10.3

10.4

10.1 Inferior Transpalpebral Approach

397

10.5

10.6

398

10  Orbital Surgery

10.7

10.8

10.1 Inferior Transpalpebral Approach

399

10.9

10.10

400

10  Orbital Surgery

10.11

10.12

10.1 Inferior Transpalpebral Approach

401

10.13

10.14

402

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10.15

10.16

10.1 Inferior Transpalpebral Approach

403

10.17

10.18

404

10  Orbital Surgery

10.19

10.20

10.1 Inferior Transpalpebral Approach

405

10.21

406

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10.1.2 Potential Problems

References to Operative Procedure

1 . Bleeding from a vessel in the fat 2. Difficulty in finding V2 on the floor 3. V2 lesion during floor drilling 4. Lesion of the orbicularis muscle during the dissection of the conjunctiva in the swinging eyelid approach 5. Lesion of an extrinsic muscle or optic nerve during the removal of a tumor

1. Goldberg RA, Perry JD, Hortaleza V, Tong JT (2000) Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy. Ophthalmic Plast Reconstr Surg 16:271–277 2. Ben Simon GJ, Wang L, McCann JD, Goldberg RA (2004) Primary-gaze diplopia in patients with thyroid-­ related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome. Thyroid 14:379–383 3. Leong SC, Karkos PD, MacEwen CJ, White P (2009) A systematic review of outcomes following surgical decompression for dysthyroid orbitopathy. Laryngoscope 119:1106–1115 4. Sellari-Franceschini S (2012) Balanced orbital decompression in Graves’ orbitopathy. Oper Tech Otolayngol Head Neck Surg 23:219–226 5. Sellari-Franceschini S (2016) Surgical complication in orbital decompression for Graves’ orbitopathy. Acta Otorhinolaryngol Ital 36:265–274

10.1.3 Suggested Solutions 1 . Cauterize the fat with bipolar diathermy before cutting it. 2. If V2 is not visible distally, raise the periosteum of the floor small blood vessels that run between the nerve canal and the periorbita appear. Washing the bone with saline makes it easier to identify the nerve. 3. Drilling is performed by the nerve canal in the lateral direction and by the nerve canal in medial direction. 4. It is necessary to lift the muscle-cutaneous flap and carefully detach the adipose tissue from the flap. 5. A neoplasm should be identified in the adipose tissue at the point furthest from the nerve and muscles; and the tumor is isolated carefully by separating it progressively from orbital tissues using cottonoids.

10.2 Superior Transpalpebral Approach

10.2 Superior Transpalpebral Approach

407

9. To remove the greater wing of sphenoid, drilling begins in the supero-lateral area with cutting and diamond burrs Stefano Sellari-Franceschini (Fig. 10.30a), until the dura mater of the anterior cranial fossa (2) is seen through the bone (Fig. 10.30b). Drilling also continues medially and inferiorly until 10.2.1 Operative Steps temporalis muscle (1) and dura of the middle cranial fossa (3) are visible (Fig.  10.30b). In cadaver dissection (White arrow in the photographs indicates the head end of (Fig. 10.30c), superior orbital fissure (1), temporalis musthe patient) cle (2), meninges of the middle cranial fossa (3), and the roof of the orbit (4) are visible. 5 mm bone of the orbital 1. The eyelids are closed with 5/0 nylon stitch in order to frame is always spared to avoid aesthetic damage. avoid damages to the cornea. Skin incision is made in a 10. Removal of spheno-orbital meningioma: to remove skin fold a few millimeters above the upper margin of spheno-orbital meningioma (1), the healthy dura of the the tarsus (Fig. 10.22). anterior cranial fossa (2) is uncovered and it is a land 2. The skin is elevated and the orbicularis muscle is dismark to reach the meningioma of the sphenoid; malleasected (Fig. 10.23). ble elevator to protect the eye (3) (Fig. 10.31). 3. Elevation of the musculocutaneous flap continues later- 11. The meningioma is removed and temporal lobe of the ally until the fronto-zygomatic arch. The skin-muscle brain (∗); anterior cranial fossa (1); temporalis muscle flap is fixed with a stitch (Fig. 10.24). (2); and retracted eye (3) are visible (Fig. 10.32). 4. The periosteum (1) is incised and it is lifted from the 12. A strip of fascia lata (∗) is used to close the dural wound edge of the orbital frame (Fig. 10.25). (Fig. 10.33a); meninges (1) of the anterior cranial fossa 5. The eyeball is retracted medially with a malleable retracare visible. tor. Blunt dissection of the periorbita starts supero-­ Abdominal fat can be placed to prevent laterally and continues on the external half of the orbital enophthalmia. roof (2) where the bone is smooth and elevation is easier Removal of intraconal tumor: When surgery is per(Fig. 10.26). formed to remove an intraconal tumor, the silicone sheet 6. Small vessels running from the bone to the periorbita are is not used. Adequate periorbita is opened and the tumor cauterized and sectioned (Fig. 10.27). is gently removed from the fatty tissue (Fig. 10.33b) 7. Elevation of the periorbita ends at the superior orbital 13. Orbital decompression: During orbital decompression fissure (1) (Fig. 10.28a). It is advisable to perform the for Graves’ orbitopathy, the periorbita is incised elevation of all the periorbita in a 180° field. Dissection (Fig.  10.34a) and extraconal and intraconal fat is on the cadaver demonstrates the amplitude of the operaremoved (Fig. 10.34b). tive field after lifting up the periorbita (Fig. 10.28b). 14. While removing the upper periorbital, it is necessary to 8. A silicone sheet (black arrow) is inserted to protect the be careful not to injure V1 (1) that runs over the levator periorbital soft tissue in case orbital bone has to be oculi muscle (2); also visible are retro-orbital fat (3) and drilled for orbital decompression in Graves’ disease, orbital roof (4) (Fig. 10.35). spheno-orbital meningioma and fibrous dysplasia 15. A drainage tube (∗) is placed for 24 h (Fig. 10.36). The (Fig. 10.29a–c). upper lid incision is closed with a single stitch.

408

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10.22

10.23

10.2 Superior Transpalpebral Approach

409

10.24

10.25

410

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10.26

10.27

10.2 Superior Transpalpebral Approach

411

10.28a

10.28b

412

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10.29a

10.29b

10.2 Superior Transpalpebral Approach

413

10.29c

10.30a

414

10  Orbital Surgery

10.30b

10.30c

10.2 Superior Transpalpebral Approach

415

10.31

10.32

416

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10.33a

10.33b

10.2 Superior Transpalpebral Approach

417

10.34a

10.34b

418

10  Orbital Surgery

10.35

10.36

10.2 Superior Transpalpebral Approach

419

10.2.2 Potential Problems

References to Operative Procedure

1. Section of the levator palpebrae muscle during the incision of the eyelid skin. 2. Lesions of the periorbita during elevation: adipose tissue may enter in the operative field. 3. Bleeding from the spongy bone of the greater wing sphenoid bone. 4. Rupture of the meninges (anterior or middle cranial fossae) during bone drilling. 5. Injury of one of the lateral rectus muscles.

1. Goldberg RA, Perry JD, Hortaleza V, Tong JT (2000). Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy Ophthalmic Plast Reconstr Surg 16:271–277 2. Ben Simon GJ, Wang L, McCann JD, Goldberg RA (2004) Primary-gaze diplopia in patients with thyroid-­ related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome. Thyroid 14:379–383 3. Leong SC, Karkos PD, MacEwen CJ, White P (2009) A systematic review of outcomes following surgical decompression for dysthyroid orbitopathy. Laryngoscope 119:1106–1115 4. Sellari-Franceschini S (2012) Balanced orbital decompression in Graves’ orbitopathy. Oper Tech Otolayngol Head Neck Surg 23:219–226 5. Sellari-Franceschini S (2016) Surgical complication in orbital decompression for Graves’ orbitopathy. Acta Otorhinolaryngol Ital 36:265–274 6. Dallan J, Caniglia M, Turri-Zanoni M, Prevedello DM, De Notaris M, Battaglia P, Sellari-Franceschini S, Castelnuovo P (2018) Transorbital superior eyelid endoscopic approach to the temporal lobe. J Neurosurg Sci 62(3):369–372

10.2.3 Suggested Solutions 1. Do the skin incision 2–4 mm above the upper edge of the tarsus. Incise only the skin and then lift the skin and incise the orbicularis muscle that is attached to the skin. 2. Coagulate and cut blood vessels that run from bone to the periorbita and place a silastic sheet to protect the periorbita. 3. Use the diamond burr drilling without irrigation. If it is not enough use wax, but when all the bone has been removed. 4. For small injuries, you can do nothing: blindfold the eye with a minimum compression 2–3 days. For larger injuries, use a fragment of adipose tissue. 5. Use a fascia lata graft to close the perforation of meninges.

Parapharyngeal Space and Upper Lateral Neck Tumor Surgery

11.1 Transcervical and Transmandibular Approaches Siba P. Dubey, Charles P. Molumi, and Herwig Swoboda

11.1.1 Operative Steps 1. In transcervical approach, a roughly transverse skin incision is made along the skin crease over the swelling, two to three fingers breadth below and behind the mandibular margin up to the greater cornu of the hyoid bone; for bigger tumor in the neck, the incision is extended anterosuperiorly and inferiorly; the cervical incision is extended in the preauricular region like modified Blair’s incision to resect large tumor (Fig. 11.1). The skin flap is elevated in subplatysmal plane till the lower border of the mandible. The hypoglossal nerve and submandibular gland are identified and preserved (Fig. 11.2). The mandible is retracted upward. A plane of cleavage is created between mandible laterally and pharyngeal constrictors medially. By this approach, up to medium-sized benign tumor is removed and the surrounding vital structures are kept intact (Fig. 11.3). 2. Bigger (or dumbbell) tumor requires larger exposure. It is achieved by (i) submandibular sialoadenectomy, (ii) division of digastric muscle, and (iii) division of the styloid process or stylomandibular ligament. 3. Bigger tumor or those located in the superior part of the parapharyngeal space requires combined transmandibular and transcervical approach. The cervical incision is extended for lip-split (Fig. 11.4). Angled mandibulotomy incision is marked on the mandible in the midline (Fig.  11.5). Subsequently, an angled mandibulotomy is performed with oscillating saw (Fig.  11.6). The tongue is retracted to the nonpathological side. The incision in the oral mucosa started from in-between two central incisors and is extended posteriorly along the gingivolingual sulcus, lateral to the anterior tonsillar pillar, and then superiorly. The hypoglossal and lingual nerves are protected, and the mylohyoid and

11

the anterior belly of the digastric muscles are divided to make oral cavity continuous with the neck and the mandible is swung laterally (Fig. 11.7). The tumor is removed completely and bleeding is controlled. This approach provides better neurovascular control at the base of the skull. The floor of mouth is closed. The mandible is replaced with miniplates (Fig. 11.8). Split-lip is sutured meticulously. 4. The tumors, namely, paraganglioma, schwannoma, and carotid body tumor, located in the mid- and/or upper lateral neck region are approached with smaller incisions or similar incisions to that described above. The mandibular osteotomy is also extremely helpful in these tumors with extension to the parapharyngeal space. With smaller tumor at the carotid bifurcation, the lower four cranial nerves, and carotid arteries and internal jugular vein are dissected away from the tumor and are protected; the tumor is removed (Figs. 11.9, 11.10 and 11.11; photographs by Dr. Swoboda, Vienna; excision of left neck paraganglioma showing CCA—common carotid artery, ICA—internal carotid artery, ECA—external carotid artery, IJV—internal jugular vein, D—posterior belly of digastric muscle, X—vagus nerve, XI—spinal accessary nerve, SCM—sternocleiodomastoid muscle, C2— transverse process of second cervical vertebra, GN—great auricular nerve, EJV—external jugular vein, T—tumor, P—parotid gland, OH—superior belly of omohyoid muscle, CS—cut section of specimen, EL—ear lobule). In bigger carotid body tumor, the external carotid artery is removed along with the tumor (Figs. 11.12 and 11.13). Tumor arising from the deeper neural structures (namely, paraganglioma of the sympathetic chain) of the neck pushes the carotid arteries outward (Fig. 11.14—CT angiogram and Fig. 11.15—intraoperative picture). Adequate intracranial collateral circulation developed when the patient presented with bigger tumor involving the carotids for 3–5 years after the appearance of the tumor. Hence, in these cases, the internal carotid artery of the pathological side became smaller in diameter and did not cause any deleterious effect to the patient when it is ligated. In these situations, it is also not unusual to find the tumor involving X, XI, and XII cranial nerves.

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_11

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11.1

Pinna

Sternocleidomastoid muscle

Tumor Hypoglossal nerve Internal jugular vein

Submandibular salivary gland

Common carotid artery

Vagus nerve

11.2

11.1  Transcervical and Transmandibular Approaches

423

Hypoglossal nerve Submandibular salivary gland

Internal carotid artery

Spinal accessary nerve

External carotid artery

Internal jugular vein

Common carotid artery

Vagus nerve

Omohyoid muscle

Sternocleidomastoid muscle

11.3

Previous biopsy site

11.4

424

11  Parapharyngeal Space and Upper Lateral Neck Tumor Surgery

Marking for mandibulotomy

11.5

Tongue

Midline mandibulotomy

11.6

11.1  Transcervical and Transmandibular Approaches

425

Soft palate and uvula

Tonsillar fossa

Mandibular cut end II

TONGUE Mandibular cut end I

Endotracheal tube

11.7

11.8

426

11  Parapharyngeal Space and Upper Lateral Neck Tumor Surgery

11.9

11.10

11.1  Transcervical and Transmandibular Approaches

427

11.11

Intermediate tendon of digastric muscle Pinna Submandibular salivary gland Parotid gland

Hypoglossal nerve

Ligated and transected external carotid artery

Spinal accessary nerve

Internal jugular vein

Common carotid artery

Sternocleidomastoid muscle

11.12

428

11  Parapharyngeal Space and Upper Lateral Neck Tumor Surgery

11.13

External carotid artery

Internal carotid artery

Tumor

Common carotid artery

11.14

11.1  Transcervical and Transmandibular Approaches

429

Pinna

External carotid artery

Internal carotid artery

Tumor Tumor Common carotid artery

Internal jugular vein

Sternocleidomastoid muscle

11.15

430

11.1.2 Potential Problems 1. Injury to XII and X cranial nerve or any of its branches with lifelong functional deficit of speech and swallowing 2. Injury to XI with shoulder joint morbidity 3. Injury to VII cranial nerve during division of the styloid process

11.1.3 Suggested Solutions 1. Adequate exposure and visualization of the neurovascular structures all around the tumor including the skull base. 2. Meticulous control of smaller bleeding vessels; vessel loop control of the major vessels. 3. Advance ligation of the ascending pharyngeal and occipital arteries in case they are supplying the tumor as demonstrated in preoperative radiology. 4. Early identification and mobilization of X, XI and XII cranial nerves away from the tumor. 5. Careful division of the styloid process whenever necessary. 6. Intraoperative monitoring of nerves with a nerve integrity monitor (NIM). References to Operative Procedure 1. Som PM, Biller HF, Lawson W (1981) Tumors of the parapharyngeal space. Preoperative evaluation, diagnosis and surgical approaches. Ann Otol Rhinol Laryngol Suppl 90:3–14

11  Parapharyngeal Space and Upper Lateral Neck Tumor Surgery

2. Olsen KD (1994) Tumors and surgery of the parapharyngeal space. Laryngoscope 104(5 Pt 2 Suppl 63): 1–28 3. Raveh E, Segal K, Chaimoff M, Feinmesser R (1996) Surgical approaches to the parapharyngeal space. Oper Tech Otolayngol Head Neck Surg 7:327–332 4. Hallett JW, Nora JD, Hollier LH, Cherry KJ, Pairolero PC (1988) Trends in neurovascular complications of surgical management for carotid body and cervical paragangliomas: a fifty-year experience with 153 tumors. J Vasc Surg 7:284–291 5. Persky MS, Setton A, Niimi Y, Hartman J, Frank D, Berenstein A (2002) Combined endovascular and surgical treatment of head and neck paragangliomas—a team approach. Head Neck 24:423–431 6. Gibber MJ, Zevallos JP, Urken ML (2012) How I do it: enucleation of vagal nerve schwannoma using intraoperative nerve monitoring. Laryngoscope 122:790–792 7. van der Bogt KEA, Peeters MFMV, van Baalen JM, Hamming JF (2008) Resection of carotid body tumors: results of an evolving surgical technique. Ann Surg 247:877–884 8. Spinelli F, Massara M, La Spada M, Stilo F, Barilla D, De Caridi G (2014) A simple technique to achieve bloodless excision of carotid body tumors. J Vasc Surg 59:1462–1464 9. Ma Y, Huang D, Liu L, Xiang M, Oghagbon EK, Zhai S (2014) Surgical treatment of carotid body tumour: a report of 39 cases and a new classification of carotid body tumour: our experience. Clin Otolaryngol 39:254–257

Pediatric Head and Neck Surgery

12.1 Excision of Branchial Cyst Siba P. Dubey and Charles P. Molumi

12.1.1 Operative Steps 1. A curved incision is marked over lower part of the cyst on a skin crease below and behind the angle of the mandible (Fig. 12.1). 2. Subplatysmal flaps are raised. The cyst is encountered below the platysma muscle. The surgical field is widened till the circumference of the cyst reached in anterior, posterior, and inferior directions. The cyst is freed from the surrounding structures in its lateral (superficial), medial (deep), anterior, and posterior aspects. Cranial part of the

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cyst tract is extended upward between the posterior belly of digastric muscle laterally and deep fascial covered carotids (carotid sheath) and hypoglossal nerve medially (Fig. 12.2). 3. The cranial part of the tract is followed deep to the posterior belly of the digastric muscle. This part of the dissection is carried out bluntly and by staying very close to the tract. In this way, injury to 9th, 10th, and 11th cranial nerve is avoided. At this stage, the tract became cord-like (without lumen). The tract is cut, and ligated 2.5 cm above the level of the digastric muscle and the cyst is removed. The appearance of the surgical field after removal of the cyst (Fig. 12.3). 4. The cyst is cut open and thick secretion is removed. No lumen is found in the cranial most part of the tract (Fig. 12.4).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_12

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12.1

Posterior belly of digastric muscle

Cyst

Hypoglossal nerve

Carotid sheath

Cranial part of cyst tract

Sternocleido -mastoid muscle Great auricular nerve

12.2

12.1 Excision of Branchial Cyst

433

Digastric tendon and muscle

Hypoglossal nerve through gap in deep cervical fascia

Carotid sheath

Sternocleido -mastoid muscle

Cranial extension of cyst tract Great auricular nerve

12.3

12.4

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12.1.2 Potential Problems

References to Operative Procedure

1 . Injury to IX–XII cranial nerves 2. Injury to carotids in case the cyst is intimately related to them 3. Residual cyst tract

1. Deane SA, Telander RL (1978) Surgery of Thyroglossal duct and branchial cleft anomalies. Am J Surg 136:348–353 2. Acierno SP, Waldhausen JHT (2007) Congenital cervical cyst, sinuses and fistulae. Otolaryngol Clin N Am 40:161–176 3. LaRiviere CA, Waldhausen JHT (2012) Congenital cervical cysts, sinuses, and fistulae in pediatric surgery. Surg Clin N Am 92:583–597 4. Prosser JD, Myer CM (2015) Branchial cleft anomalies and thymic cysts. Otolaryngol Clin N Am 48:1–14

12.1.3 Suggested Solutions 1. Dissection must be blunt and meticulous around cranial nerves. 2. Cyst wall should be separated carefully from the carotids. 3. Preoperative investigations should indicate the extent of the cyst lumen which should be excised completely.

12.2 Excision of Cystic Hygroma

12.2 Excision of Cystic Hygroma Siba P. Dubey and Charles P. Molumi

12.2.1 Operative Steps 1. The incision is outlined to remove the cyst as well as the redundant skin due to large cystic hygroma in the neck (Fig. 12.5a, b). 2. The excision of the lesion is begun by incising the skin and dissecting over the surface of the cyst and separating

435

it from adjacent normal adjacent structures. After the superior flap is raised, the mandibular division of the facial nerve is identified (Fig. 12.6). 3. The cyst is completely separated from surrounding normal structures; and the extension of the cyst is followed to the floor of mouth (Fig. 12.7a). 4. In this patient, the mandible is thinned at its anterior surface due to long-standing pressure of the cyst (Fig. 12.7b). 5. The surgical field after removal of the cyst is washed with saline, and a penrose drain is inserted. The wound is closed in layers. The postoperative specimen of excised cystic hygroma (Fig. 12.8).

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12  Pediatric Head and Neck Surgery

12.5a

12.5b

12.2 Excision of Cystic Hygroma

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Marginal mandibular branch of facial nerve

Tail of parotid gland

Cyst

12.6

Posterior belly of digastric muscle Sternocleidomastoid muscle

Extension of cyst to floor of mouth

Submandibular salivary gland with cyst

Superior belly of omohyoid muscle

Skin attached with cyst

12.7a

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Marginal mandibular branch of facial nerve Mylohyoid muscle

Posterior belly of digastric muscle

12.7b

12.8

12.2 Excision of Cystic Hygroma

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12.2.2 Potential Problem

References to Operative Procedure

1 . Recurrence following incomplete removal 2. Accidental entry into oral cavity

1. Emery PJ, Bailey CM, Evans JNG (1984) Cystic hygroma of the head and neck: a review of 37 cases. J Laryngol Otol 98:613–619 2. Seashore JH, Gardiner LJ, Ariyan S (1985) Management of giant cystic hygroma in infants. Am J Surg 149:459–465 3. Ricciardelli EJ, Richardson MA (1991) Cervicofacial cystic hygromas. Arch Otolaryngol Head Neck Surg 117:546–553 4. Tubbs RS, Bradley N, Harmon D, Hankinson TC, Kelly DR, Wellons JC (2011) Involvement of the brachial plexus and its branches by cystic hygromas: report of 4 cases. J Neurosurg Pediatr 7:282–285

12.2.3 Suggested Solution 1. Cystic hygroma used to have extensions along the spaces in between the tissues. All these extensions are to be removed. With bigger cyst, the ipsilateral submandibular and sublingual salivary glands can be involved extensively; in this situation, the gland has to be removed with the cyst. 2. Accidental tear in the floor of the oral cavity can happen. The tear is to be diagnosed and is to be repaired before the end of the procedure.

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12.3 Excision of Nasal Dermoid Cyst Siba P. Dubey and Charles P. Molumi

12.3.1 Operative Steps 1. A vertical midline incision is marked out on the nasal dorsum (Fig. 12.9).

12  Pediatric Head and Neck Surgery

2. The skin incision is carried to the surface of the cyst. The cyst is separated from the upper lateral cartilage, dorsal septum, and nasal bones and removed (Fig.  12.10a). A magnified image of the central part of Fig. 12.10a shows hairs coming out of cyst and the cyst tract on the nasal dorsum (Fig. 12.10b). The nasal pit is removed. Wound is closed in layers.

12.3 Excision of Nasal Dermoid Cyst

441

12.9

12.10a

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Cyst

Dermoid cyst tract

Hairs in dermoid cyst

Nasal dorsum

12.10b

12.3 Excision of Nasal Dermoid Cyst

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12.3.2 Potential Problems

References to Operative Procedure

1. Resecting a large dermoid may leave a significant soft tissue defect as well as splayed nasal bones. 2. Intracranial extension of dermoid.

1. Sessions RB (1982) Nasal dermal sinuses—new concepts and explanations. Laryngoscope 92(8 Pt 2):1–28 2. Pollock RA (1983) Surgical approaches to nasal dermoid cyst. Ann Plast Surg 10:498–501 3. Posnick JC, Bortoluzzi P, Armstrong DC, Drake JM (1994) Intracranial nasal dermoid sinus cyst: computed tomographic scan findings and surgical results. Plast Reconstr Surg 93:745–754 4. Herrington H, Adil E, Moritz E, Robson C, Perez-Atayde A, Proctor M, Rahbar R (2016) Update on current evaluation and management of pediatric nasal dermoid. Laryngoscope 126:2151–2160

12.3.3 Suggested Solutions 1. Always splint the nose with plaster of Paris as following rhinoplasty 2. Neurosurgeon’s cooperation is needed to manage intracranial extension

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12.4 Excision of Thyroglossal Cyst Siba P. Dubey and Charles P. Molumi

12.4.1 Operative Steps 1. A 5–6  cm transverse incision is made over the cyst; in case of a sinus, the central part of the incision should encircle the opening of the sinus (Fig. 12.11). 2. The skin is incised and platysma muscle is encountered. The platysma muscle is cut and the dissection proceeds cranially in the subplatysmal plane. The sinus opening with the attached skin or the cyst is grasped and retracted superiorly to

12  Pediatric Head and Neck Surgery

free the cyst from the tissues at its deeper surface (Fig. 12.12). The integrity of the tract is preserved and the dissection is continued till hyoid bone reached (Fig. 12.13). 3. The muscles attached at the superior and inferior border of the central part of the hyoid bone are cut; the body of the bone is also cut while the thyroglossal duct is left attached with the specimen (Fig. 12.14). The tract is followed through the floor of mouth muscles till the base of the tongue is reached. A part of the tongue around the foramen cecum is included in the specimen. The tongue base and its musculature are sutured together. A drain is placed in the subplatysmal plane and the platysma muscle is approximated. The skin is closed in layers. 4. The intact and cut specimen (Figs. 12.15 and 12.16).

12.4 Excision of Thyroglossal Cyst

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12.11

12.12

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Thyroglossal tract deep to body of hyoid bone

Body of hyoid bone

Cyst

12.13

Cranially directed thyroglossal cyst tract

Cut body of hyoid bone

Cyst

12.14

12.4 Excision of Thyroglossal Cyst

447

Resected hyoid bone

12.15

12.16

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12.4.2 Potential Problems

References to Operative Procedure

1. Recurrence if the entire tract, including the cranial most part, is not removed.

1. Sistrunk WE (1920) The surgical treatment of cysts of the thyroglossal tract. Ann Surg 70:121–124 2. Sistrunk WE (1928) Techniques of removal of cyst and sinuses of the thyroglossal duct. Surg Gynecol Obstet 46:109–112 3. Goldzstein N, Khan A, Pereira KD (2009) Thyroglossal duct cyst excision—the Sistrunk procedure. Oper Tech Otolayngol Head Neck Surg 20:256–259 4. Ahmed J, Leong A, Jonas N, Grainger J, Hartley B (2011) The extended Sistrunk procedure for the management of thyroglossal duct cysts in children: how we do it. Clin Otolaryngol 36:271–275 5. Ryu Y, Kim DW, Jeon HW, Chang H, Sung MW, Hah JH (2015) Modified Sistrunk operation: new concept for management of thyroglossal duct cyst. Int J Pediatr Otorhinolaryngol 79:812–816

12.4.3 Suggested Solutions 1. The thyroglossal tract usually runs in the midline on the posterior aspect of the hyoid bone; very rarely, the tract may even go through this part of the bone. Hence, it is mandatory to remove the middle third of the body of hyoid bone. The cranial most part of the tract lies within the tongue and has to be accessed and removed to avoid recurrence. 2. The tongue base is pushed downward toward the wound by placing a retractor at the valleculae. This helps to identify and access the foramen cecum.

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Robot Surgery

13.1 Supraglottic Laryngectomy Mohssen Ansarin, Augusto Cattaneo, and Francesco Chu

13.1.1 Operative Steps General anesthesia is induced via naso-tracheal intubation. Transoral exposure is achieved with a Feyh–Kastenbauer retractor (Gyrus ACMI, Southborough, MA, USA) (Fig. 13.1). The Da Vinci system with three arms is used (one endoscopic arm with integrated cameras for the tridimensional view and two instrument arms, a 5-mm Maryland forceps and a 5-mm monopolar spatula cautery, interchangeable during the procedure). Adequate exposure is considered when a full vision of the supraglottis, glottis, and folded/unfolded pyriform sinus is obtained.

13.1.1.1 Type IIb Supraglottic Laryngectomy Case 1: Squamous Cell Carcinoma of the lingual surface of the epiglottis partially extended to the pyriform sinus, pharyngoepiglottic, and aryepiglottic fold. Stage cT2N0 tumor showing (1) neoplasia, (2) aryepiglottic fold, (3) epiglottis, (4) right pyriform sinus, (5) monopolar spatula cautery, and (6) Maryland forceps (Fig. 13.2). The epiglottis is pulled posteriorly with the Maryland forceps. The incision is made at the level of the left free border of the epiglottis and extended contralaterally. Along the dissection, malignancy is identified at the level of the right aryepiglottic fold. The incision is made at the level of the free border of the epiglottis (1), on the left side, far from the neoplasia (2) (Fig. 13.3). The epiglottis (1) is pulled laterally and the neoplasia is also identified at the level of the right aryepiglottic fold (2) (Fig. 13.4).

Dissection proceeds until the right aryepiglottic fold and pyriform sinus is excised in order to achieve the goal of a radical surgery. The incision is made at the level of the right aryepiglottic fold (1) and extended to the ipsilateral pyriform sinus (2) (Fig. 13.5). Final endoscopic view: (1) base of the tongue, (2) ventricular folds, and (3) right arytenoid cartilage (Fig. 13.6). Case 2: Squamous cell carcinoma of the right aryepiglottic fold. Stage cT1N0 tumor showing (1) neoplasia at the level of the right aryepiglottic fold, (2) right arytenoid cartilage, (3) epiglottis, (4) monopolar spatula cautery, and (5) Maryland forceps (Fig. 13.7). The epiglottis is pulled posteriorly with the Maryland forceps. The incision is made at the level of the left free border of the epiglottis and extended counter-laterally until the free portion of the epiglottis is excised and the neoplasia is fully visible at the endoscopic view. Incision at the level of the free border of the epiglottis, left side. (1) Epiglottis, (2) left arytenoid cartilage (Fig. 13.8). The dissection proceeds carefully to resect the affected mucosa, sparing the right arytenoid cartilage and the mucosa of the ventricular folds. Endoscopic view of the neoplasia (1) once the epiglottis has been resected. (2) Right arytenoid cartilage (Fig. 13.9). Excision of the neoplasia (1) sparing the arytenoid cartilage (2) (Fig. 13.10). Final endoscopic view. (1) Right ventricular fold, (2) right arytenoid cartilage (Fig. 13.11).

13.1.1.2 Type IIIb Supraglottic Laryngectomy Case 1: Squamous cell carcinoma of the laryngeal surface of the epiglottis, infiltration the pre-epiglottic space, and partially extended to the supraglottis and ventricular folds. Stage cT3N0 tumor showing the epiglottis (1) is pushed anteriorly and the neoplasia is easily visualized at the level of the infra-hyoid portion of the epiglottis (2). The robotic arms

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_13

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are equipped with a 5-mm Maryland forceps (3) and a 5-mm monopolar spatula cautery (4) (Fig. 13.12). The incision begins at the level of the left aryepiglottic fold and extending contralaterally through the glossoepiglottic vallecula until the fat of the pre-epiglottic space is fully exposed. The left aryepiglottic fold (1) is put into ­traction by the Maryland forceps (2) so that the incision may be given with the monopolar cautery (3) (Fig. 13.13). The epiglottis (1) is pushed posteriorly. The incision proceeds until the fat of the pre-epiglottic space is exposed (2) (Fig. 13.14).

13  Robot Surgery

The epiglottis is pushed anteriorly, careful dissection proceeds further until the pre-epiglottic space is completely emptied. An assistant takes care of suction and cauterization in case of intraoperative bleeding. The fat of pre-epiglottic space is excised (1). An assistant takes care of suction and cauterization in case of bleeding (2) (Fig. 13.15). The dissection proceeds to include the arytenoid mucosa bilaterally, both the ventricular folds and the supracommissural space inferiorly. Final view showing (1) glottic plane, (2) Arytenoid cartilages (Fig. 13.16).

13.1  Supraglottic Laryngectomy

451

13.1

13.2

452

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13.3

13.4

13.1  Supraglottic Laryngectomy

453

13.5

13.6

454

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13.7

13.8

13.1  Supraglottic Laryngectomy

455

13.9

13.10

456

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13.11

13.12

13.1  Supraglottic Laryngectomy

457

13.13

13.14

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13.15

13.16

13.1  Supraglottic Laryngectomy

13.1.2 Potential Problems 1. The postoperative complications include tooth injury, percutaneous endoscopic gastrostomy tube dependency, pharyngocutaneous fistula, airway obstruction, aspiration, hypoglossal nerve injury, lingual nerve injury, dehydration requiring readmission, and first bite syndrome.

13.1.3 Suggested Solutions 1 . Postoperative vessel ligation or embolization 2. Readmission and management of respective complication, namely, rehydration, tracheostomy, and antibiotics for sepsis or systemic infection and pneumonia 3. Prophylactic ligation of selected branches of the external carotid artery. References to Operative Procedure 1. McLeod IK, Melder PC (2005) Da Vinci robot-assisted excision of a vallecular cyst: a case report. Ear Nose Throat J, 84:170–172

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2. Weinstein GS, O’Malley BW Jr, Snyder W, Sherman E, Quon H (2007) Transoral robotic surgery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg 133:1220–1226 3. Weinstein GS, O’Malley BW Jr, Magnuson JS, Carroll WR, Olsen KD, Daio L, et  al (2012) Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope 122:1701–1707 4. Grillone GA, Jalisi S (2015) Robotic surgery of the head and neck: a comprehensive guide. Springer, New York 5. Topf MC, Moritz E, Gleysteen J, Curry JM, Cognetti DM, Luginbuhl AJ (2017) First bite syndrome following transcervical arterial ligation after transoral robotic surgery. Laryngoscope 128:1589–1593 6. Pahar HS, Gausden E, Patel J, Prisman E, Anderson DW, Durham JS, Rush B (2018) Analysis of readmissions after transoral robotic surgery for oropharyngeal squamous cell carcinoma. Head Neck 40:2416–2423 7. Kubik M, Mandal R, Albergotti W, Duvvuri U, Ferris RL, Kim S (2017) Effect of transcervical arterial ligation on the severity of postoperative hemorrhage after transoral robotic surgery. Head Neck 39:1510–1515

Surgery of Salivary Glands

14.1 Submandibular Sialoadenectomy Siba P. Dubey and Charles P. Molumi

14.1.1 Operative Steps 1. The patient lied supine with the head tilted to the opposite side and slightly extended. A submandibular incision is made in a natural skin crease 3 cm below the lower border of the mandible over the submandibular swelling (Fig. 14.1). 2. Skin incision is carried through the subcutaneous fat and the platysma muscle. The flap is elevated superiorly in the subplatysmal plane to the rim of the mandible and inferiorly to just below the hyoid. Elevate the flap to expose all boundaries of the tumor. The marginal mandibular branch of the facial nerve is identified in front of the angle of mandible as it crosses over the facial artery and vein (Fig. 14.2a). And great auricular nerve and sternocleidomastoid muscle are visible at the posterior extreme of the operative field (Fig. 14.2b). 3. Superior dissection is begun by ligating the facial artery and vein running under the marginal mandibular nerve. The upper stump of the ligated facial vessels are deflected upwards and anchored which protects the marginal mandibular branch of the facial nerve during further dissection (Fig. 14.3).

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4. Anterior dissection is done by dividing the vessels to the mylohyoid muscle in the submental region. The gland is mobilized posteriorly exposing the mylohyoid muscle . The posterior border of the mylohyoid muscle is retracted anteriorly, while maintaining gentle traction on the submandibular gland. This exposes the submandibular duct, the lingual nerve in a ‘V’-shaped curve and submandibular ganglion (Fig.  14.4). The contribution of the lingual nerve to the submandibular ganglion is divided releasing the lingual nerve and it disappears from view under the mandible. The submandibular duct is cut and ligated and the deeper part of the gland is freed (Fig. 14.5). The last attachment of the gland is by the facial artery as it runs along the superior boundary of the posterior belly of digastric muscle. The facial artery is divided for a second time and the submandibular gland with the tumor is removed. 5. The surgical field after tumor removal showed the myolohyoid, hyoglossus thyrohyoid and digastric muscles, and the hypoglossal nerve (Fig. 14.6). The wound is irrigated with saline, a penrose drain is inserted, and closed in layers. 6. The tumor is examined to ensure complete removal and cut open to examine the content and texture before sending for histopathological examination (Fig. 14.7a, b).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_14

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14.1

Mandibular branch of facial nerve

Tumor

Facial artery

14.2a

14.1 Submandibular Sialoadenectomy

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Great auricular nerve Tumor

Sternocleidomastoid muscle

14.2b

Mandibular branch of facial nerve

Tumor

Divided and ligated facial artery

14.3

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14  Surgery of Salivary Glands Submandibular ganglion

Tumor Lingual nerve

Submandibular duct

Deep lobe of submandibular gland

14.4

Mylohyoid muscle Submandibular duct

Hyoglossus muscle

Tumor

Deep part of submandibular gland

14.5

14.1 Submandibular Sialoadenectomy

Chin

465

Mylohyoid muscle Hypoglossal nerve

Anterior belly of digastric muscle

Hyoglossus muscle

Thyrohyoid muscle

Intermediate tendon of digastric muscle

14.6

14.7a

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14.7b

14.1 Submandibular Sialoadenectomy

14.1.2 Potential Problems 1 . Injury to the mandibular branch of facial nerve. 2. Injury to hypoglossal nerve. 3. Accidental entry into the oral cavity.

14.1.3 Suggested Solutions 1. Great care should be taken to avoid injury of the marginal mandibular branch of the facial nerve. The nerve lies beneath the deep cervical fascia and is easily identified at the point of crossing over the facial artery and vein. A small lymph node in this area which occasionally obscures the nerve is dissected away. Transection of the facial vessels and deflecting the superior stump upwards places the nerve at risk of injury, as the nerve may lie slightly lower than the point at which the vessels are identified. Hence, always identify the nerve first before transecting the facial vessels. If the nerve is not identified, incise the fascia of the submandibular gland at the level of the hyoid bone and reflect this fascia upwards and suture it to the undersurface of the superior skin flap to protect the mandibular branch of the facial nerve. 2. The hypoglossal nerve is seen in a deep plane to the Wharton’s duct. It should be carefully protected. The nerve is accompanied on either side by veins; these veins cause profuse bleeding when injured. Avoid the use of

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diathermy to control brisk bleeding to prevent thermal injury to the nerve. Use ligature clips or simple ligature to stop the bleeding; ligature must avoid kinking of the nerve. 3. Ensure that there is no communication of the surgical wound into the oral cavity as leakage of saliva and food particles into the surgical wound causes infection and wound break down. If the entry into the oral cavity is not detected during excision of the tumor, always check the oral cavity along the gingivolingual sulcus of the ipsilateral side after closure of the neck wound. If a tear in the oral mucosa is detected, an airtight closure must be done. It is always wise to insert a nasogastric tube for feeding for a few days if a communication between the oral cavity and wound is detected. References to Operative Procedure 1. Maynard J (1978) Submandibular and parotid gland resection. Br J Hosp Med 20:70–79 2. Kennedy PJ, Poole AG (1989) Excision of the submandibular gland: Minimizing the risk of nerve damage. Aust N Z J Surg 59:411–414 3. Ichimura K, Nibu K, Tanaka T (1997) Nerve paralysis after surgery in the submandibular triangle: review of University of Tokyo Hospital experience. Head Neck 19:48–53

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14.2 Superficial Parotidectomy with Sternocleidomastoid Muscle Flap Siba P. Dubey and Charles P. Molumi

14.2.1 Operative Steps 1. Modified Blair’s incision is marked out beginning near the upper part of the auricle, then curved downward into the tragal notch and continued downward to the lobe of the ear, then curved backward at almost a right angle to the tip of the mastoid process, and finally curved downward toward the hyoid bone in the natural skin crease (Fig. 14.8). 2. The skin incision is carried down to the subcutaneous tissue. The anterior skin flap is elevated superficial to the parotid fascia in the preauricular region and in the subplatysmal plane in the cervical extension of the incision. The skin flaps are anchored with silk sutures. The great auricular nerve and external jugular vein over the sternocleidomastoid muscle are identified. The external jugular vein is divided and ligated and the great auricular nerve is transected or preserved (Fig. 14.9). The posterior belly of digastric muscle is exposed proximal to its attachment to the mastoid bone. The anterior border of the sternocleidomastoid muscle is skeletonized. 3. The preauricular space is opened by dissecting the fascia between the parotid gland and the cartilaginous external auditory canal, and the parotid gland is retracted anteri-

14  Surgery of Salivary Glands

orly. The cartilage of the external auditory canal is skeletonized and the tragal cartilage (the tragal pointer) is exposed; it serves as the landmark for the facial nerve identification. The trunk of the facial nerve is identified at a location approximately 1 cm deep and 1 cm inferior to the tragal pointer (Fig. 14.10). 4. The parotid tissue overlying adjacent branches of the facial nerve is elevated with fine hemostat and the intervening parotid tissues in between are divided in posteroanterior direction. The process is continued in all the branches in caudocranial or craniocaudal direction. In this way, the entire superficial lobe is removed, preserving the integrity of the facial nerve branches (Figs. 14.11 and 14.12). 5. The entire postoperative specimen (Fig. 14.13). 6. Removal of part or the entire gland results in a depression or hollow in the parotid area. The resultant deformity leads to anxiety and cosmetic deformity when compared with the normal side. It is corrected with a superiorly based sternocleidomastoid muscle flap covering the parotidectomy bed. Through the cervical part of the incision, the sternocleidomastoid muscle above the level of spinal accessory nerve is elevated according to the desired length (Fig. 14.14); the muscle is transected with monopolar coagulation diathermy and placed on the defect created by parotidectomy (Fig. 14.15). The muscle is sutured to the margin of the defect, avoiding the facial nerve branches (Fig. 14.16). 7. A drain is inserted and the incision is closed in layers with interrupted sutures.

14.2 Superficial Parotidectomy with Sternocleidomastoid Muscle Flap

469

14.8

Parotid tumor

Great auricular nerve

Tragal cartilage

Preauricular space

14.9

470

14  Surgery of Salivary Glands

Parotid tumor

Facial nerve trunk

Great auricular nerve

Tragal cartilage Sternocleidomastoid muscle

Great auricular nerve

14.10

Tumor

Facial nerve trunk and its divisions

14.11

14.2 Superficial Parotidectomy with Sternocleidomastoid Muscle Flap

471

Posterior facial vein

Great auricular nerve

Facial nerve branches

14.12

14.13

472

14  Surgery of Salivary Glands

Parotidectomy bed

Sternocleidomastoid muscle

Spinal accessary nerve

14.14

Superficial part of sternocleidomastoid muscle in parotidectomy bed

Spinal accessary nerve

Deep part of sternocleidomastoid muscle

14.15

14.2 Superficial Parotidectomy with Sternocleidomastoid Muscle Flap

473

Superficial part of sternocleidomastoid muscle stitched in parotidectomy bed

Deep part of sternocleidomastoid muscle Spinal accessary nerve

14.16

Tumor

Facial nervetrunk,

Marginal mandibular branch of facial nerve lateral to facial vessels

upper and lower divisions Lower buccal branch of facial nerve lateral to retromandibular vein

Sternocleidomastoid muscle External jugular vein

Cervical branch of facial nerve

14.17

474

14.2.2 Potential Problems 1 . Accidental creation of buttonhole in the skin flap 2. Difficulty identifying facial nerve trunk 3. Facial Nerve injury 4. Bleeding from accidental superficial temporal artery injury 5. Indiscriminate transaction of great auricular nerve

14.2.3 Suggested Solutions 1. When parotid tumors stretch the skin, ensure that no buttonhole is created in the skin. Bevel the knife when dissecting the skin away from the tumor. 2. Always have the alternative options of identifying the facial nerve, as it may not be possible to identify by tragal pointer, especially in large tumors where the facial nerve trunk is displaced. Identify the attachment of the posterior belly of digastric muscle to the mastoid tip; the facial nerve trunk bisects the angle between the muscle and the styloid process. Another method is to identify the tympanomastoid suture line, the nerve lies 6–8 mm deep to it. In huge tumors where the tumor is directly over the facial nerve trunk, identify the marginal mandibular branch at the lower border of the mandible as it crosses superficial to the facial artery and vein beneath the deep cervical fascia; or the lower buccal branch of the facial nerve passes superficial to the retromandibular or posterior facial vein which is reached by following the external jugular vein cranially, and follow this branch proximally to the facial nerve trunk (Fig. 14.17). 3. Avoid the use of monopolar electrocautery; instead, use bipolar diathermy or cotton ball soaked in adrenaline to control bleeding. As the dissection of the skin flap is continued to the anterior border of the tumor, note that the facial nerve becomes superficial and there is high tendency to injury during dissection. As the cervical or mandibular division is followed, there is injury to the posterior facial vein which lies directly under it and causes bleed-

14  Surgery of Salivary Glands

ing. Trying to control bleeding will risk the nerve being injured. Carefully elevate the vein with a hemostat, clamp, and ligate. A small branch of the occipital artery is commonly encountered just lateral to the facial nerve close to the stylomastoid foramen. Arterial bleeding in this area indicates close proximity of facial nerve. Use bipolar diathermy to cauterize this bleeding. 4. Superficial temporal artery is easily injured when dissecting parotid tissue near the superior division of facial nerve in front of the preauricular region causing troublesome bleeding. Great care must be taken to preserve this vessel if temporoparietal fascial flap is planned to be raised to prevent Frey’s syndrome. 5. The great auricular nerve running obliquely upward and forward at the junction of the upper and the middle thirds of the sternocleidomastoid muscle should be preserved. It can be used as a jump nerve graft if facial nerve is resected. If situation demands, resection of this nerve may be inevitable. 6. Use of nerve integrity monitor (NIM) to locate the facial nerve or its branches. References to Operative Procedure 1. Beahrs OH (1977) The surgical anatomy and technique of parotidectomy. Surg Clin N Am 57:477–493 2. Maynard J (1978) Submandibular and parotid gland resection. Br J Hosp Med 20:70–79 3. Woods JE (1983) Parotidectomy: points of technique for brief and safe operation. Am J Surg 145:678–683 4. Jost G, Guenon Ph, Gentil S (1999) Parotidectomy: a plastic approach. Aesthet Plast Surg 23:1–4 5. Anjum K, Revington PJ, Irvine GH (2008) Superficial parotidectomy: antegrade compared with modified retrograde dissections of the facial nerve. Br J Oral Maxillofac Surg 46:433–434 6. Casler JD, Conley J (1991) Sternocleidomastoid muscle transfer and superficial musculoaponeurotic system plication in the prevention of Frey’s syndrome. Laryngoscope 101:95–100

14.3 Removal of Deep Lobe Parotid Tumor

14.3 Removal of Deep Lobe Parotid Tumor Herwig Swoboda

14.3.1 Operative Steps 1. The tumor is defined and the facial nerve and its branches are identified (Fig. 14.18).

475

2. The attached segment of the facial nerve trunk and its branches are freed entirely from the tumor (Fig. 14.19). 3. The normal superficial lobe is placed back (Fig. 14.20). 4. The wound is closed and the specimen is inspected (Fig. 14.21).

476

14  Surgery of Salivary Glands

Deep lobe parotid tumor

Facial nerve trunk and branches

14.18

Ear lobe Facial nerve branches

Facial nerve trunk

Parotid tumor

14.19

14.3 Removal of Deep Lobe Parotid Tumor

477

Right ear lobe

Normal parotid tissue of superficial lobe

Intact facial nerve trunk and branches

14.20

14.21

478

14  Surgery of Salivary Glands

14.3.2 Potential Problems

References to Operative Procedure

1. Increased risk of facial nerve injury due to its course distorted by the tumor

1. Olsen KD, Moore EJ (2014) Deep lobe parotidectomy: clinical rationale in the management of primary and metastatic cancer. Eur Arch Otorhinolaryngol 271:1181–1185 2. Olsen KD, Quer M, de Bree R, Poorten VV, Rinaldo A, Ferlito A (2017) Deep lobe parotidectomy—why, when and how? Eur Arch Otorhinolaryngol 274:4073–4078

14.3.3 Suggested Solutions 1. As mentioned in the previous section

14.4 Surgery of Malignant Parotid Tumors

14.4 Surgery of Malignant Parotid Tumors

479

ter divides into two branches, an anterior branch which passes forward and unites with the facial vein, and a posSiba P. Dubey, Charles P. Molumi, and Herwig Swoboda terior which is joined by the posterior auricular vein to form the external jugular vein. The nerves, blood vessels, and muscles are preserved and hemostasis is achieved by 14.4.1 Operative Steps bipolar diathermy at the end of the procedure. The great auricular nerve and external jugular vein running over the 1. The incision marking and elevation of the skin flaps are sternocleidomastoid muscle are preserved (Fig. 14.24). A done as described in superficial parotidectomy for low-­ suction drain is inserted, the flap is returned, and the grade malignancy (low-grade myoepithelial cell carciwound is closed in layers. Examination of postoperative noma) (Fig.  14.22). Bigger incision with extensive specimen revealed diffuse infiltration of the gland dissection is needed for more virulent malignant parotid (Fig. 14.25). tumors. 4. The advanced malignant parotid tumors (namely, adeno-, 2. The great auricular nerve is identified and preserved. The adenoid cystic, mucoepidermoid, and squamous cell carfacial nerve trunk is identified as described in superficial cinomas) involve ear and require bigger incision parotidectomy (Fig.  14.23). The parotid duct is ligated (Fig.  14.26). In these situations, total parotidectomy is and removed. combined with subtotal petrosectomy. Involved skin, soft 3. The facial nerve branches are individually elevated with a tissues, and mandibular ramus are also removed nerve hook and all parotid tissues are dissected and (Fig. 14.27). The involved portion of the facial nerve is removed under operating microscope. The facial nerve also removed. Sural nerve is sutured between the proxitrunk, the upper and lower divisions and their subsequent mal trunk and distal intact branches of the facial nerve branches, and hypoglossal and great auricular nerves are (Fig.  14.28). Instead of suturing, fibrin glue is used to highlighted with blue marker underneath them hold the facial and sural nerve endings at the anastomotic (Fig. 14.24). The superficial temporal vein joins with the sites (Fig.  14.29; Photograph provided by Dr Herwig maxillary vein to form the retromandibular vein. The latSwoboda, Vienna).

480

14  Surgery of Salivary Glands

14.22

Transverse facial artery

Parotid duct

Tumor Facial nerve trunk

Sternocleidomastoid muscle

14.23

14.4 Surgery of Malignant Parotid Tumors

Facial nerve – upper and lower divisions

481

Masseter muscle Retromandibular vein

Facial vein

Hypoglossal nerve External jugular vein Superficial temporal vessels

Facial nerve trunk

Great auricular nerve

14.24

14.25

482

14  Surgery of Salivary Glands

14.26

Mandibular condyle

Mandibular ramus

14.27

14.4 Surgery of Malignant Parotid Tumors

483

VII nerve lower division– sural nerve anastomosis

VII nerve upper division–sural nerve anastomosis

Maxillary artery VII nerve trunk–sural nerve anastomosis

Internal Jugular vein

Mastoid bowl

Sternocleidomastoid muscle

Sinus plate

14.28

Facial nerve–sural nerve anastomosis by fibrin glue

Masseter muscle Segment of sural nerve Ear lobe

Parapharyngeal space Stylopharyngeus muscle

Sternocleidomastoid muscle

Posterior belly of digastric muscle

14.29

484

14.4.2 Potential Problems 1. Facial nerve injury during dissection of deep lobe

14.4.3 Suggested Solutions 1. Always dissect the superficial lobe as a separate specimen exposing all the branches of the facial nerve. Dissect the main trunk and meticulously dissect each of the peripheral branches. References to Operative Procedure 1. Beahrs OH (1977) The surgical anatomy and technique of parotidectomy. Surg Clin N Am 57:477–493 2. Maynard J (1978) Submandibular and parotid gland resection. Br J Hosp Med 20:70–79

14  Surgery of Salivary Glands

3. Woods JE (1983) Parotidectomy: points of technique for brief and safe operation. Am J Surg 145:678–683 4. Jost G, Guenon Ph, Gentil S (1999) Parotidectomy: a plastic approach. Aesthet Plast Surg 23:1–4 5. Anjum K, Revington PJ, Irvine GH (2008) Superficial parotidectomy: antegrade compared with modified retrograde dissections of the facial nerve. Br J Oral Maxillofac Surg 46:433–434 6. Leonetti JP, Smith PG, Anand VK, Kletzker GR, Hartman JM (1993) Subtotal petrosectomy in the management of advanced parotid neoplasms. Otolaryngol Head Neck Surg 108:270–276 7. Komune N, Komune S, Morishita T, Rhoton AL Jr (2014) Microsurgical anatomy of subtotal temporal bone resection en bloc with the parotid gland and temporomandibular joint. Neurosurgery;10(Suppl 2):334–356; discussion p 356

15

Skull Base Surgery

15.1 A  nterior Approach: Open Craniofacial Subcranial Approach C. Suarez, F. López, and José Luis Llorente Pendas

15.1.1 Operative Steps 15.1.1.1 Standard Approach 1. The patient is positioned in supine position without any type of head fixation. The scalp is shaved, if necessary, and the face and scalp are scrubbed. A bicoronal incision is made about 2–3 cm behind the hairline (or at least 10 cm above the glabella), extending from above and anterior to the tragus to the same point on the opposite side. (Fig. 15.1). Eyelids are closed with stitches for a temporary tarsorrhaphy. 2. The frontal skin flap is elevated in the subcutaneous plane anterior to the submucosal aponeurotic system (SMAS) fascia without cutting the calvarial periosteum (pericranium). The scalp flap is brought down low over the orbits and the nasion, preserving the supraorbital and supratrochlear neurovascular bundles (Fig. 15.2). 3. The pericranium is elevated as a separate layer taking care not to tear it; and the supraorbital neurovascular pedicle must be preserved (Figs. 15.3, 15.4, and 15.5). This flap is usually designed in rectangular fashion with the base in the supraorbital area and its tip at the level of the bicoronal scalp incision. Its length from the supraorbital level is approximately 10  cm (Fig.  15.3). Occasionally, additional lateral rotation of the flap is necessary. In such instance, sacrifice of the contralateral supraorbital pedicle permits further rotation (Fig. 15.5). 4. With an electrosurgical scalpel, the profile of the frontal sinus is outlined over the bone using a template of a sinus radiography or a neuronavigator (Fig. 15.6).

5. By means of an oscillating saw, a bevel cut is made through the previously marked line around the margin of the frontal sinus until it enters in the frontal sinus anterior to the posterior sinus wall, thus avoiding dura mater damage (Fig. 15.7). 6. In some cases, we can leave the anterior osteoplastic flap attached to the periosteum (Fig. 15.8) or remove it completely including nasal bones (Fig. 15.9). 7. In the case of large or bilateral tumors requiring extensive exposure, an osteotomy is performed which includes the anterior wall of the frontal sinus, orbit, part of the roof of the orbit and nasal bones, which is known as the subcranial approach (Fig. 15.10). 8. Thus, an osteoplastic flap is created which is replaced later at the end of the procedure (Figs. 15.11 and 15.12). 9. Without neumatization of the frontal sinus, a small quadrangular supraorbital craniectomy is performed (Fig. 15.13). (a) Preferably under microscope, a meticulous drilling is done removing all the frontal sinus mucosa to avoid re-­epithelization or infection. (b) The posterior wall of the frontal sinus bone is removed by drilling; the dura is dissected and elevated from the floor of the anterior fossa, beginning with the detachment of the crista galli and the cribriform plate with the help of tip of suction (Fig.  15.14). During dural elevation over the cribriform plate, the olfactory fibers are cut, if not involved by the tumor. This produces some small CSF leaks. We continued the dissection at least to reach the planum sphenoidale. The dura has to be resected with adequate free margin when dura is involved by the tumor without any brain retraction. A wider resection is needed in case there is a clear cerebral tissue infiltration by the tumor. However, due the bad prognosis of brain infiltration (often preoperatively identify by CT or MRI), an alternative therapy is considered.

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_15

485

486

Once the tumor is dissected and isolated from the brain, the floor of the anterior cranial fossa is removed intra- or extradurally and osteotomies are performed through the sphenoid sinus, medial part of the orbital roofs, and anterior to the crista galli. In some cases, the tumor is delivered through the frontal sinus in piecemeal or en bloc (Figs. 15.15 and 15.16) or through the facial incision. (c) Optic chiasm is the posterior most extent of the surgical field from where the tumor is removed (Fig. 15.17). (d) Operative cavity after excision of an ethmoid-sphenoid tumor (Fig. 15.18). (e) Once the tumor has been removed, intraoperative frozen biopsies can be performed to complete a safe resection of the tumor (Fig. 15.19). (f) Operative cavity after removal of a large tumor (Fig. 15.20). (g) When the tumor has an important component in the nasal cavities and even intramaxillary, a lateral rhinotomy incision is made (Fig. 15.21); it is followed by an osteotomy of the frontal process (Fig.  15.22). A dacryocystorhinostomy is performed (Fig. 15.23). (h) The tumor is exposed (Fig.  15.24) and is resected completely (Fig. 15.25); during this process, a medial maxillectomy is done, and the lamina papyracea, ethmoid, pterygoid plate, rostrum, septum or inferior turbinate are removed whenever necessary. (i) After the tumor is removed by cranial, nasal, or combined approach, the defect is repaired to reestablish extracranial (nasal cavities) and intracranial separation. (j) When a considerable segment of dura has been removed, the most appropriate method of reconstruction is to replace it with a cryopreserved fascia lata graft in two layers (in and overlay) (Figs. 15.26, 15.27, and 15.28). (k) Once the skull base is repaired and isolated, the bony flap is fixed with microplates (Figs. 15.29 and 15.30). Pericranial flap is sutured back (Fig. 15.31).

15  Skull Base Surgery

In the case of removal of the basal dura, it is necessary to use the pericranial flap to isolate the cranial cavity from the nasal cavities. Given its length, the flap can be folded and the fronto-nasal osteoplastic flap is replaced on it (Fig. 15.32). (l) When there is no deficiency in the basal dura, it is not necessary to develop a pericranial flap; so, the osteopericranial flap is fixed with microplates and the pericranium of the bicoronal flap is sutured directly to the adjacent pericranium (Figs. 15.33, 15.34, and 15.35). (m) In small dural defect, the temporalis fascia is sufficient to close the dural gap (Fig. 15.36). (n) The nasal cavity is packed (Fig. 15.37) and the lateral nasal and coronal incision are sutured in two layers (Figs.  15.38 and 15.39) with very good aesthetic results.

15.1.1.2  Technical Variations 1. In case of tumor extension to the anterior part of the middle fossa, it is necessary to perform an anterolateral approach. Once the craniofacial approach is completed, the zygomatic-malar complex is resected, the lateral wall of the orbit is removed, and a small temporal craniectomy is performed (Fig. 15.40). 2. Once the tumor is resected, the frontal craniotomy and the zygomatic-malar complex are replaced (if not infiltrated) with microplates (Fig. 15.41). 3. In the case of tumors that invade deeply the orbit and the cranial base, it is necessary to add an orbital exenteration to the craniofacial approach. Figure 15.42 shows that the invasion of the cranial base has extended to the orbit and to the frontal bone. 4. This results in a large cavity that should be filled with a flap of the temporalis muscle (Fig. 15.43) or with a microvascular free flap (anterior thighs, parascapular, latissimus dorsi, or rectus abdominis).

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

487

15.1

15.2

488

15  Skull Base Surgery

Skin flap

Pericranial flap

15.3

Pericranialflap

15.4

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

489

Transected arterial supply from left to rotate pericranial flap to right side

15.5

Frontal sinus outline

15.6

490

15  Skull Base Surgery

Saw cut of anterior frontal sinus wall

15.7

Frontal sinus opened

15.8

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

491 Frontonasal junction

Skin flap

Frontal sinus opened

15.9

Composite bone flap with frontal sinus anterior wall, orbital roof and nasal bone

Crista galli

Frontal sinus mucosa

15.10

492

15  Skull Base Surgery

15.11

Bony nasal dorsum

Anterior wall of frontal sinus with miniplates

15.12

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

493

Supraorbital craniectomy

15.13

Dural elevation over cribriform plate

Frontal dura

15.14

494

15  Skull Base Surgery

Tumor delivery through frontal sinus

15.15

Tumor delivery through frontal sinus

15.16

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

495

Left optic nerve

Optic chasm

15.17

Optic nerves

Left supraclinoid internal carotid artery Optic chasm

15.18

496

15  Skull Base Surgery

Dura mater

Brain

15.19

Eyeballs

Nasal cavities

Dural remnant

15.20

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

497

Lateral rhinotomy incision

15.21

Osteotomy at frontal process of maxilla

15.22

498

15  Skull Base Surgery

Lacrimal sac

Nasolacrimal duct

15.23

Intranasal tumor

15.24

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

499

Sphenoid sinus

Cavity after tumor removal

15.25

Fascia lata graft

15.26

500

15  Skull Base Surgery

Fascia lata graft

15.27

Fascia lata graft

15.28

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

501

15.29

15.30

502

15  Skull Base Surgery

15.31

Folded pericranial flap

15.32

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

503

15.33

15.34

504

15  Skull Base Surgery

15.35

Area of harvesting temporalis fascia

15.36

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

505

15.37

15.38

506

15  Skull Base Surgery

15.39

Craniofacial surgical field

Malar-zygomatic complex

15.40

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

507

Malar-zygomatic complex

Frontal craniotomy

15.41

Tumor invasion of orbit and frontal bone

15.42

508

15  Skull Base Surgery

Temporalis muscle

15.43

15.1 Anterior Approach: Open Craniofacial Subcranial Approach

509

15.1.2 Potentials Problems

References to Operative Procedure

1. Possibility of CSF rhinorrhea when the dura has been removed. 2. In the event of a CSF leak, there is a risk of meningitis. 3. When there is a deep invasion of the brain, surgery is not advised because of poor prognosis and associated neurological deficits. 4. Formation of mucocele which may simulate tumor recurrence in the postoperative period. 5. Risk of injury to the optic nerve and intracavernous carotid artery.

1. Sisson GA, Bytell DE, Becker SP, Ruge D (1976) Carcinoma of the paranasal sinuses and cranio-facial resection. J Laryngol Otol 90:59–68 2. Johns ME, Winn HR, McClean WC, Cantrell RW (1981) Pericranial flap for the closure of defect of craniofacial resections. Laryngoscope 91: 952–959 3. Ketcham AS, Van Buren JM (1985) Tumors of the paranasal sinuses: a therapeutic challenge. Am J Surg 150:406–413 4. Cheesman AD, Lund VJ, Howard VJ (1986) Craniofacial resection for tumors of the nasal cavity and paranasal sinuses. Head Neck Surg 8:429–435 5. Bridger GP, Baldwin M (1989) Anterior craniofacial resection for ethmoid and nasal cancer with free flap reconstruction. Arch Otolaryngol Head Neck Surg 115:308–312 6. Cantu G, Solero CL, Mariani L, Salvatori P, Mattavelli F, Pizzi N, Riggio E (1999) Anterior craniofacial resection for malignant ethmoid tumors—a series of 91 patients. Head Neck 21:185–191 7. Solero CL, DiMeco F, Sampath P, Mattavelli F, Pizzi N, Salvatori P, Cantu G (2000) Combined anterior craniofacial resection for tumors involving the cribriform plate: early postoperative complications and technical considerations. Neurosurgery 47:1296–1305

15.1.3 Suggested Solutions 1. To avoid CSF rhinorrhea, a dural graft should be carefully sutured and postural measurements should be taken. If the fistula appears, lumbar drainage may be necessary. 2. To avoid mucoceles, the mucosa of the frontal sinus and its diverticula must be completely removed. 3. In tumors that invade extensively the roof of the orbit and the planum sphenoidale, it is necessary to have the osteotomies of the base of the tumor.

510

15.2 L  ateral Approach: Preauricular Infratemporal Subtemporal Approach José Luis Llorente Pendas, M. Costales, and C. Suarez

15.2.1 Operative Steps 15.2.1.1 Standard Approach 1. The lateral portion of the head is partially shaved. A hemicoronal incision is made from the tragus, which passes through the hair-bearing area. The incision extended to the hyoid bone after rounding the earlobe for adequate exposure of the vessels and nerves of the upper neck, the facial nerve, and the parotid gland (Fig. 15.44). 2. The skin flap is raised up to the lateral orbital rim with exposure of the temporalis muscle, parotid gland, and upper neck muscles. The deep temporal fascia is cut at the upper border of the zygomatic arch, and the fat layer that extends between the superficial and deep layers of the deep temporal fascia is identified. The superficial layer of the deep temporal fascia, which is continuous with the orbito-zygomatic periosteum, is raised with the skin flap, thereby protecting the zygomatic branches of the facial nerve (Fig. 15.45). 3. The zygomatic arch is exposed and freed on both sides by detaching it from the temporalis muscle and from the orbital content anteriorly (Fig. 15.46). 4. Three osteotomies are performed. Two are at the lateral orbital rim, namely, superiorly at the frontozygomatic and inferiorly at the maxillozygomatic sutures. The posterior

15  Skull Base Surgery

osteotomy is made just above and in front of the glenoid cavity until the zygoma is free (Fig. 15.47). 5. The temporalis muscle is stripped off its attachment at the temporal lines, elevated from the temporal fossa, and reflected inferiorly and posteriorly; the infratemporal fossa is exposed once the muscle is reflected downward (Fig.  15.48). In this way, the mandible is approached medially, while the orbit is exposed. With separation and reflection of the temporal muscle, the medial and lateral pterygoid muscles are exposed. Once the lateral pterygoid muscle is detached from the infratemporal fossa roof, the internal maxillary artery and the mandibular nerve and its branches, which could be followed proximally to the foramen ovale, are found and dissected; infratemporal fossa, reflected temporalis muscle, and orbit are visible (Fig. 15.49). 6. The tumor is resected; infratemporal fossa, temporalis muscle are seen (Fig. 15.50). The resulting cavity is filled with part of the longitudinally split temporalis muscle; middle cranial fossa dura, temporalis muscle are seen (Fig. 15.51). One part of the temporalis muscle is used for the infratemporal fossa and other part for the temporal fossa (Fig. 15.52). The rest of the muscle is repositioned in its place, while the orbito-zygomatic bone segment is placed in its original position and fixed with titanium microplates (Fig. 15.53). Sometimes, the entire temporalis muscle is used to fill the dead spaces in the infratemporal and the temporal fossa. 7. Finally, a cervical suction drain is placed and the hemicoronal incision is closed in two layers (Fig. 15.54). 8. The same is done in cases where it was not necessary to perform a cervical extension of the incision (Fig. 15.55).

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

15.2.1.2 Technical Variants 1. Sometimes, very large tumor involves the infratemporal fossa and the deep lobe of the parotid. Exposure of the temporalis muscle, parotid gland, and cervical region is mandatory. The facial nerve is dissected and the superficial lobe of the parotid gland is removed (Fig. 15.56). 2. Resection is done of the deep lobe of the parotid gland with preservation of all branches of the facial nerve. Removal of the condyle and part of the ascending ramus of the mandible is done to access the tumor remnant (Fig. 15.57). 3. Operative cavity and facial nerve branches are visible more clearly. The mandibular remnant, XII cranial nerve and the large cervical vessels, and other lower cranial nerves are also seen (Fig. 15.58). 4. In tumors with limited intracranial involvement, the infratemporal fossa roof is drilled; temporalis muscle is also seen (Fig.  15.59—right side and Fig.  15.60—left side). Sometimes, it is necessary to perform a small craniotomy in the area corresponding to the anterior part of the temporal lobe (Fig.  15.61); dura is opened and brain is exposed (Fig.  15.62).Continuing the intradural dissection exposes the parasellar region and middle fossa dura (Fig. 15.63) and internal carotid artery (Fig. 15.64). Subsequently, the dura mater is repaired with fascia lata and the bone segment is replaced with titanium miniplates (Fig. 15.65). 5. In some cases, moreover, the resection of the ascending ramus of the mandible also involves the removal of the parotid gland and facial nerve. In these cases, the

511

temporalis muscle cannot be used to obliterate the defect due to involvement of the deep temporal arteries which are the branches of the maxillary artery (Fig. 15.66). 6. View of the infratemporal fossa and skull base and glenoid cavity after removal of the tumor (Fig. 15.67). 7. Replacement of the malar zygomatic bone is done (Fig.  15.68). Reconstruction with an SMAS flap (superficial musculoaponeurotic system) is performed; temporalis muscle, which is not used in reconstruction, is also visible (Fig. 15.69). 8. Sometimes, it is necessary to dissect and mobilize the internal carotid artery by drilling through the glenoid cavity and adjacent to the floor of the middle cranial fossa (Fig. 15.70). 9. Finally, the dura is reconstructed with fascia lata when the procedure has been intradural (Fig.  15.71) and the bone flap is replaced (Fig. 15.72). The bone flap and the temporalis muscle are placed back (Fig.  15.73); temporalis muscle and zygoma are held in position (Figs. 15.74, 15.75, and 15.76). 10. In some cases, the temporalis muscle cannot be replaced either because its blood supply through the deep temporal arteries has been damaged or because it has been used in its entirety to fill the operative cavity (Fig.  15.77). In order to fill the defect in the temporal fossa, biocompatible synthetic material such as high-density porous polyethylene is used, which is anchored to the posterior-­ cranial part above the orbito-zygomatic complex (Fig. 15.78). 11. Appearance during the immediate postoperative period (Fig. 15.79).

512

15  Skull Base Surgery

15.44

15.45

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

513

Zygomatic bone

Temporalis muscle

15.46

15.47

514

15  Skull Base Surgery

Temporalis muscle Orbit

Infratemporal fossa

15.48

Infratemporal fossa

Orbit

Temporalis muscle

15.49

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

515

Infratemporal fossa

Temporalis muscle

15.50

Temporalis muscle

Middle cranial fossa dura

15.51

516

15  Skull Base Surgery

Temporalis muscle divided in two halves

15.52

Zygomatic bone fixed with microplates

Repositioned temporalis muscle

15.53

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

517

15.54

15.55

518

15  Skull Base Surgery

Superficial lobe of parotid gland

Facial nerve trunk

15.56

Mandibular condyle and part of ascending ramus

Facial nerve trunk and its division

15.57

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

Mandibular remnant

519

Hypoglossal nerve

Accessary nerve Carotid sheath contents

15.58

Temporalis muscle

Infratemporal fossa roof

15.59

520

15  Skull Base Surgery

Infratemporal fossa roof

Temporalis muscle

15.60

Craniotomy

15.61

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

521

Dura

Temporal lobe

15.62

Parasellar region

Middle fossa dura

15.63

522

15  Skull Base Surgery

Internal carotid artery

15.64

Fascia lata

Bone segment fixed with miniplates

15.65

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

523

Ascending ramus of mandible

15.66

Infratemporal fossa

Glenoid cavity

15.67

524

15  Skull Base Surgery

Replacement of zygomatic bone

15.68

Temporalis muscle

Superficial musculoaponeurotic system

15.69

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

525

Internal carotid artery

15.70

Fascia lata

15.71

526

15  Skull Base Surgery

Bone flap

15.72

Bone flap

Temporalis muscle

15.73

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

527

Zygomatic bone

Temporalis muscle

15.74

Zygomatic bone

Temporalis muscle

15.75

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15  Skull Base Surgery

Temporalis muscle

15.76

Zygomatic bone

Temporalis muscle

15.77

15.2 Lateral Approach: Preauricular Infratemporal Subtemporal Approach

529

Porous polyethylene

15.78

15.79

530

15.2.1.3 Potential Problems 1. Temporalis muscle necrosis if the deep temporal arteries, which are the branches of the internal maxillary artery, are not preserved. These branches supply the muscle from its deep surface. 2. Possibility of infection if alloplastic fillers are used. 3. Possibility of injuring the internal carotid artery if the fundus of the glenoid cavity is drilled or when the Eustachian tube is removed. 4. Possibility of CSF leak if the procedure is combined with an intradural procedure. 5. A certain degree of trismus results when it is necessary to remove the condyle from the mandible. 6. Contraindication in recurrent nasopharyngeal tumors that present extensive intradural invasion, involvement of the cavernous sinus and invasion of the pharyngobasilar fascia. 7. In the case of big juvenile angiofibromas with a large anterior extension, it may be necessary to combine this approach with another anterior procedure, endoscopic or open.

15.2.2 Suggested Solutions 1. Check the vascularization of the temporalis muscle at the end of the intervention. A microvascular free flap is needed to fill a large space and to block the open nasopharyngeal airway in case the muscle is not viable.

15  Skull Base Surgery

2. Alloplastic material is used in the first stage only if the nasopharyngeal airway is blocked off. Otherwise, the implant is placed at a second-stage procedure. 3. To avoid injury to the internal carotid artery, it should be noted that the carotid canal is below the junction of the third branch of the trigeminal nerve (V3) with the greater superficial petrosal nerve, and is crossed anteriorly by the Eustachian tube. 4. Meticulously suture the dura mater or the replacement material. Use additional biological glue. References to Operative Procedure 1. Sekhar LN, Schramm VL, Jones NF (1987) Subtemporal-­ preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms. J Neurosurg 67:488–499 2. Youssef A, Carrau RL, Tantawy A, Ibraheim A, Solares AC, Otto BA, Prevedello DM, Filho LD (2015) Endoscopic versus open approach to the infratemporal fossa: a cadaver study. J Neurol Surg B Skull Base 76:358–364 3. Leonetti JP, Anderson DE, Marzo SJ, Origitano TC, Schuman R (2008) The preauricular subtemporal approach for transcranial petrous apex tumors. Otol Neurotol 29:380–383 4. Llorente JL, Nazar G, Cabanillas R, Fernández de León R, Suárez C (2006) Subtemporal-preauricular approach in the management of infratemporal and nasopharyngeal tumours. J Otolaryngol 35:173–179

15.3 Posterior Approach: Surgery for Temporal Bone Malignancy

15.3 P  osterior Approach: Surgery for Temporal Bone Malignancy Siba P. Dubey and Charles P. Molumi

15.3.1 Operative Steps 1. Incision is made three to four fingerbreadth behind the postauricular sulcus. The superior limb of the incision is extended over the temporalis muscle in case its mobilization is needed in the later part of the procedure. The ­inferior limb of the incision is extended into the neck for exposure of the great vessels and neck dissection. Such wide incision also maintains good blood supply to the flap anteriorly (Fig. 15.80). 2. Anteriorly based mastoid musculoperiosteal flap is raised and left attached to the cartilaginous external canal (Fig. 15.81). This flap can be used to obliterate mastoid cavity or to strength the blind sac closure of the external auditory canal. The external canal skin is elevated like a ‘tube’ for blind sac closure (Fig. 15.81). The skin flap with the “tube” of external canal skin is elevated anterior to external auditory canal (Fig. 15.81). The flap is elevated till the entire superfacial lobe of the parotid gland is exposed. The sternomastoid is detached from the mastoid tip. Facial nerve is identified at the stylomastoid foramen and total parotidectomy is completed (Fig. 15.82). Neck dissection is done and common carotid artery, internal jugular vein, posterior belly of the

531

digastric muscle, and XI and XII cranial nerves are identified (Fig. 15.82). 3. Radical mastoidectomy is done. The tegmen, posterior fossa plate, sigmoid sinus from sinodural angle to the jugular bulb are skeletonized (Fig. 15.83). The common, internal, and external carotid arteries, internal jugular vein, and IX and X cranial nerves are also defined (Fig. 15.83). 4. Tumor extension in the temporal bone and skull base is removed. In the process, glenoid fossa’s soft tissue and cartilage, glenoid fossa, pterygoid muscles, ascending ramus of mandible are explored and/or resected to remove the tumor. The internal carotid artery is completely skeletonized and the styloid process and the lateral tympanic bone covering the carotid foramen are removed; artery is elevated from its bony canal to remove the tumor in the area of carotid jugular spine. The bony Eustachian tube is drilled down to isthmus. The internal carotid artery is exposed medial to the Eustachian tube (blue marker) (Fig. 15.84). 5. A drain is placed and the wound is closed in layers. A BIPP-soaked ribbon gauze is placed over the closed external auditory canal (Fig. 15.85). 6. Skin loss is inevitable in case ear carcinoma involves skin (Fig.  15.86). In such situation, large pectoralis major myocutaneous with nipple and areola is used to cover the defect (Fig. 15.87). At a later date, the nipple and areola are returned to its approximate location and a split thickness skin graft is placed over the raw area in the flap (Fig. 15.88).

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15  Skull Base Surgery

15.80

Outer cuff of canal skin for blind sac closure

Inner cuff of canal skin for removal

15.81

15.3 Posterior Approach: Surgery for Temporal Bone Malignancy

533

15.82

15.83

534

15  Skull Base Surgery Glossopharyngeal nerve

Internal carotid artery Tegmen antri

Lateral sinus

Transverse process of C2

Common carotid artery

Hypoglossal nerve

Vagus nerve

Accessary nerve Internal jugular vein

15.85

15.84

15.3 Posterior Approach: Surgery for Temporal Bone Malignancy

535

15.86

15.87

536

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15.88

15.3 Posterior Approach: Surgery for Temporal Bone Malignancy

15.3.2 Potential Problems 1 . Sigmoid sinus involvement. 2. Involvement of middle and posterior fossa dura. 3. Surgical defect in the side of face when case of total parotidectomy is done. 4. Involvement of the labyrinth by the tumor. 5. Involvement of the facial nerve.

537

References to Operative Procedure

1. Kinney SE, Wood BG (1987) Malignancies of external ear canal and temporal bone: surgical techniques and results. Laryngoscope 97:158–164 2. Prasad SC, D’Orazio F, Medina M, Bacciu A, Sanna M (2014) State of the art in temporal bone malignancy. Curr Opin Otolaryngol Head Neck Surg 22:154–165 3. Moore MG, Lin DT, Mikulec AA, McKenna MJ, Varvares MA (2008) The occipital flap for reconstruction after 15.3.3 Suggested Solutions temporal bone resection. Arch Otolaryngol Head Neck Surg 134:587–591 1. Outer wall of the sigmoid sinus is removed after blocking 4. Gal TJ, Kerschner JE, Futran ND, Bartels LJ, et al (1998) the cranial and caudal ends of it. Reconstruction after temporal bone resection. 2. Involved part of the middle and/or posterior fossa is Laryngoscope 108:476–481 resected and replaced by fascia lata in collaboration with 5. Leonetti JP, Smith PG, Anand VK, Kletzker GR, Hartman the neurosurgeon. JM (1993) Subtotal petrosectomy in the management of 3. Depression on the side of the face is corrected by tempoadvanced parotid neoplasms. Otolaryngol Head Neck ralis or pectoralis muscle flap or fat graft. Surg 108:270–276 4. Labyrinthectomy is performed when it is involved by 6. Asano K, Somekawa Y, Yoshioka I, Ikeda H (1998) En tumor. block resection of the temporal bone by the lateral 5. The mastoid segment of the VII nerve is dissected off the approach in carcinoma of the middle ear associated with fallopian canal and stylomastoid foramen. Direct end-to-­ skull infiltration with reference to the resection of the side VII–XII anastomosis or via jump-graft facial hypopetrous apex. Skull Base Surg 8:195–204 glossal nerve anastomosis or cable graft with sural nerve 7. Moffat DA, Wagstaff SA, Hardy DG (2005) The outcome of is used depending on the length of facial nerve deficiency radical surgery and postoperative radiotherapy for squamous as described in the salivary gland surgery. carcinoma of the temporal bone. Laryngoscope 115:341–347 6. Skin graft is spread from the external canal margin over to 8. Komune N, Komune S, Morishita T, Rhoton AL Jr (2014) rotated muscle in limited disease with smaller cavity; Microsurgical anatomy of subtotal temporal bone resection blind sac closure of the external canal is not necessary in en bloc with the parotid gland and temporomandibular such situation. joint. Neurosurgery;10 Suppl 2:334–256; discussion 356

Surgery for Benign Laryngotracheal Conditions

16.1 L  ateralization of Vocal Cord (Modified Woodman’s Operation) Siba P. Dubey and Charles P. Molumi

16.1.1 Operative Steps 1. A tracheostomy is usually already performed or done at the beginning, as most of the patients suffer from bilateral abductor palsy. A 6–7 cm horizontal incision is given at the level of the lower border of the thyroid cartilage; it extends from the midline to the sternocleidomastoid muscle laterally (Fig. 16.1). 2. The strap muscles are identified and undermined in a superoinferior direction and retracted laterally (Fig. 16.2). 3. The great vessels of the neck and the thyroid gland are identified (Fig. 16.3). 4. The thyroid cartilage is rotated with the help of a sharp double-pronged hook to expose the entire posterior border of the thyroid ala. The inferior constrictor muscle is incised along the entire length of the thyroid ala (Fig. 16.4). The inferior horn of the thyroid cartilage and the cricothyroid articulation are identified. The cricothyroid joint is disarticulated. 5. From this step onward, the operating microscope and the microsurgical instruments are used to facilitate the subsequent dissections. The aryenoid cartilage is identified by

16

following the upper border of the cricoid cartilage posteromedially. The muscular attachments are removed and the laryngeal mucosa is reflected from the arytenoid with finer instruments and microscopic vision. The cricoarytenoid joint is disarticulated and the arytenoid is carefully retracted laterally to facilitate further separation of the remaining soft tissues from the arytenoid (Fig. 16.5). The medialward dissection is done carefully to avoid accidental entry to larynx. 6. A gentle lateral traction on the arytenoid exposes the vocal process and the vocal ligament. A 4-0 nylon suture is passed through the substance of the vocal cord around the anterior end of the vocal process. The suture is fixed through a separate hole made at the posteroinferior aspect of the thyroid cartilage (Fig. 16.6). At this stage, the thyroid cartilage is returned to the neutral position and the assistant passes a fiberoptic nasolaryngoscope to see the intercordal distance which, after tightening the sutures, should be between 4 and 5 mm. Endoscopic examination also confirms the extramucosal nature of the procedure. 7. Knots are placed to approximate the vocal process with the thyroid cartilage (Fig. 16.7); the wound is closed in layers after placing a drain. 8. Preoperative fiberoptic nasolaryngoscopy shows vocal cords on inspiration (Fig.  16.8a) and on expiration (Fig.  16.8b). Postoperative fiberoptic nasolaryngoscopy after decannulation shows adequate airway on expiration (Fig. 16.8c) and on inspiration (Fig. 16.8d).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_16

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16  Surgery for Benign Laryngotracheal Conditions

16.1

Sternothyroid muscle

Cut end of sternohyoid muscle

16.2

16.1 Lateralization of Vocal Cord (Modified Woodman’s Operation) Common carotid artery

541 Thyroid gland

Internal jugular vein

Cut end of thyropharygeus muscle

16.3

Thyroid cartilage-posterior border and lamina

Cricoid cartilage

Thyroid cartilage– inferior horn

16.4

542

16  Surgery for Benign Laryngotracheal Conditions Arytenoid cartilage– freed and disarticulated

Arytenoid cartilage– vocal process

16.5

Nylon suture through thyroid cartilage

Nylon suture through vocal process

16.6

16.1 Lateralization of Vocal Cord (Modified Woodman’s Operation)

543

Nylon sutures through thyroid cartilage and vocal process tied together

16.7

16.8a

544

16  Surgery for Benign Laryngotracheal Conditions

16.8b

16.8c

16.1 Lateralization of Vocal Cord (Modified Woodman’s Operation)

545

16.8d

546

16  Surgery for Benign Laryngotracheal Conditions

16.1.2 Potential Problems

References to Operative Procedure

1 . Failure to achieve adequate abduction for decannulation 2. Accidental entry into larynx

1. Newman MH, Work WP (1976) Arytenoidectomy revisited. Laryngoscope 86:840–849 2. Woodson GE (2007) Spontaneous laryngeal reinnervation after recurrent laryngeal or vagus nerve injury. Ann Otol Rhinol Laryngol 116:57–65 3. Woodson G, Weiss T (2007) Arytenoid abduction for dynamic rehabilitation of bilateral laryngeal paralysis. Ann Otol Rhinol Laryngol 116:483–490 4. Woodson G (2012) Arytenoid abduction for bilateral vocal fold paralysis. Oper Tech Otolaryngol 23:178–182

16.1.3 Suggested Solutions 1 . The same operation can be performed to the other side. 2. Decannulation delayed till the epithelization of the laryngeal lumen is complete.

16.2  Resection of Stenosis and Laryngotracheal Anastomosis

16.2 Resection of Stenosis and Laryngotracheal Anastomosis 16.2.1 Operative Steps 1. Postintubation tracheal stricture at the first tracheal ring. Vocal cords and subglottis are normal. Patient is tracheostomized preoperatively to relieve airway obstruction (Fig. 16.9). 2. Patient is placed in neck extended position. Incision is marked out over the hyoid for hyoid drop and ‘U’ collar incision on either side of tracheostoma to approach the trachea (Fig. 16.10). 3. Through the short transverse incision over the hyoid, the suprahyoid muscles attached to the hyoid are released (Fig. 16.11). 4. The suprahyoid membrane is opened and preepiglottic space is entered without opening the pharynx (Fig. 16.12). 5. The digastric muscle sling attached to the hyoid is left intact. The hyoid bone is divided on both sides anterior to the digastric muscles attachments and lateral to the lesser cornu (Fig. 16.13). A penrose drain is inserted and the incision is closed in layers. 6. Through the ‘U’ collar incision, a subplatysmal flap is raised and the strap muscles are exposed (Fig. 16.14). 7. The strap muscles are divided below the level of the cricoid cartilage. Tracheal opening (arrow) is made above the level of the stenosis (between first and second tracheal rings). A catheter, used as a ‘leader’, is passed through the nose to the trachea to indicate the beginning of stenosis (Fig. 16.15). 8. Exploratory incisions are made in the anterior tracheal wall where there was still minimal residual narrowing, so that no more trachea would be excised than is absolutely necessary (Fig. 16.16). 9. The recurrent laryngeal nerves are protected, and the stenosed segment of the trachea is separated from the esophagus posteriorly by blunt dissection; index finger

547

protects the recurrent laryngeal nerves and the esophagus (Fig. 16.17a). The stenosed segment of the trachea is then resected (Fig. 16.17b). 10. Lateral stay sutures are placed superiorly and inferiorly. (Fig. 16.18). 11. The initial vicryl suture is placed between subglottis above and trachea below in the posterior midline in such way that the knot stays extraluminal. Hemostat holds the suture and this in turn is clipped to the drape laterally. Each hemostat is clipped to the drape from cephalic to caudal direction so that most posterior suture is most cephalic. Anastomotic vicryl sutures are placed about 4 mm apart from the posterior aspect of the cut ends and progressed anteriorly (Fig. 16.19). In consultation with the anesthetist, the endotracheal tube in the distal trachea may be removed intermittently if it interferes with suture placement. The most posterior suture is tied by palpation rather than by direct vision. 12. The endotracheal tube in the tracheostoma is removed and new endotracheal tube is passed to the trachea guided by the “leader” catheter. The “leader” catheter is then removed. The anesthetic circuit is moved to the head from the neck to be connected to the endotracheal tube (Fig. 16.20). 13. The subglottis and tracheal ends are approximated together by tying the vicryl sutures in the reverse order, which means, from anterior to posterior direction (Fig. 16.21a). The presence of air bubbles will indicate leak when wound is flooded with saline after deflating the cuff of the endotracheal tube. The stay sutures are also tied together (Fig. 16.21b). The strap muscles may be sutured above or below the anastomosis or sutured in the midline. A suction drain is inserted and platysma and skin are closed. 14. . “Guardian” or “check” sutures from the chin to the sternum are placed to prevent overextension (Fig. 16.22). The patient is kept intubated for 5–7 days. 15. The stenosed segment is opened up to show the interior of it (Fig. 16.23).

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16  Surgery for Benign Laryngotracheal Conditions

16.9

16.2 Resection of Stenosis and Laryngotracheal Anastomosis

549

16.10

Head end Detached suprahyoid muscles Suprahyoid membrane

Anterior belly of digastric muscle

Hyoid bone

Hyoid-drop by attached infrahyoid muscles

16.11

550

16  Surgery for Benign Laryngotracheal Conditions Head end

Suprahyoid membrane opened Hyoid bone

16.12

Digastric muscle

Head end

Hyoid bone – transected end

16.13

16.2 Resection of Stenosis and Laryngotracheal Anastomosis

551

Chin

Drain in hyoid drop wound

16.14

Head end

Thyroid cartilage

16.15

552

16  Surgery for Benign Laryngotracheal Conditions

Catheter Stenosed segment

16.16

16.17a

16.2 Resection of Stenosis and Laryngotracheal Anastomosis

553

Stenosed segment from below

16.17b

Endotracheal tube with catheter inside

Upper lateral stitch

Left recurrent laryngeal nerve Lower lateral stitch

16.18

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16  Surgery for Benign Laryngotracheal Conditions

16.19

16.20

16.2 Resection of Stenosis and Laryngotracheal Anastomosis

555

16.21a Drain in hyoid drop wound

Line of anastomosis

16.21b

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16  Surgery for Benign Laryngotracheal Conditions

16.22

16.23

16.2 Resection of Stenosis and Laryngotracheal Anastomosis

16.2.2 Potential Problems 1. Injury to blood supply of the normal trachea results in tracheal necrosis and severe restenosis. 2. Injury to recurrent laryngeal nerve. 3. Injury to esophagus. 4. Injury to brachiocephlic artery particularly when dense peritracheal fibrosis and subsequent stenosis lies directly behind the artery.

16.2.3 Suggested Solutions 1. Circumferential dissection of the trachea must be limited at the level of the lesion that is to be excised. 2. Secondary resection and anastomosis give excellent result. 3. The recurrent laryngeal nerve should be identified on each side and traced upward behind the cricothyroid joint. This will help to keep the nerves under constant view during the entire procedure and consequently avoiding any injury. 4. Putting the index finger behind trachea before division of the stenotic segment will prevent esophageal injury.

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5. No attempt should be made to dissect out the brachiocephalic artery. During repeat surgery or in the presence of risk, pedicled strap muscle or thymus lobe is interposed between the artery and trachea. References to Operative Procedure 1. Montgomery WW (1974) Suprahyoid release for tracheal anastomosis. Arch Otolaryngol 99:255–260 2. Grillo HC (1979) Surgical treatment of postintubation tracheal injuries. J Thorac Cardiovasc Surg 78:860–875 3. Grillo HC (1982) Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 33:3–18 4. Maddaus MA, Toth JLR, Gullane PJ, Pearson FG (1992) Subglottic tracheal resection and synchronous laryngeal reconstruction. J Thorac Cardiovasc Surg 104:1443–1450 5. Grillo HC, Mathisen DJ, Wain JC (1992) Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg 53:54–63 6. Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD (1995) Postintubation tracheal stenosis: treatment and results: J Thorac Cardiovasc Surg 109:486–493

Surgery of Miscellaneous Cervicothoracic Pathology

17.1 E  xcision on Lower Neck and Superior Mediastinal Neurofibroma Siba P. Dubey and Charles P. Molumi

17.1.1 Operative Steps 1. The tumor occupied lower part of the neck and in the superior mediastinum (Fig. 17.1). 2. Orotracheal intubation is done; an inverted “L” shaped incision given whose horizontal limb is on the tumor in

17

the lower part of the neck and the vertical limb on the sternum (Fig. 17.2). 3. The tumor is separated from skin and subcutaneous tissue, neck structures, and clavicle. The skin over the vertical limb is cleared and sternum exposed for manubriotomy (Fig. 17.3). 4. The sternum is retracted to expose the mediastinal extension of the tumor. The mediastinal extension of the tumor is removed together with the neck extension (Fig. 17.4). 5. Operative field after excision of tumor; the neurovascular structures exposed and preserved (Fig. 17.5).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_17

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17  Surgery of Miscellaneous Cervicothoracic Pathology

17.1

17.2

17.1 Excision on Lower Neck and Superior Mediastinal Neurofibroma

561

17.3

Tumor

17.4

562

17  Surgery of Miscellaneous Cervicothoracic Pathology

Common carotid artery Recurrent laryngeal nerve hooking round subclavian artery

Trachea

Internal Jugular vein

Brachiocephalic artery

Vagus nerve Subclavian artery

Superior mediastinum

17.5

17.1 Excision on Lower Neck and Superior Mediastinal Neurofibroma

563

17.1.2 Potential Problems

References to Operative Procedure

1. Neurovascular injury, namely, brachiocephalic artery and recurrent laryngeal nerve 2. Infection, namely, mediastinitis which may in turn lead to vascular accident 3. Chylous leak 4. Recurrence of neurofibroma

1. Sisson GA, Bytell DE, Becker SP (1977) Mediastinal dissection–1976: indications and newer techniques. Laryngoscope 87:751–759 2. Schuller DE, Hamaker RC, Gluckman JL (1981) Mediastinal dissection. A multi-institutional assessment. Arch Otolaryngol 107:715–720. 3. Najah H, Gaudric J, Kasereka-Kisenge F, Taieb A, Goutard M, Menegaux F, Trésallet C (2017) SURGICAL TECHNIQUE.  Sternal manubriotomy for mediastinal goiter. J Visc Surg 154:361–364.

17.1.3 Suggested Solutions 1 . Intraoperative protection of great vessels 2. Prevention and urgent management of infection at the onset in early postoperative period 3. To rule out chylous leak intraoperatively; thoracic duct is ligated and transected in case it is identified 4. Meticulous tumor removal and hemostasis during operation

564

17.2 E  xcision of Subclavian Artery Aneurysm Siba P. Dubey and Charles P. Molumi

17.2.1 Operative Steps 1. An 11-year-old female presented with pulsatile swelling behind the clavicular end of the left sternocleidomastoid muscle (Fig. 17.6).

17  Surgery of Miscellaneous Cervicothoracic Pathology

2. Examination revealed weak pulse, weak power on the left hand and clubbing of the left fingers (Fig. 17.7). 3. The aneurysm is excised and the aorta is repaired. The left common carotid artery is transected below the bifurcation (Fig. 17.8). 4. The common carotid artery is moved down laterally and anastomosed with the left axillary artery (Fig. 17.9). 5. The aneurysm is cut open to show its interior (Fig. 17.10).

17.2 Excision of Subclavian Artery Aneurysm

565

17.6

17.7

566

17  Surgery of Miscellaneous Cervicothoracic Pathology

Subclavian aneurysm

Clavicle Transected left common carotid artery

Transected sternocleidomastoid muscle

Arch of aorta Internal jugular vein

17.8

Brachial plexus Transected sternocleidomastoid muscle

Clavicle

Internal jugular vein Brachiocephalic artery

Arch of aorta Cut surface of manubrium

Left common carotid artery to left axillary artery anastomosis

17.9

17.2 Excision of Subclavian Artery Aneurysm

567

17.10

568

17  Surgery of Miscellaneous Cervicothoracic Pathology

17.2.2 Potential Problems

References to Operative Procedure

1. Neurological weakness in the postoperative period

1. Nehler MR, Taylor LM, Moneta GM, Porter JM (1997) Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Arch Surg 132:527–532

17.2.3 Suggested Solutions 1. Full recovery in the postoperative period

Surgery for Laryngeal Malignancy

18.1 Frontolateral Vertical Partial Laryngectomy Siba P. Dubey and Charles P. Molumi

18.1.1 Operative Steps 1. The incision could be a small or a big apron-flap; it depends on the necessity of neck dissection. The tracheostomy could be performed at the beginning or at the end of the procedure (Fig. 18.1). 2. The skin flap is elevated at the subplatysmal level. The strap muscles are separated in the midline. The muscles are retracted laterally using a self-retaining retractor to expose more than the anterior half of the thyroid cartilage (Fig. 18.2). 3. The perichondrium (periosteum) attached externally on the inferior border of the exposed thyroid cartilage is incised by a scalpel. With the help of a fine elevator, the outer perichondrium (periosteum) of the thyroid cartilage is elevated superiorly (Fig. 18.3). The laryngeal soft tissues are separated from the superior and inferior margins of each thyroid ala. 4. A Freer’s elevator is placed in the subperichondrial plane at the superior margin of the thyroid cartilage and laryngeal soft tissues are elevated (Fig. 18.4). This step is continued till a tunnel is created between the thyroid cartilage and laryngeal soft tissue on either side of the midline. 5. Saw cuts are made in the paramedian position (Fig. 18.5). The elevator used for protection of the laryngeal tissue underneath and a triangular portion of the thyroid cartilage is cut; the portion of the cartilage falls equally on either sides of the midline. The triangular portion of the thyroid cartilage is left attached to the underlying laryngeal soft tissues (Fig.  18.5). The larynx is entered through the contralateral side (right in this patient) by

18

cutting through the cricothyroid ligament at the inferior border of the thyroid cartilage. The distance of this incision from the midline depends on the extent of the tumor which now could be visualized through the aperture created. 6. Depending on the extent of the tumor, the inner perichondrium of the involved side is separated in an anteroposterior direction. With the help of a sharp scalpel or sickle knife, the superior, the inferior and the posterior margins of the resection are delineated on the left side; it should roughly take the shape of an ‘U’ which opens anteriorly. The degree of posterior resection depended on the tumor extension toward the arytenoid cartilage (Fig. 18.6). 7. The rest of the attachments of the tumor is cut with a strong curved scissors and the specimen (inset) is removed (Fig. 18.7). 8. To prevent the posterior retraction, the true and the false cords of the normal right side are pulled forward and sutured to the anterior border of the ipsilateral thyroid cartilage with fine sutures; these sutures are anchored to holes made on the thyroid cartilage with a fine diamond burr, as the ossified thyroid cartilage is friable. The small raw area is expected to heal by granulation and epithelization (Fig. 18.8). 9. Complete hemostasis is achieved and a tracheotomy is done in case it was not done at the beginning. The two halves of the thyroid cartilage are sutured together by a slowly absorbing thick suture material (Fig. 18.9). The external periosteum is stitched back. 10. The strap muscles are reapproxmated and overlapped in the midline in a closed watertight way over a suction drain (Fig. 18.10). The rest of the incision is closed in two layers. 11. After 4 weeks, the raw area is epithelized and the tracheostomy tube is removed. The endoscopic appearance is satisfactory (Fig. 18.11).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_18

569

570

18  Surgery for Laryngeal Malignancy

18.1

18.2

18.1 Frontolateral Vertical Partial Laryngectomy

571

Reflected outer perichondrium of thyroid cartilage

Ossified thyroid cartilage

Endotracheal tube

18.3

Freer elevator between thyroid cartilage and its inner perichondrium

Endotracheal tube

18.4

572

18  Surgery for Laryngeal Malignancy

Right laryngotomy

Left laryngotomy

18.5

Head end

Left paraglottic space

Excised piece of thyroid cartilage

18.6

18.1 Frontolateral Vertical Partial Laryngectomy

573 Left false vocal cord

Left laryngeal ventricle

Left true vocal cord with tumor

Tracheal lumen

Endotracheal tube

18.7

Right false vocal cord anchored to thyroid cartilage

Right laryngeal ventricle Raw area due to left true vocal cord tumor removal Right true vocal cord anchored to thyroid cartilage

Tracheal lumen

18.8

574

18  Surgery for Laryngeal Malignancy

18.9

Sutures apposing strap muscles in midline Endotracheal tube

18.10

18.1 Frontolateral Vertical Partial Laryngectomy

575

18.11

576

18.1.2 Potential Problems 1. Involvement of thyroid cartilage beyond preoperative assessment. 2. Involvement of arytenoid cartilage. 3. Tear of the intralaryngeal tissue during subperichondrial elevation. 4. Fracture of ossified thyroid cartilage during its retraction with a retractor. 5. Irregular cutting of thyroid cartilage by scissors or scalpel can lead to perichondritis. 6. Development of laryngeal synechiae. 7. Scarring of the raw area and functional compromise.

18.1.3 Suggested Solutions 1. The oblique cartilage incision should be angled more posteriorly to encompass the tumor bearing area in case there is involvement of thyroid cartilage beyond preoperative assessment. 2. Resection of arytenoid cartilage should be avoided, as it leads to protracted dysphagia; this situation is beyond the scope of frontolateral partial laryngectomy. At least apical portion of the cartilage and aryepiglottic fold should

18  Surgery for Laryngeal Malignancy

preserved to avoid dysphagic complaint. Not more than one fourth of the healthy vocal cord is to be resected. 3. Subperichondrial elevation of intralaryngeal soft tissue to be done carefully and with instrument with round tip. 4. Careful use of self-retaining retractor to avoid fracturing of the thyroid cartilage. 5. Thyroid cartilage to be cut with saw. 6. Fixation of the false and true cords of the nontumor side to the thyroid cartilage to be done with optimum tension to avoid tear of the vocal cords which will retract posteriorly. 7. Bigger intralaryngeal raw area or exposed part of the arytenoid cartilage should be covered with mucosal graft. References to Operative Procedure 1. Leroux-Robert J (1956) Indications for radical surgery, partial surgery, radiotherapy and combined surgery and radiotherapy for cancer of the larynx and hypopharynx. Ann Otol Rhinol Laryngol 65:137–153 2. Brumund KT, Gutierrej-Fonseca R, Garcia D, Babin E, Hans S, Laccourreye O (2005) Frontolateral vertical partial laryngectomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience. Ann Otol Rhinol Laryngol 114:314–322

18.2 Supraglottic Horizontal Partial Laryngectomy

18.2 S  upraglottic Horizontal Partial Laryngectomy Siba P. Dubey and Charles P. Molumi

18.2.1 Operative Steps 1. Following ‘U’ incision, the flap is raised in the subplatysmal plane, exposing the underlying strap muscles and hyoid bone (Fig. 18.12). 2. The internal laryngeal nerve is identified and preserved, as it runs along with the superior laryngeal artery (Fig. 18.13). 3. The superior horn of the thyroid cartilage is dissected out on both sides. This is done to preserve the pyriform sinus mucosa during removal of the specimen (Fig. 18.14). 4. The sternohyoid, omohyoid, and thyrohyoid muscles are sectioned at their insertion along the margin of the hyoid bone and the hyoid bone is removed (Fig. 18.15). 5. After removal of the hyoid bone, the thyrohyoid membrane and the thyroid cartilage are exposed by reflecting the thyrohyoid, sternohyoid, and omohyoid muscles inferiorly (Fig. 18.16). 6. An incision is made across the superior border of the thyroid cartilage up to the base of each superior horn (Fig. 18.17). 7. The perichondrium is elevated from the anterolateral surface of the thyroid cartilage and reflected inferiorly. After removal of the hyoid bone, the thyrohyoid membrane and the thyroid cartilage are exposed by reflecting the thyrohyoid, sternohyoid, and omohyoid muscles inferiorly (Fig. 18.18). 8. A plane of cleavage is established between the thyroid cartilage to be resected and the underlying perichon-

577

drium. With a small circular saw, horizontal incisions are made across the thyroid cartilage just above midpoint between the thyroid notch and the inferior border. The thyroid cartilage incision is continued superiorly at each side along the lines corresponding to the perichondrial incisions (Fig. 18.19). 9. The thyroid cartilage above the horizontal incision is resected exposing the underlying perichondrium (Fig. 18.20). 10. The pharynx is entered as described in laryngectomy. After exposure of the pharynx, the surgeon moves to the head end of the table. The tip of the epiglottis is grasped and retracted anteriorly and inferiorly. Depending on the extension of the tumor, the aryepiglottic fold is transected on each side by placing the blade of the dissecting scissors into the laryngeal ventricle below or above the false cord and the other blade in the pyriform sinus (Fig. 18.21). 11. The repair begins by approximating the mucosa of the pyriform sinus to the margins of the resected false cords with 3-0 chromic catgut (Fig. 18.22). 12. Laterally, the base of the tongue is sutured to the inferior constrictor musculature with chronic catgut 3-0. Anteriorly, interrupted sutures are placed through the base of the tongue, the internal thyroid cartilage perichondrium, the thyroid cartilage, and the external thyroid cartilage perichondrium. The neck is flexed and the laryngeal mucosa and the tongue base mucosa are approximated together (Fig. 18.23). 13. The strap muscles are sutured to the mylohyoid muscle (Fig. 18.24). “Guardian” or “check” sutures are placed between the skin of the chin and the manubrium with two silk to prevent sudden over extension of the neck.

578

18  Surgery for Laryngeal Malignancy Mylohyoid muscle

Cricothyroid muscle Thyroid cartilage

Sternothyroid muscle Hyoid bone Mandible

Submandibular salivary gland

Omohyoid muscle

Sternocleidomastoid muscle

18.12

Thyrohyoid muscle

Sternohyoid muscle

Internal laryngeal nerve

Superior laryngeal artery Omohyoid muscle

18.13

18.2 Supraglottic Horizontal Partial Laryngectomy

579

Hyoid bone

Internal laryngeal nerve

Superior horn of thyroid cartilage

Omohyoid muscle Sternohyoid muscle

18.14

18.15

580

18  Surgery for Laryngeal Malignancy

18.16

Thyrohyoid membrane Thyroid notch

Incision of perichondrium at superior border of thyroid cartilage

Endotracheal tube

18.17

18.2 Supraglottic Horizontal Partial Laryngectomy

581

18.18

Reflected perichondrium of outer surface of thyroid cartilage

Incision for removal of upper half of thyroid cartilage

18.19

582

18  Surgery for Laryngeal Malignancy

Upper half of thyroid cartilage being removed

Thyroid cartilage perichondrium – inner layer

Thyroid cartilage perichondrium – outer layer

Internal Laryngeal nerve

Superior laryngeal artery

Lower half thyroid cartilage

Thyrohyoid muscle

Endotracheal tube

18.20

Epiglottis

Tumor Aryepiglottic folds

False vocal cords

True vocal cords

Neck dissection tissues

Lower half of thyroid cartilage

Posterior pharyngeal wall

18.21

18.2 Supraglottic Horizontal Partial Laryngectomy

True vocal cords

Remaining false vocal cord mucosa

583

Pyriform sinus mucosa

Lower half of thyroid cartilage

Nasogastric tube

18.22

Sutures through tongue base mucosa

Lower half of thyroid cartilage

Endotracheal tube

Sutures through outer and inner perichondrium of thyroid cartilage

18.23

584

18  Surgery for Laryngeal Malignancy

18.24

18.2 Supraglottic Horizontal Partial Laryngectomy

18.2.2 Potential Problems 1. Injury to anterior commissure, laryngeal soft tissues, and vocal cord during sectioning thyroid cartilage and separation of supraglottis from glottis. 2. Preservation of at least one superior laryngeal nerve. 3. Removal of arytenoid cartilage. 4. Damage to cricoarytenoid joint.

585

3. Removal of arytenoid must be avoided to avoid prolonged postoperative aspiration. 4. Damage to cricoarytenoid joint must be avoided, as it will cause phonatory impairment. 5. Feeding by tube and voice rest to continue for 2 weeks. Subsequently, the diet is progressed to liquid, to soft solid, and to solid. References to Operative Procedure

18.2.3 Suggested Solutions 1. Small-diameter circular saw usually avoids damage to the underlying soft tissue. Thyroid cartilage should be resected 1–2  mm above the label of the vocal cords. Horizontal cut over the thyroid cartilage is made at the junction of the upper third and lower two-thirds of the distance between superior thyroid notch and the inferior border of the thyroid cartilage. 2. Preservation of superior laryngeal nerve will improve postoperative functions better and quicker.

1. Tabb HG, Druck NS, Thornton RS, Gibbens WP (1978) Supraglottic laryngectomy. South Med J 71:114–117 2. Friedman M, Venkatesan TK (1990) Supraglottic laryngectomy: technique. Oper Tech Otolayngol Head Neck Surg 1:47–51 3. Rassekh CH, Driscoll BP, Seikaly H, Laccourreye O, Calhoun KH, Weinstein GS (1998) Preservation of the superior laryngeal nerve in supraglottic and supracricoid partial laryngectomy. Laryngoscope 108:445–447 4. Tufano RP (2003) Open supraglottic laryngectomy. Oper Tech Otolayngol Head Neck Surg 14:22–26

586

18.3 S  upracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy Siba P. Dubey, Charles P. Molumi, and Herwig Swoboda

18.3.1 Operative Steps 1. A ‘U’ type incision is marked. It is passed along the anterior border of the sternocleidomastoid muscles, down to the level of the cricoid cartilage (Fig. 18.25). A subplatysmal skin flap is elevated at least 1 cm above the level of the hyoid bone. A functional neck dissection is performed at this stage. 2. The sternohyoid and thyrohyoid muscles are cut along the upper border of the thyroid cartilage. The former muscles are dissected downward to expose the sternothyroid muscles. The muscles along the oblique line of the thyroid cartilage are cut and the thyroid and cricoid cartilages are defined (Fig. 18.26). 3. The sternothyroid muscles are dissected downward beyond the cricoid cartilage, thereby exposing the cricothyroid muscles. The muscles are carefully transected to expose the cricothyroid membrane (Fig.  18.27). With the help of the perichondrial elevator, the subglottic mucosa overlying the cricoid cartilage is elevated on the side of the tumor. This step is necessary to achieve wider resection on the diseased side. 4. The external thyroid perichondrium and the inferior constrictor muscles are cut along the posterior borders of the thyroid cartilage. Using a perichondrium elevator, the pyriform sinus mucosa is released from the inner surface of the thyroid cartilage (Fig. 18.28). The superior laryngeal vessels are identified and ligated, and the internal laryngeal nerves are preserved. 5. The inferior horn of the thyroid cartilage is removed on the nontumor side to avoid injury to the recurrent laryngeal nerve during the removal of the thyroid cartilage (Fig. 18.29). The inferior horn on the tumor side is disarticulated to allow the paraglottic space to be removed completely. 6. The periosteum of the hyoid bone (arrow) is incised anteriorly and laterally using a periosteum elevator and the preepiglottic space is separated from the posterior surface of the hyoid bone (Fig. 18.30). 7. From the head end, the larynx is opened just above the false vocal cord, thus allowing good exposure of the extent of the tumor. At this stage, a tracheotomy is performed between third and the fourth tracheal rings through a separate incision. A tracheal intubation is done

18  Surgery for Laryngeal Malignancy

while the oroendotracheal tube is removed. The larynx is entered through an inferiorly directed horizontal pharyngotomy (arrowhead), thereby preserving the entire epiglottis (Fig. 18.31). 8. The larynx is grasped with an Allis forceps and pulled in an anteroinferior direction to have maximum visualization (Fig.  18.32). The endolaryngeal resection is performed under direct vision. On the nontumor (right) side, a vertical prearytenoid incision is made from the aryepiglottic fold to the superior border of the cricoid cartilage with a pair of scissors. The entire paraglottic space is anterior to the cut while the pyriform sinus is behind it, and both are spared. The vertical prearytenoid incision and the medial transverse cricothyroidotomy are connected. This allows the lateral cricoarytenoid muscle to be spared on the contralateral side; so, it will assist the anterior motion of the remaining arytenoid. 9. On the side (left) of the tumor, the extent of resection is much wider. The cuts are made over the arytenoid, conserving the posterior mucosa, then continued vertically in the posterior subglottis through the interarytenoid muscle. Subsequently, the cut on the tumor-bearing side proceeds anteriorly in the cricothyroid membrane and is joined with the cut from the contralateral side (Fig. 18.33). Hemostasis is achieved. Before closure, it is made sure that the ventricular mucosa is removed entirely and there is no perforation of the pyriform sinus mucosa. The mucosa of the arytenoid cartilage is sutured covering the cartilage. The remaining arytenoid mucosa is sewn over the denuded cricoid cartilage on the side of arytenoid resection. The remaining arytenoid cartilage is pulled forward to the posterolateral aspect of the cricoid cartilage to avoid the posterior sliding of the former. 10. Three thick sutures (‘0’ vicryl) are placed, one in the midline and one on either side 1 cm away from midline. They are passed to encircle the cricoid cartilage, cross the epiglottis and the base of the tongue and lastly, encircle the hyoid bone (Fig. 18.34). The neck is flexed and the sutures are tied tightly leaving no gap between the cricoid cartilage and the hyoid bone. The tension is less in the suture line as the previously released cervicomediastinal trachea moves upward. At this stage, the final refinement of the tracheotomy is made. The previously sectioned sternohyoid muscles are sutured, drain inserted and the skin closed in two layers. 11. Postoperative specimen showed the inner aspect of the thyroid cartilage and the tumor (Fig. 18.35). 12. The same operation is performed by inferosuperior approach. The front of the larynx is exposed after transecting the strap muscles; the cricothyroid muscles are

18.3  Supracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy

also transected (Fig. 18.36). The cricothyroid membrane is cut along the upper border of the cricoid cartilage in order to include microscopic extralaryngeal spread along the inferior border of the thyroid cartilage; the interior of the larynx is entered and the extent of the tumor is assessed (Fig. 18.37). The inferior horns of the thyroid cartilage are transected and kept attached to protect the recurrent laryngeal nerves (Fig. 18.38). The thyroid cartilage is rotated to expose the inferior constrictor

587

muscle which is to be transected from the thyroid cartilage (Fig. 18.39). Midline laryngotomy is done through thyrohyoid membrane before the removal of the specimen (Fig. 18.40). The cricohyoid epiglottopexy is done as mentioned before (Fig.  18.41). The specimens are examined for completeness of removal of the tumor (Fig. 18.42a, b; Figs. 18.36 to 18.42 are provided by Dr Swoboda, Vienna).

588

18  Surgery for Laryngeal Malignancy

18.25

Thyroid cartilage

Cricothyroid muscles

Cricoid cartilage Thyroid gland

18.26

18.3  Supracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy

589

External perichondrium of thyroid cartilage Thyroid cartilage

Transected cricothyroid muscle

Cricothyroid membrane

Cricoid cartilage

18.27

Superior horn of thyroid cartilage lamina

Posterior border of thyroid cartilage lamina

Pyriform sinus

Inferior constrictor muscle of pharynx

Thyroid gland

18.28

590

18  Surgery for Laryngeal Malignancy Posterior border of thyroid cartilage

Inferior horn of right thyroid cartilage removed Outwardly bulged pyriform sinus mucosa

Inferior constrictor muscle

18.29

18.30

18.3  Supracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy

591

18.31

Left vocal cord tumor

Normal right vocal cord Laryngotracheal lumen

Pharyngoesophageal lumen

18.32

592

18  Surgery for Laryngeal Malignancy

Right vocal cord with intact arytenoid Raw area of left hemilarynx be covered

Hypopharynx

18.33

Superior cut ends of sternohyoid muscles

18.34

18.3  Supracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy

593

18.35

Thyroid cartilage

Transected cricothyroid muscle

Cricoid cartilage

18.36

594

18  Surgery for Laryngeal Malignancy

Cricothyroid opening

18.37

Transection of inferior horn of thyroid cartilage

18.38

18.3  Supracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy

595

External thyroid perichondrium

Cricothyroid membrane

18.39

Arytenoid cartilages Suprahyoid epiglottis

Infrahyoid epiglottis

Upper border of thyroid cartilage

18.40

596

18  Surgery for Laryngeal Malignancy

Hyoid-epiglottis complex

Cricoid cartilage

Trachea

18.41

18.3  Supracricoid Subtotal Laryngectomy with Cricohyoidoepiglottopexy

597

Infrahyoid epiglottis

Thyroid lamina

Thyroid lamina

Inner perichondrium of thyroid lamina

Tumor

18.42a

Thyroid notch at upper border of thyroid cartilage

Left thyroid lamina Right thyroid lamina

Inferior border of thyroid cartilage with cricothyroid membrane Both inferior horns of thyroid cartilage transected

18.42b

598

18  Surgery for Laryngeal Malignancy

18.3.2 Potential Problems

References to Operative Procedure

1. Postoperative aspiration pneumonia may develop due to severe gastroesophageal reflux. 2. Vascular injury during the release of the cervicomediastinal trachea. 3. Postoperative laryngeal stenosis.

1. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D (1990) Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope 100:735–741 2. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D (1990) Supracricoid laryngectomy with cricohyoidoepiglottopexy: a partial laryngeal procedure for glottis carcinoma. Ann Otol Rhinol Laryngol 99:421–426 3. Piquet JJ, Chevalier D (1991) Subtotal laryngectomy with crico-hyoido-epiglotto-pexy for the treatment of extended glottis carcinomas. Am J Surg 162:357–361 4. Lima RA, Freitas EQ, Dias FL, Barbosa MM, Kligerman J, Soares JR, Santos IC, Rocha RM, Cernea CR (2006) Supracricoid laryngectomy with cricohyoidoepiglottopexy for advanced glottis cancer. Head Neck 28:481–486

18.3.3 Suggested Solutions 1. Endoscopic gastrostomy is needed in case there is weight loss or pneumonia at the end of the first postoperative month. Rarely, a completion laryngectomy is needed in refractory case with severe aspiration. 2. Blunt dissection with the pulp of the finger along the anterior wall of the cervicomediastinal trachea to the level of the carina. 3. The three sutures are tied tightly so that anterior borders of the hyoid bone and cricoid cartilage must be aligned carefully without any gap in between them. 4. Stenting with a Montgomery silicone T. tube for 3 months is needed for postoperative laryngeal stenosis.

18.4 Total Laryngectomy with Partial Pharyngectomy

18.4 T  otal Laryngectomy with Partial Pharyngectomy Siba P. Dubey and Charles P. Molumi

18.4.1 Operative Steps 1. A ‘U’ flap incision is marked out; extension could be made for neck dissection (Fig. 18.43). 2. The flap consists of skin, subcutaneous tissue, and platysma, elevated above to the level of the hyoid bone and stitched with the skin of the chin (Fig. 18.44). 3. The medial borders of the sternomastoid muscles are identified and dissected in its medial plane. The carotid sheath is identified and the common carotid artery, internal jugular vein, and vagus nerve are retracted laterally. The superior belly of omohyoid muscle is incised. The dissection is continued to the level of the clavicle below and hyoid bone above on both sides. The anterior jugular vein is transected and the ends are tied (Fig. 18.45). 4. On the side of the tumor, appropriate neck dissection is done depending on the neck node metastasis. The superior and inferior thyroid arteries and veins, and the middle thyroid vein are ligated; this helped easier removal of the corresponding thyroid lobe in continuity with the laryngeal specimen (Fig. 18.46). 5. On the contralateral side of the tumor, the superior and inferior thyroid artery and vein are preserved (Fig. 18.47). 6. The thyroid isthmus is divided. The thyroid gland on the contralateral side is peeled off from the trachea by blunt dissection and is preserved (Fig. 18.48). 7. The strap muscles attached at the hyoid bone and the sternum are transected. Transection of sternal attachment of the strap muscles exposed the trachea. The larynx is now free of muscular attachments (Fig. 18.49). 8. The superior horns of the thyroid cartilage on both sides are removed (Fig. 18.50). 9. A transverse pharyngotomy is made at the thyrohyoid membrane to enter the pharyngeal lumen in the area of the vallecula between the base of the tongue and the epiglottis. The surgeon with headlight moves to the head end of the table. Through the pharyngotomy, the epiglottis is grasped with Allis forceps (Fig. 18.51). The pharyngeal mucosa is cut with scissors laterally on each side of the epiglottis and then the cut follows inferiorly along the aryepiglottic folds on each side and turns medially just below the level of the superior border of the cricoid cartilage to join the incision from the opposite side.

599

10. The larynx is released by dividing the extramucosal tissues. Any residual part of the inferior constrictor muscles cut along the same line of the mucosal cut. Both right and left cuts are joined posteroinferior to the cricoarytenoid articulation, thereby keeping away from probable malignant spread to the latter (Fig. 18.52). 11. The separation between the laryngotracheal and esophageal lumens are achieved with the help of gauze dissection on the posterior surface of the cricoid cartilage (Fig. 18.53). 12. The larynx with attached one thyroid lobe is removed. A new tracheostoma is made through the skin below the tip of the incision in patients who did not have any prior tracheostomy. The anesthetist gradually removes the orotracheal tube and the surgeon inserts a new endotracheal tube through the tracheostoma. The shape of the tracheal cut is beveled so it is extended backward and obliquely upward, making the membranous part 5 mm higher than cartilaginous one (Fig. 18.54). 13. After removal of the specimen, the nasogastric tube is directed into the stomach (Fig. 18.55). 14. A cricopharyngeal pharyngeal myotomy is made using a sharp knife till the mucosa is seen transparent (Fig. 18.56). 15. The pharynx is closed by carefully apposing mucosal edges with the help of mucosal or extramucosal sutures from above downward or vice versa (Fig. 18.57). During this first layer of closure, the mucosal edges should be carefully inverted so that outer surface is opposed to outer surface when approximated. Usual pharyngeal closure line looks like a straight line or “T” shaped. 16. The second layer of pharyngeal closure is done by interrupted sutures so as to bury the first one; the pharyngeal wall is picked up with a fine, atraumatic round needle just lateral to the crease of the first suture line without penetrating the mucosa, and the knots are tied. The third layer of the pharyngeal closure is made using pharyngeal constrictors and the preserved strap muscles of the neck. Particular attention is given to the suprastomal area, the commonest site of fistula formation (Fig. 18.58). 17. At this stage, the patient head is made slightly flexed from extended position to lessen the tension on the suture lines. Using heavy and fine sutures, the peritracheal fascia is stitched to the subcutaneous tissues around the tracheostoma. Additional suturing of the skin to the mucosa above the tracheal cartilage is necessary to make the closure airtight (Fig. 18.59). A suction drain is inserted and the skin flaps are sutured with the tracheostoma and with the rest of the cervical incision.

600

18  Surgery for Laryngeal Malignancy

18.43

Superior skin flap

Anterior jugular vein

External jugular vein

Sternocleidomastoid muscle

18.44

18.4 Total Laryngectomy with Partial Pharyngectomy

601

Sternocleidomastoid muscle

Omohyoid muscle

Internal jugular vein

Common carotid artery

18.45

Ligated superior thyroid artery Neck dissection tissues

Vagus nerve

Thyroid gland

Internal Jugular vein

Common carotid artery

18.46

602

18  Surgery for Laryngeal Malignancy

Submandibular salivary gland Superior thyroid artery

Thyroid gland

Endotracheal tube through tracheostoma

Internal jugular vein Common carotid artery

18.47

18.48

18.4 Total Laryngectomy with Partial Pharyngectomy

Strap muscles transected at hyoid bone

603 Left internal jugular vein

Left common carotid artery

Trachea

Strap muscles transected above sternum

18.49

Superior horn of thyroid cartilage

Endotracheal tube

18.50

604

18  Surgery for Laryngeal Malignancy

Hyoid bone

Epiglottis

Pharyngotomy

18.51

Hyoid bone Epiglottis Nasogastric tube

Tongue base

Laryngeal inlet

Left pyriform sinus location

Right pyriform sinus location

Pharyngoesophageal lumen

Postcricoid mucosa Right and left side cuts joined

Posterior pharyngeal wall mucosa

Right common carotid artery

Sternocleidomastoid muscle

18.52

18.4 Total Laryngectomy with Partial Pharyngectomy

605 Postcricoid mucosa

Posterior wall of trachea

Right internal jugular vein Esophagus Right common carotid artery

Posterior pharyngeal wall mucosa

Head end

18.53

Nasogastric tube within neopharynx

Skin around fisrt tracheostoma

Anterioposteriorly beveled new tracheostoma Sternocleidomastiod muscle

18.54

606

18  Surgery for Laryngeal Malignancy Left submandibular salivary gland

Left internal jugular vein Left common carotid artery

Trachea

Tongue base mucosa Nasogastric tube within neopharynx

Right common carotid artery Right sternocleidomastoid muscle

18.55

Knife

Nasogastric tube

Tongue base mucosa

Cricopharyngeal myotomy done

18.56

18.4 Total Laryngectomy with Partial Pharyngectomy

607

Submandibular salivary glands

18.57

Left submandibular salivary gland

Tongue base inverting sutures

Pharyngeal inverting sutures

18.58

New tracheostoma

18.59

608

18.4.2 Potential Problems 1. Too tight pharyngeal suture will cut through the mucosa, leading to dehiscence and fistula formation. 2. Improper suturing with thinner suture at the tongue base can also lead to fistula formation. 3. Perichondritis of the tracheal cartilage at tracheostoma can lead to improper healing. 4. Inadequate hemostasis can also lead to fistula formation. 5. Collection around tracheostoma.

18.4.3 Suggested Solutions 1. First and second layers of closure should be done with optimum tension to avoid tear, necrosis, and fistula formation. 2. Tongue base suture should be done with broad bites of tissue or with mattress sutures. 3. Suture should encompass tracheal ring without piercing the cartilage in constructing the tracheostoma. The exposed cut edge of the cartilage rings should be covered with skin around tracheostoma. 4. Hemostasis should be complete and adequate.

18  Surgery for Laryngeal Malignancy

5. The dead space around the stoma and accumulation of secretions there can be prevented by raising a cuff of tissue above the posterior circumference of the stump and good use of suction drainage. References to Operative Procedure 1. Stell PM (1981) Total laryngectomy. Clin Otolaryngol 6:351–360 2. Tucker HM (1990) Total laryngectomy: technique. Oper Tech Otolayngol Head Neck Surg 1:42–44 3. McKenna JA, Dedo HH (1992) Cricopharyngeal myotomy: indications and technique. Ann Otol Rhinol Laryngol 101:216–221 4. Pearson BW, DeSanto LW (1990) Near-total Laryngectomy. Oper Tech Otolayngol Head Neck Surg 1:28–41 5. Maclean J, Cotton S, Perry A (2008) Variations in surgical methods used for total laryngectomy in Australia. J Laryngol Otol 122:728–732 6. Spriano G, Mercante G, Pellini R, Ferreli F (2018) Total laryngectomy: a new lateral cervical approach. Clin Otolaryngol 43:784–785

18.5 Total Laryngopharygoesophagectomy with Gastric Pull-Up with Pharyngogastric Anastomosis

18.5 Total Laryngopharygoesophagectomy with Gastric Pull-Up with Pharyngogastric Anastomosis Siba P. Dubey and Charles P. Molumi

18.5.1 Operative Steps 1. The initial steps are the same as skeletonizing of the larynx as described in total laryngectomy. With the help of blunt finger dissection, the esophagus is mobilized from above through the neck incision. At the same time, the stomach is mobilized endoscopically or by open abdominal surgery (Fig. 18.60). 2. By traction on the pharynx and esophagus, the stomach is mobilized to the neck (Fig. 18.61).

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3. Anchor sutures are placed through the muscular wall of the stomach and anchored to the prevertebral fascia (Fig. 18.62). 4. The esophagus is excised at the gastroesophageal junction and the lumen is closed. An opening is created at the fundus of the stomach for anastomosing with the pharynx. At first, the posterior wall of the pharynx is sutured with the posterior wall of the stomach (Fig. 18.63). 5. After the posterior wall of the pharynx is sutured to the stomach, a nasogastric tube is passed through the nose and directed to the stomach (Fig. 18.64). Then, the anterior wall of pharynx and anterior wall of the stomach are sutured together. 6. The wound is closed in layers (Fig. 18.65). 7. The specimen contains pharynx, larynx, and esophagus. The posterior aspect of the specimen is cut open, showing carcinoma involving hypopharynx and upper esophagus (Fig. 18.66).

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18  Surgery for Laryngeal Malignancy

18.60

18.61

18.5 Total Laryngopharygoesophagectomy with Gastric Pull-Up with Pharyngogastric Anastomosis

611

18.62

Anterior wall of pharynx Posterior wall of pharynx sutured to posterior wall of stomach

Anterior wall of stomach

Stomach

18.63

612

18  Surgery for Laryngeal Malignancy

Anterior wall of pharynx

Nasogastric tube

Stomach

18.64

Tracheostoma

18.65

18.5 Total Laryngopharygoesophagectomy with Gastric Pull-Up with Pharyngogastric Anastomosis

Tumor in hypopharynx

Laryngeal inlet

Esophagus 18.66

613

614

18.5.2 Potential Problems 1. Chest X-ray in the immediate postoperative procedure to detect pneumothorax. A water seal intercostal drain to be inserted in the presence of pneumothorax. 2. The stomach is located in neck and mediastinum; hence, the feeding tube has to be adjusted accordingly. 3. Some patients may suffer from regurgitation.

18.5.3 Suggested Solutions 1. A water seal drain at the end of the procedure should be inserted in advance, as pleural injury is common even with endoscopic mobilization of the stomach. 2. Tube feeding starts as soon as bowel sound returns; mouth feeding starts 7–10 days later. 3. Regurgitation can be avoided by taking the food slowly and in smaller amount. References to Operative Procedure 1. Le quesne LP, Ranger D (1966) Pharyngolaryngectomy with immediate pharyngogastric anastomosis. Br J Surg 53:105–109

18  Surgery for Laryngeal Malignancy

2. Leonard JR, Maran AGD (1970) Reconstruction of the cervical esophagus via gastric anastomosis. Laryngoscope 80:849–862 3. Freeman JL, Brondbo K, Osborne M, Noyek AM, Shaw HJ, Rubin A, Chapnik JS (1982) Greater omentum used for carotid cover after pharyngolaryngoesophagectomy and gastric pull-up or colonic swing. Arch Otolaryngol 108:685–687 4. Goldberg M, Freeman J, Gullane PJ, Pattersen GA, Todd TRJ, McShane D (1989) Transhiatal esophagectomy with gastric transposition for pharyngolaryngeal malignant disease. J Thorac Cardiovasc Surg 97:327–333 5. Krasna MJ, Phillips SD, Gray WC, Biedlingmaier JF (1995) Anastomosis technique for high pharyngogastrostomy. Ann Thorac Surg 60:1821–1823 6. Dai Z, Hi Q, Pan B, Liu L, Zhou D (2018) Postoperative complication assessments of different reconstruction procedures after total pharyngolaryngoesophagectomy: tubular gastric pull-up versus whole gastric pull-up. Am Surg 84:1927–1931

Surgery of Thyroid Gland

19.1 Hemithyroidectomy and Total Thyroidectomy Siba P. Dubey and Charles P. Molumi

19.1.1 Operative Steps 1. With the neck slightly flexed, identify the line of skin crease for incision which is one fingerbreadth above the clavicle. Extend the marking laterally to about 2  cm or more lateral to the anterior border of the sternocleidomastoid muscle on each side (Fig. 19.1a, b). 2. The skin incision is carried to the subcutaneous tissue to the platysma. Subplatysmal flaps are elevated superiorly to the level of the thyroid notch superiorly, sternal notch inferiorly, and sternocleidomastoid muscle laterally. Dissection is done in the plane separating the cervical fascia from the superficial layer of the deep cervical fascia, resulting in the platysma muscle on the flap and blood vessels on the patient side (Fig. 19.2a, b). 3. Divide the midline raphe between the sternohyoid muscles from the thyroid notch superiorly to the sternal notch inferiorly. Retract the sternohyoid muscles laterally to expose the sternothyroid muscles. (Fig. 19.3). 4. Retract the sternohyoid and sternothyroid muscles laterally on the side of the tumor; tissues over the thyroid gland are dissected off by blunt finger dissection and the thyroid lobe is delivered into the surgical field. The lower pole of the thyroid gland is released thereby exposing the tracheoesophageal groove. The recurrent

19

laryngeal nerve is identified in the tracheoesophageal groove in the Simon’s triangle is formed by the common carotid artery laterally, esophagus medially, and inferior thyroid artery superiorly. The nerve runs either lateral (Fig. 19.4a), medial (Fig. 19.4b), or through the branches (Fig. 19.4c) of the inferior thyroid artery. The right recurrent laryngeal nerve ascends cranially and medially over the upper tracheal rings, while the left one occupies the tracheoesophageal groove. 5. The recurrent laryngeal nerves are freed from the surrounding tissues and traced cranially; the nerves enter the larynx behind the articulation of the inferior horn of the thyroid with the cricoid cartilage. The thyroid lobe is retracted further medially to provide traction on the posterior suspensory ligament (Berry’s Ligament). The inferior thyroid artery is ligated close to the gland to maintain vascular supply to the parathyroid glands (Fig. 19.5a, b). 6. Medial 1  cm of the sternothyroid muscle is divided to expose the upper pole of the thyroid gland. Retract the upper pole inferiorly and laterally and dissect the avascular space between the upper pole of the thyroid lobe and cricothyroid muscle and identify the external laryngeal nerve (Fig. 19.6). 7. The superior thyroid vessels are ligated superficial to the external laryngeal nerve. The isthmus is dissected off the trachea and divided and the lobe is removed (Fig. 19.7). 8. A separate incision 1 cm to the surgical field is done and drain inserted. The incision is closed in layers (Fig. 19.8). 9. During total thyroidectomy, with a bigger incision (Fig. 19.9a), the same procedure is repeated on both sides (Fig. 19.9b) without dividing the isthmus (Fig. 19.9c).

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_19

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19  Surgery of Thyroid Gland

19.1a

19.1b

19.1  Hemithyroidectomy and Total Thyroidectomy

617

19.2a

External jugular vein

Anterior jugular vein

19.2b

618

19  Surgery of Thyroid Gland

Thyroid tumor

Strap muscles

19.3

19.1  Hemithyroidectomy and Total Thyroidectomy

619

Right thyroid lobe tumor

Right recurrent laryngeal nerve

Right inferior parathyroid gland

Right inferior thyroid artery medial to nerve

19.4a

Thyroid tumor

Right recurrent laryngeal nerve deep to artery

Right inferior thyroid artery

19.4b

620

19  Surgery of Thyroid Gland

Tumor

Branches of left inferior thyroid artery

Left recurrent laryngeal nerve through inferior thyroid artery branches

19.4c

19.1  Hemithyroidectomy and Total Thyroidectomy

621

Right recurrent laryngeal nerve

Right thyroid lobe tumor

Right inferior parathyroid gland with blood supply

19.5a

Left cricothyroid joint

Esophagus

Trachea

Left recurrent laryngeal nerve in tracheosophageal groove Left sternocleidomastoid muscle

19.5b

622

19  Surgery of Thyroid Gland

Right thyroid tumor

Superior thyroid vessels

Right recurrent laryngeal nerve

Cricothyroid muscle Right external laryngeal nerve

19.6

Right thyroid lobe tumor

Thyroid isthmus within hemostat

Right recurrent laryngeal nerve

19.7

19.1  Hemithyroidectomy and Total Thyroidectomy

623

19.8

19.9a

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19  Surgery of Thyroid Gland

Thyroid cartilage

Left sternocleidomastoid muscle

Right internal jugular vein

Left common carotid artery

Right common carotid artery Trachea

19.9b

19.9c

19.1  Hemithyroidectomy and Total Thyroidectomy

19.1.2 Potential Problems 1 . Injury to the recurrent laryngeal nerve 2. Injury to superior laryngeal nerve

19.1.3 Potential Sites of Injury to Recurrent Laryngeal Nerve and Suggested Solutions 1. Injury at the thoracic inlet. Locate the RLN in the tracheoesophageal groove within the triangle bounded by the trachea, carotid artery, and inferior pole of thyroid lobe. 2. Injury when ligating inferior thyroid artery. Identify the inferior thyroid artery. The nerve runs medial, lateral, or between branches of the inferior thyroid artery. Identify and determine all branches of the inferior thyroid artery before ligating. 3. Injury at the Berry’s ligament. Dissect the recurrent laryngeal nerve superiorly to the level of the cricothyroid joint. This decreases the chance of pressure or traction injury to the nerve while retracting and dissecting the Berry’s ligament off the trachea. 4. Always keep the dissection close to the thyroid capsule when dissecting the superior thyroid pedicle. Ligate the superior thyroid artery close to the thyroid capsule with right-angle clamp.

References to Operative Procedure 1. Moosman DA, DeWeese MS (1968) The external laryngeal nerve as related to thyroidectomy. Surg Gynecol Obstet 127:1011–1016 2. Attie JN, Khafif RA (1975) Preservation of parathyroid glands during total thyroidectomy: Improved technic utilizing microsurgery. Am J Surg 130:399–404

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3. Dozois RR, Beahrs OH (1977) Surgical anatomy and technique of thyroid and parathyroid surgery. Surg Clin N Am 57:647–661 4. Lore JM (1983) Practical anatomical considerations in thyroid tumor surgery. Arch Otolaryngol 109:568–574 5. Martensson H, Terins J (1985) Recurrent laryngeal nerve palsy after thyroid gland surgery related operations and nerves at risk. Arch Surg 120:475–477 6. Jansson S, Tisell L-E (1987) Autotransplantation of diseased parathyroid gland into subcutaneous abdominal adipose tissue. Surgery 101:549–556 7. Herranz-Gonzalez J, Gavila J, Matinez-Videl J, Gavilan C (1991) Complications following thyroid surgery. Arch Otolaryngol Head Neck Surg 117:516–518 8. Delbridge L, Reeve TS, Khadra M, Poole AG (1992) Total thyroidectomy: the technique of capsular dissection. Aust N Z J Surg 62:96–99 9. Jatzko GR, Lisborg PH, Muller MG, et  al (1994) Recurrent nerve palsy after thyroid operation-principle nerve identification and literature review. Surgery 115:139–144 10. Freidman M, LoSavio P, Ibrahim H (2002) Superior laryngeal nerve identification and preservation in thyroidectomy. Arch Otolaryngol Head Neck Surg 128:296–303 11. Nemiroff PM, Katz AD (1982) Extralaryngeal divisions of the recurrent laryngeal nerve. Surgical and clinical significance. Am J Surg 144:466–469 12. Friedman M, Toriumi DM (1986) How I do it: Functional identification of the external laryngeal nerve during thyroidectomy. Laryngoscope 96:1291–1292 13. Gavilan J, Gavilan C, Tomas MD (1986) Methylene blue infusion for intraoperative identification of the parathyroid glands. Laryngoscope 96:1389–1390 14. Schwartz AE, Friedman EW (1987) Preservation of the parathyroid glands in total thyroidectomy. Surg Gynecol Obstet 165:327–332

Surgery for Obstructive Sleep Apnea Syndrome

20.1 Drug-Induced Sleep Endoscopy (DISE) Phillip Huyett and Ryan J. Soose Sleep endoscopy was first described in 1978 and drug-­induced sleep endoscopy in 1991 as a means to observe patterns of upper airway collapse during natural and pharmacologically induced sleep respectively. DISE has gained significant attention in the last 15 years as the procedure of choice for directing surgical decision-making in the OSA patient [1]. Many authors have described improved surgical decision-making when guided by DISE; however, the major limitation of propofol- or midazolam-induced sleep is the dissimilarity in sleep architecture when compared to natural sleep [2]. Although limited evidence suggests that DISE findings impact outcomes with hypoglossal neurostimulation therapy, more studies are needed to determine if DISE actually changes surgical outcomes [3]. A slow gradual propofol infusion, either with bispectral analysis (BIS) or with targeted controlled infusion (TCI), is one of the most commonly used methods and has been shown to correlate with critical closing pressure (Pcrit) and genioglossus electromyography (EMG) activity [4].

20.1.1 Surgical Steps 1. Suggested room setup for DISE (Fig.  20.1). Note the room is quiet and darkened, the patient is comfortably

20

supine on a stretcher not the OR table, one side of the nose has been anesthetized and decongested with 4% lidocaine and 0.05% oxymetazoline or equivalent, the screen is opposite the endoscopist, and the anesthesiologist is at the head of the bed running the propofol infusion. A BIS monitor may be used to titrate the pharmacologically induced sleep to the 50–70 range. The patient should also be observed clinically for loss of response to quiet verbal and tactile stimuli as well as clinical signs of obstructive sleep-disordered breathing and intermittent oxygen desaturations. The flexible laryngoscope is then introduced to examine the nose, pharynx, and larynx under this steady state that mimics sleep. 2. The structure and levels of the upper airway (velum, oropharyngeal lateral walls, tongue base, and epiglottis) are inspected sequentially for anatomic locations and patterns of collapse. The VOTE classification is one example of a scoring system for DISE [5]. The velum or retropalatal collapse may be absent (left, Fig. 20.2), in an antero-­posterior direction (second from left), in a lateral configuration (third from left) or concentrically collapsed (right). 3. Oropharyngeal collapse is either absent (left, Fig. 20.3) or lateral (right). 4. Tongue base or retrolingual collapse is either absent (left, Fig. 20.4) or antero-posterior/present (right). 5. Epiglottic collapse is absent (left, Fig.  20.5), antero-­ posterior (right) or lateral.

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8_20

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20.1

20.2

20.1 Drug-Induced Sleep Endoscopy (DISE)

629

20.3

20.4

20.5

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20  Surgery for Obstructive Sleep Apnea Syndrome

20.1.2 Potential Problems

References to Operative Procedure

1 . Loss of airway 2. Minor epistaxis

1. De Vito A, Carrasco Llatas M, Vanni A, Bosi M, Braghiroli A, Campanini A, et al (2014) European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath 18:453–465 2. Kezirian EJ, Hohenhorst W, de Vries N (2011) Drug-­ induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol 268:1233–1236 3. Lo YL, Ni YL, Wang TY, Lin TY, Li HY, White DP, et al (2015) Bispectral index in evaluating effects of sedation depth on drug-induced sleep endoscopy. J Clin Sleep Med 11:1011–1020 4. Rabelo FA, Braga A, Kupper DS, De Oliveira JA, Lopes FM, de Lima Mattos PL, et al (2010) Propofol-induced sleep: polysomnographic evaluation of patients with obstructive sleep apnea and controls. Otolaryngol Head Neck Surg 142:218–224 5. Gillespie MB, Reddy RP, White DR, Discolo CM, Overdyk FJ, Nguyen SA (2013) A trial of drug-induced sleep endoscopy in the surgical management of sleep-­ disordered breathing. Laryngoscope 123:277–282

20.1.3 Suggested Solutions 1. When performing DISE, the otolaryngologist and anesthesia team should anticipate that apneic events would occur. Should apneas be accompanied by significant desaturations, a jaw thrust should be performed while utilizing the endoscope to visualize relief of upper airway obstruction and supplemental oxygen administered. If central apneas have been pharmacologically induced, bag mask ventilation, or in very rare cases, endotracheal tube intubation, should be performed. 2. Minor nasal trauma from endoscopy may be avoided by decongestion of the nose and care when advancing the scope through the nose.

20.2 Expansion Sphincter Pharyngoplasty (ESP, Modified UPPP)

20.2 E  xpansion Sphincter Pharyngoplasty (ESP, Modified UPPP) Phillip Huyett and Ryan J. Soose

20.2.1 Introduction Numerous modifications have been made to the traditional uvulopalatopharyngoplasty (UPPP) introduced by Fujita in 1981, both to improve outcomes and to reduce morbidity [1, 2]. Newer palatal surgery modifications emphasize upper airway reconstruction and stabilization rather than traditional excisional or ablative techniques. Herein, we will discuss expansion sphincter pharyngoplasty (ESP), introduced by Pang and Woodson in 2007 [3]. Appropriate candidates for ESP have bulky lateral pharyngeal walls and a concentric or lateral pattern of retropalatal collapse on DISE. The goal of this procedure is to improve the lateral retropalatal dimension using bilateral palatopharyngeus pedicled muscle flaps that are suspended anteriorly, laterally, and superiorly toward the hamulus and pterygomandibular raphe. Advantages of ESP over traditional UPPP include preservation of mucosa and muscular structures of the uvula and soft palate and improved surgical success rates in appropriately selected patients.

631

20.2.2 Operative Steps 1. If the palatine tonsils are present, tonsillectomy is performed with maximal preservation of the mucosa and muscle of the posterior tonsillar pillars (Fig. 20.6). An incision is made in the posterior tonsillar pillar to expose the vertically oriented fibers of the palatopharyngeus muscle (Fig. 20.7). 2. The palatopharyngeus muscle is dissected in 360° and transected inferiorly to create a superiorly based palatopharyngeus muscle flap (Fig. 20.8). 3. The palatopharyngeus muscle flap is elevated toward its insertion into the soft palate and then rotated toward the hamulus and pterygomandibular raphe. An incision is made in the soft palate just lateral to the hamulus of the pterygoid bone. A submucosal tunnel is dissected posteriorly to the superior pole of the tonsillar fossa. The muscle flap on each side is pulled through the submucosal tunnel. Using 2-0 vicryl suture, two figure-of-eight or tendon sutures are placed to secure each muscle flap to the fibrous tissue adjacent to the hamulus and pterygomandibular raphe (Fig. 20.9). 4. The palatopharyngeus muscle is now oriented superiorly, laterally, and anteriorly, thereby increasing the retropalatal space (Fig. 20.10). The tonsillar pillars may be apposed with additional 2-0 vicryl suture and a partial uvulectomy may be performed if indicated. The procedure is repeated on the opposite side.

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20  Surgery for Obstructive Sleep Apnea Syndrome

20.6

20.7

20.2 Expansion Sphincter Pharyngoplasty (ESP, Modified UPPP)

633

20.8

20.9

634

20  Surgery for Obstructive Sleep Apnea Syndrome

20.10

20.2 Expansion Sphincter Pharyngoplasty (ESP, Modified UPPP)

635

20.2.3 Potential Problems

References to Operative Procedure

1 . Resection of the posterior pillar during tonsillectomy 2. Tearing of the palatopharyngeus muscle flap 3. Perforation of the lateral oropharyngeal wall mucosa

1. Pang KP, Woodson BT (2007) Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg 137:110–114 2. Woodson BT, Sitton M, Jacobowitz O (2012) Expansion sphincter pharyngoplasty and palatal advancement pharyngoplasty: airway evaluation and surgical techniques. Oper Tech Otolayngol Head Neck Surg 23:3–10 3. Pang KP, Pang EB, Win MT, et al (2016) Expansion sphincter pharyngoplasty for the treatment of OSA: a systemic review and meta-analysis. Eur Arch Otorhinolaryngol 273:2329–2333

20.2.4 Suggested Solutions 1. Care must be taken at all stages of the operation to preserve the posterior pillar, palatopharyngeus flap, and lateral oropharyngeal wall mucosa.

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20.3 Lingual Tonsillectomy (Coblation) Phillip Huyett and Ryan J. Soose

20.3.1 Introduction Lingual tonsillectomy can be effective in properly selected pediatric OSA patients with persistent disease after adenotonsillectomy or in adult OSA patients as part of multi- or single-level surgery [1]. It contrasts to a base of tongue reduction, in that only lymphoid tissue is removed, thereby limiting postoperative pain and bleeding risk.

20.3.2 Surgical Steps 1. Proper positioning may be obtained in a variety of ways that are surgeon- and patient-specific. A mouth gag

20  Surgery for Obstructive Sleep Apnea Syndrome

(McIvor, e.g.,) or suspended direct laryngoscope (Lindholm, e.g.,) may be used for exposure of the lingual tonsils. Alternatively, a side biting mouth gag or prop can be used with a 2-0 silk suture placed anteriorly within the tongue to distract the base of tongue anteriorly (Fig. 20.11). Direct visualization or a 0° or 30° endoscope may be used. 2. The coblator wand (Smith & Nephew, U.S.) is used oriented in the direction of the lingual tonsils (Fig. 20.12). Caution must be used to not “bury” the coblator tip within the lingual tonsil, as this puts deeper tissues unnecessarily at risk and will clog the coblator wand. The lingual tonsils are ablated until tongue musculature and minor salivary glands are visualized (Fig. 20.13). Note that the lingual arteries are at greatest risk laterally in this region; however, by treating tonsillar tissue only, the arteries should not be encountered.

20.3  Lingual Tonsillectomy (Coblation)

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20.3.3 Potential Problems

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carried anteriorly toward the foramen caecum. Maintain plane of dissection superficial to tongue musculature.

1. Bleeding References to Operative Procedure

20.3.4 Suggested Solutions 1. Knowledge of tongue base neurovascular anatomy. Avoid lateral aspect of tongue, particularly as the dissection is

1. Kang KT, Koltai PJ, Lee CH, Lin MT, Hsu WC (2017) Lingual tonsillectomy for treatment of pediatric obstructive sleep apnea: a meta-analysis. JAMA Otolaryngol Head Neck Surg 143:561–568

640

20.4 Hypoglossal Nerve Stimulation

20  Surgery for Obstructive Sleep Apnea Syndrome

the chest wall by following the inframammary crease posteriorly at approximately its intersection with the anterior Phillip Huyett and Ryan J. Soose axillary line The hypoglossal nerve has been dissected anteriorly Hypoglossal nerve stimulation received FDA approval in under the mylohyoid muscle (Fig. 20.16). The ranine vein is 2014 as a treatment alternative for CPAP-intolerant OSA often clamped, divided, and ligated to maximally expose the patients [1]. The current hypoglossal nerve stimulation sys- distal branches of the hypoglossal nerve. Care must be taken tem produced by Inspire Medical Systems coordinates to exclude all retrusor branches (innervating the styloglossus ­titratable electrical stimulation of the hypoglossal nerve with and hyoglossus muscles) and include all protrusor branches inspiration such that the tongue is anteriorly displaced to of the nerve (innervating the genioglossus muscle) including relieve airway obstruction. Appropriate candidates have pre- the C1 branch to the geniohyoid muscle (Fig.  20.17). dominantly moderate–severe obstructive (as opposed to cen- Individual branches can be tested using a nerve stimulator tral or mixed) sleep apnea and documented PAP, therapy and sensing lead in the oral tongue within the genioglossus failure. Patients additionally undergo DISE and are currently (protrusor, blue lead) and styloglossus (retrusor, red lead) excluded from candidacy if the velum demonstrates the con- muscles (Fig. 20.18) centric collapse pattern (see above). Short-term and long-­ A pocket is made overlying the pectoralis major fascia but term outcome studies have demonstrated good adherence, deep to subcutaneous fat measuring 4  cm  ×  5  cm for the low morbidity, and sustained improvements in both subjec- implanted pulse generator tive and objective measures of OSA [2]. A 3 cm incision is utilized to dissect down to the intercostal muscles. The neurovascular bundle runs on the inferior surface of each rib, so the rib is approached along the supe20.4.1 Operative Steps rior aspect. A pocket between the external and internal intercostal muscles is dissected bluntly and the chest sensing lead The 3.5-cm stimulator incision is an anteriorly placed sub- is placed with the respiratory sensor facing the pleura mandibular incision centered on the expected location of the (Fig. 20.19) posterior edge of the mylohyoid muscle (Fig.  20.14)— The stimulator and chest sensing leads are connected to (drawn are the inferior border of mandible, inferior edge of the implanted pulse generator by tunneling the leads subplasubmandibular gland, anterior belly of digastric muscle, tysmally in the neck and within the subcutaneous fat of the hyoid, midline, and incision). The incision for the implanted chest (Fig. 20.20). The system is tested to ensure adequate pulse generator is placed inferior to the clavicle over the respiratory sensing waveform and proper uninhibited anteright breast and measures 4  cm  ×  5  cm (Fig.  20.15). The rior displacement of the tongue prior to closing the skin inci3-cm incision for the chest wall sensor is placed laterally in sions (Fig. 20.21)

20.4  Hypoglossal Nerve Stimulation

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20.4.2 Potential Problems

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tion paper on drug-induced sedation endoscopy (DISE). Sleep Breath 18:453–465 1. Bleeding from Ranine veins 2. Rabelo FA, Braga A, Kupper DS, De Oliveira JA, Lopes 2. Marginal mandibular nerve injury FM, de Lima Mattos PL, et al (2010) Propofol-induced 3. Poor tongue protrusion sleep: polysomnographic evaluation of patients with 4. Pneumothorax obstructive sleep apnea and controls. Otolaryngol Head 5. Postoperative hematoma or seroma Neck Surg 142:218–224 3. Vanderveken OM, Maurer JT, Hohenhorst W, Hamans E, Lin HS, Vroegop AV, et al (2013) Evaluation of drug-­ 20.4.3 Suggested Solutions induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep 1. Meticulous dissection around the nerve. apnea. J Clin Sleep Med 9:433–438 2. Placement of incision at least two fingerbreadths below 4. Hillman DR, Walsh JH, Maddison KJ, Platt PR, Kirkness the inferior border of the mandible and anterior to the JP, Noffsinger WJ, et al (2009) Evolution of changes in standard submandibular gland excision incision. upper airway collapsibility during slow induction of 3. Ensure that the cuff placement has selectively excluded anesthesia with propofol. Anesthesiology 111:63–71 the retrusor branches of the hypoglossal nerve. 5. Kezirian EJ, Hohenhorst W, de Vries N (2011) Drug-­ 4. Anatomic dissection between the external and internal induced sleep endoscopy: the VOTE classification. Eur intercostal muscles for chest sensor placement. Arch Otorhinolaryngol 268:1233–1236 5. Compressive dressings at completion of case, limited 6. Fujita S, Conway W, Zorick F, Roth T (1981) Surgical exertional activity postoperatively. correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. References to Operative Procedure Otolaryngol Head Neck Surg 89:923–934 7. Woodson BT, Wooten MR (1994) Manometric and 1. Strollo PJ Jr, Soose RJ, Maurer JT, et  al (2014) Upper-­ endoscopic localization of airway obstruction after uvuairway stimulation for obstructive sleep apnea. N Engl J lopalatopharyngoplasty. Otolaryngol Head Neck Surg Med 370:139–149 111:38–43 2. Woodson BT, Gillespie MB, Soose RJ, et  al (2014) 8. Pang KP, Woodson BT (2007) Expansion sphincter pha Randomized controlled withdrawal study of upper airway ryngoplasty: a new technique for the treatment of stimulation on OSA: short-term and long-term effect. obstructive sleep apnea. Otolaryngol Head Neck Surg Otolaryngol Head Neck Surg 151:880–887 137:110–114 3. Gillespie MB, Soose RJ, Woodson BT, Strohl KP, Maurer 9. Kang KT, Koltai PJ, Lee CH, Lin MT, Hsu WC (2017) JT, de Vries N, et al (2017) Upper airway stimulation for Lingual tonsillectomy for treatment of pediatric obstrucobstructive sleep apnea: patient-reported outcomes after tive sleep apnea: a meta-analysis. JAMA Otolaryngol 48 months of follow-up. Otolaryngol Head Neck Surg Head Neck Surg 143:561–568 156:765–771 10. Strollo PJ Jr, Soose RJ, Maurer JT, de Vries N, Cornelius 4. Dedhia RC, Strollo PJ, Soose RJ (2015) Upper airway J, Froymovich O, et al (2014) Upper-airway stimulation stimulation therapy: past, present, and future. Sleep for obstructive sleep apnea. N Engl J Med 370:139–149 38:899–906 11. Gillespie MB, Soose RJ, Woodson BT, Strohl KP, Maurer JT, de Vries N, et al (2017) Upper airway stimuFurther Reading lation for obstructive sleep apnea: patient-reported outcomes after 48 months of follow-up. Otolaryngol Head 1. De Vito A, Carrasco Llatas M, Vanni A, Bosi M, Neck Surg 156:765–771 Braghiroli A, Campanini A, et al (2014) European posi-

Index

A Abdominal fat harvesting, 161, 164 Alar rim defect repair excision, 79 full thickness skin graft complications, 89 hemostasis, 84 postoperative appearance, 84 postoperative management, 89 skin incision, 84 suture, 84 wound closure, 84 rotation flap complications, 83 postoperative management, 83 suturing of, 79 rotational flap of skin, 79 superiorly based nasolabial flap, 79 Allen test, 141, 142 Anterior commissurectomy, 176 Anterolateral thigh free flap blunt dissection, 103 closure, 103 complication, 109 Doppler examination, 103 fascia opening, 103 postoperative management, 109 skin paddle circumcisation, 103 surface anatomy, 103 vascular pedicle transection, 103 vertical incision, 103 Axial flaps deltopectoral flap, 1–8 FAMM flap, 9–15 inferiorly based nasolabial flap, 1–8 latissimus dorsi myocutaneous flap, 1–8 platysma myocutaneous flap, 1–8 submental artery island flap, 54–61 superiorly-based-nasolabial flap, 28–31 temporoparietal fascial flap, 1–8 B Bilateral palatopharyngeus pedicled muscle flaps, 631 Bilateral sagittal split osteotomy, 241, 257 Bispectral analysis (BIS), 627 Branchial cyst excision, 431, 434 C Central compartment neck dissection and superior mediastinal dissection, 333 Cervicofacial rotation-advancement flap, 200, 204

Cervicothoracic neurofibroma, 559 Cheek and alar defect, V-Y advancement flap, 235, 239 Coblation, 636 Complete cordectomy, 175 Cricohyoidoepiglottopexy, 586, 587 Cystic hygroma, 439 Cystic hygroma excision, 435, 439 D Da Vinci system, 449 Deep lobe parotid tumor removal, 475 Deltopectoral flap carcinoma excision, 1 complications, 8 de-epithelializaiton, 1 pedical division, 1 pharyngolaryngectomy, 1 postoperative care, 8 reconstruction, 1 skin incision, 1 skin paddle, 1 split-thickness skin graft, 1 surface anatomy, 1 Distraction osteogenesis, 266 Double barrel technique, 121 Drug induced sleep endoscopy (DISE), 627 apneic events, 630 epiglottic collapse, 627 room set up, 627 tongue base/retrolingual collapse, 627 E Expansion sphincter pharyngoplasty (ESP), 631, 635 Extended cordectomies, 176 Extended maxillectomy with orbital exenteration, 383 External nose reconstruction modified Rieger glabella rotation flap complications, 78 dorsal nasal flap elevation, 75 incision, 75 ipsilateral oblique incision, 75 mobilization, 75 postoperative management, 78 Schmid-Meyer frontotemporal flap, 90–95 skin island flap closure, 69 complications, 74 flap elevation, 69 location of, 69 pedical incision, 69 postoperative management, 74

© Springer Nature Switzerland AG 2020 S. P. Dubey, C. P. Molumi, H. Swoboda (eds.), Color Atlas of Head and Neck Surgery, https://doi.org/10.1007/978-3-030-29809-8

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648 F Facial artery musculomucosal (FAMM) flap complications, 15 incision, 9 mandibular division, 9 mobilization, 9 nasal intubation, 9 patient positioning, 9 postopertive care, 15 Fascia lata, 165, 170 Feyh– Kastenbauer retractor, 449 Free flap anterolateral thigh, 103–109 maxillary reconstruction with parascapular free flap, 110–120 orbital exenteration defect, 103–109 osteocutaneous vascularized fibular, 121–134 radial forearm free flap, 103–109 Frontal skin flap, 485 Frontolateral vertical partial laryngectomy, 569, 576 H Hemifacial microsomia, 287, 300 Hyperkeratotic superficial infiltrating squamous cell carcinoma of the lower lip, 205 Hypoglossal nerve stimulation, 640, 645 I Inferior transpalpebral approach, 393, 394, 406 Inferiorly based nasolabial flap complications, 27 de-epithelialisation, 24 gingivolabial defect closure, 24 medial incision, 24 postoperative management, 27 Intraconal tumor, 407 Intracranial extension of dermoid, 443 Intradural procedure, 530 K Karapandzic flap, near-total Lip defect repair, 219 L Laryngotracheal anastomosis, 547, 557 Laser microsurgery for glottic cancer, 175, 176 Lateral neck paragangliomas, 421, 430 Lateral rhinotomy, 343, 349 Lateralization of vocal cord (modified Woodman’s operation), 539, 546 Latissimus dorsi myocutaneous flap blunt dissection, 16 closure of, 16 complications, 23 incision, 16 medial dissection, 16 mobilization, 16 patient positioning, 16 postoperative appearance, 16 postoperative management, 23 surface anatomy, 16 thoracodorsal artery identification, 16 Le Fort I osteotomy, 258, 265 Le Fort III osteotomy, 266, 278

Index Lingual tonsillectomy, 636, 639 Lip shaving, 205 vermilion cutaneous incision, 210, 214 Lips and facial defects repair, 187, 195, 199 cervicofacial rotation-advancement flap, 200, 204 Lower lip, ‘V’ excision, 230 M Malignant parotid tumors, 479, 484 Mandibular osteosarcoma clinical presentation, 121 diagnosis, 121 osteocutaneous vascularized fibular free flap cervical incision, 121 complications, 134 fibula flap insertion, 121 fibula graft, 121 fixation, 121 flap perfusion, 121 instruments, 121 osteotomy, 121 patient positioning, 121 postoperative management, 121 preoperative considerations, 121 preventive measures, 134 tumor resection, 121 treatment, 121 Mastoid musculoperiosteal flap, 531 Maxillary reconstruction with parascapular free flap axial and coronial facial CT imaging, 110 clinical presentation, 110 complication, 120 open biopsy, 110 osteocutaneous parascapular flap, 110 osteotomy, 110 postoperative management, 120 vascular pedicle, 110 Weber Ferguson approach, 110 Maxillomandibular advancement for obstructive sleep apnea, 279, 286 Medial canthal and eyelid defect repair with split forehead flap, 215, 218 Midfacial degloving, 350, 355 Modified Blair’s incision, 468 Modified radical neck dissection type I (MRND-I), 320, 331 Modified UPPP, 631 Modified Woodman’s operation, 539, 546 Moure’s incision, 343 N Nasal dermoid cyst, 440, 443 Near-total Lip defect repair by Karapandzic flap, 219, 224 Neck paragangliomas, 421, 430 O Odontogenic keratocyst (OKC), 110 Open craniofacial subcranial approach, 485, 486, 509 Orbital decompression, 407 Orbital decompression for Graves’ orbitopathy, 393 Orbital exenteration defect total maxillectomy, 151 vertical abdominis free flap closure lateral wall nose, 151

Index closure of rectus sheath, 151 closure palate, 151 complications and preventive measures, 160 de-epithelialization, 151 flap harvesting, 151 incision, 151 medial canthus preparation, 151 microvascular anastomosis, 151 post-operative care, 151 rectus muscle elevation, 151 suturing, 151 tunnel creation, 151 vessels into neck, 151 vessels isolations, 151 Osteosynthesis, 241 P Palatal flap complications, 48 flap elevation, 44 incision line, 44 patient positioning, 44 postoperative management, 48 removal of pterygoid hamulus, 44 Palatal osteomucoperiosteal (POMP) flap, 356, 363 Palatal surgery modifications, 631 Paralized face, temporalis muscle flap transposition, 225 Parapharyngeal tumor excision, 421, 430 Parotid tumors, malignant, 479, 484 Partial pharyngectomy, 599, 608 Pectoralis major myocutaneous flap arc of rotation, 32 blunt dissection, 32 closure of, 32 complication, 38 elevation, 32 postoperative management, 38 skin incision, 32 tunnel creation, 32 Pedicled calverial bone graft complications, 39, 43 flap elevation, 39 postoperative management, 43 split thickness skin graft placement, 39 superficial temporal artery identification, 39 vascular pedicle intact, 39 Perichondritis of the tracheal cartilage, 608 Pharyngogastric anastomosis, gastric pull-up, 609, 614 Platysma mycutaneous flap complications, 53 postoperative appearance, 49 postoperative management, 53 rotation, 49 transverse incisions, 49 vertical incisions, 49 Posterior lateral neck dissection, 339 Preauricular infratemporal subtemporal approach, 510, 511, 530 R Radial forearm free flap oropharynx and oral cavity reconstruction Allen test, 141 anastomosis, 135

649 anatomical marking, 135 complications, 141 distal skin incision, 135 flap elevation, 135 postoperative appearance, 135 preventive measures, 141 radial artery and cephalic vein exposure, 135 skin graft, 135 Resection of stenosis and laryngotracheal anastomosis, 547, 557 S Schmid-Meyer frontotemporal flap complications, 95 free bipedicled flap, 90 mobilization, 90 postoperative management, 95 preoperative and postoperative appearance, 90 split-skin graft, 90 Sleep endoscopy, 627 SMAS flap (superficial musculoaponeurotic system), 511 Spheno-orbital meningioma, 407 Sternocleidomastoid muscle, 320 Subclavian artery aneurysm, 564, 567 Subcranial approach, 485 Sub-epithelial cordectomy, 175 Subligamental cordectomy, 175 Submandibular sialoadenectomy, 461, 467 Submental artery island flap complications, 61 facial artery and vein dissection, 54 flap elevation, 54 mobilization, 54 patient position, 54 pedicle placement, 54 postoperative management, 48 reverse flow, 54 surface anatomy, 54 total maxillectomy, 54 wound closure, 54 Superficial musculoaponeurotic system (SMAS), 225 Superficial parotidectomy with sternocleidomastoid flap, 468, 474 Superiorly-based-nasolabial flap complications, 31 elevation, 28 flap rotation, 28 incision, 28 incision closure, 28 postoperative management, 31 Superior mediastinal dissection, 333 Superior transpalpebral approach, 407, 419 Supracricoid subtotal laryngectomy with cricihyoidoepiglottopexy, 586, 598 Supraglottic horizontal partial laryngectomy, 577, 585 Supraglottic laryngectomy, 449, 450 Supraomohyoid neck dissection, 311, 312, 320 Sural nerve graft, 171 T Targeted controlled infusion (TCI), 627 Temporal bone malignancy, surgery, 531, 537 Temporalis muscle flap transposition for paralized face, 225 Temporalis muscle necrosis, 530 Temporary mandibulotomy, 301, 310

650 Temporoparietal fascial flap (TPFF) complications, 67 flap elevation, 62 incision, 62 postoperative management, 67 surface anatomy, 62 suturing, 62 Thyroglossal cyst excision, 444, 448 Thyroid lobectomy, 615, 625 Total cordectomy, 176 Total laryngectomy with partial pharyngectomy, 599, 608 Total laryngopharygoesophagectomy with gastric pull-up with pharyngogastric anastomosis, 609, 614 Total laryngopharyngectomy defect tubed radial forearm free flap and bilateral neck dissection, 142 closure, 142 flap failure, 150 flap harvesting, 142 flap placement, 142 medial (ulnar) incision, 142 microvascular anastomosis, 142 perfusion, 142 pharyngeal stenosis, 150 post-operative pharyngo-cutaneous fistula, 150 preoperative preparation, 142 size determination, 142 skin incision, 142 Total maxillary swing (TMS) approach for excision of large juvenile angiofibroma, 364, 372 Total maxillectomy, 373, 374, 382 Total nose reconstruction, anterior scalping flap

Index complications, 102 flap elevation, 96 incision, 96 postoperative management, 102 split skin graft, 96 surface anatomy, 96 suturing, 96 Total parotidectomy, 537 Total thyroidectomy, 615, 625 Tracheostomy, 539 Transcervical approach, 421 Transmuscular cordectomy, 175 Transoral laser microsurgery (TLM), 175 Transpalatal approach by palatal osteomucoperiosteal (POMP) flap, 356, 363 Type IIb supraglottic laryngectomy, 449 Type IIIb supraglottic laryngectomy, 449, 450 Type VI cordectomy, 176 U Uvulopalatopharyngoplasty (UPPP), 631 V V’ excision of lip, 230 VOTE classification, 627 V-Y advancement flap for cheek and alar defect, 235, 239 W Weber- Dieffenbach incision, 383 Weber-Fergusson incision, 364, 373, 374