Atlas of Regional and Free Flaps for Head and Neck Reconstruction: Flap Harvest and Insetting

549 Pages·2011·132.66 MB·English

by  Mark L. Urken et al.

-
OIF
~ TLAS

Second Edition
ATLAS OF
Regional and Free Flaps for
Head and Neck Reconstruction:
Flap Harvest and Insetting

Mark L. Urken, MD, FACS Keith E. Blackwell, Mo
Professor Prafessor
Department of OtominolaryngoloiJ'f---Haad and Neck Surgery Diviaion af Head and Neck Surgery
Albert Einstein College of Medicine Department af Surgery
Chief of Head and Neck Surgical Oncology David Geffen School of Medicine
Continuum Cancer Cantars of New Yorlt University of Caltfornia, Loa Angeles
Division of Head and Neck Surgery Director
Department of OtDiaryngology Head and Neck Surgery SaJVica
Beth Israel Medical Center Department of Surgery
Ronald Reagan UCLA Medical Center
New York. New York
Loa Angelea, California
Mack L. Cheney, MD
Jeffrey R. Harris, MD FRCS (C)
Professor
Department of Otolaryngology-Head and Neck Surgery Associate Prafessor
HalYard Medical School Department of Surgery
Director of Facial Plastic and Reconatructive Surgery Division of Otolaryngology-Head and Neck Surgery
Department of Otolaryngology-Head and Neck Surgery University of AI be rta
MassachusettJ Eya and Ear Infirmary
Chief
Boii1Dn, MaaaachusetiB Department of Otolaryngology-Head and Neck Surgery
Neal Futran, MD, DMD University of Alberta Hospital
EdmoniDn, Alberta
Profassor and Chair of OtDiaryngology-HNS
Canada
Director af Head and Neck Surgery
Univeraity of Wuhington
Seatlla, W11hington Forewsrdby
Tessa Hadlock, MD Shan R. Baker, MD
Director
Facial Ne!Ve Center
Illustrator
Department of OtDiaryngology-Head and Neck Surgery
MaaaachuaetiB Eye and Ear Infirmary Sharon Ellis
Aaaociate Professor New York. New York
HalYard Medical School
BolltDn, MaaaachusetiB
I
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Library of Congress Cataloging-in-Publication Data
Atlas of regional and free flaps fur head and neck reconstruction: flap harvest and insetting I Mark L Urken ... [et al.); illustrator,
Sharon Ellis. - 2nd ed.
p.;cm.
Includes bibliographical references and index.
ISBN 978-1-60547-972-9
1. Head-smgery-Atlases. 2. Neck-surgery-Atlases. 3. Flaps (Smgery)-Atlases. 4. Surgery, Plastic-Atlases. I. Urken,
Mark L, 1954-
[DNLM: 1. Head-surgery-Atlases. 2. Neck-surgery-Atlases. 3. Surgery, Plastic-Atlases. 4. Surgical Flaps-Atlases.
WE 17]
RD52l.A846 2012
617. 5' 1 00223-dc23
2011022763
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9 8 7 6 5 4 3 2 1
Dedication
To Laura, for the countless ways that she has enriched my life and whose endless
love and devotion provide the fuel for all of my professional endeavors.
To Gabrielle, Grant and Hannah who provide me with indescribable joy on a daily
basis and are the source of great pride for the remarkable individuals that they have
become.
To the Board of Directors of the Thane Foundation that has provided generous
support and placed their faith in me to fight thia cruel disease in novel ways that could
not be accomplished without them.
To the Levy, Lane, Dawson and Plaut families who have always gone the extra mile
to provide their extraordinarily generous suppon that was critical to achieving success
in ao many of the initiatives of the Thane foundation.
To Elliot, for his friendship and suppon, and for putting his faith in me to help him
to combat a devutating illness, and which he has done with grace and courage.
Finally, to my fellows and residents, who have endured long hours in the operating
room and helped to provide the highest level of patient care.
Marie L Urletm
To Paul.
Mack L Cheney
To Paul Ward, MD and Mark Urken, MD for their mentonhip and teaching, and to
my wife Julie and son Ryan, for their support and understanding.
Keith E. BlacktJJell
To aU my friends and fim:Wy for their ongoing support and especially to Jody,
Jacbon, and Mackenzie who continue to show me what is truly important in life.
Jeffrey R. Harrit
For Bruce, who I am so fortunate to share life with, and our children, Rob, Kent,
McKenzie, and Forrest.
'lbsa A. Haillock
To my wonderful wife Margi, and children Alaandra, Jordan, and Evan, whose love,
devotion, and constant suppon have allowed me to pursue this endeavor, and have
enriched my life beyond compare.
Neal Furran
v
Contributors
Keith E. Blackwell, MD Jeffrey R. Harris, MD FRCS (C)
Professor Associate Professor
Division of Head and Neck Surgery Deparbnent of Surgery
Department of Surgery Division of Otolaryngology-Head and Neck Surgery
David Geffen School of Medicine University of Alberta
University of California, Los Angeles Chief
Director Department of Otolaryngology-Head and Neck Surgery
Head and Neck Surgery Service University of Alberta Hospital
Department of Surgery Edmonton, Alberta
Ronald Reagan UCLA Medical Center Canada
Los Angeles. California
Arjun S. Joshi, MD
Mack L. Cheney, MD Assistant Professor
Professor Division of Otolaryngology-Head and Neck Surgery
Department of Omlaryngology-Head and Neck Surgery The George Washington University
Harvard Medical School Attending Physician
Director of Facial Plastic and Reconstructive Surgery Daparbnent of Surgery
Department of Omlaryngology-Head and Neck Surgery The George Washington University Hospital
Massachusetts Eye and Ear Infirmary Wahingmn, DC
Boston, Massachusetts
Robin W. Lindsay, MD
Neal D. Futran, MD, DMD Assistant Professor
Professor and Chalr of Otolaryngology-H NS Daparbnent of Surgery
Direcmr of Head and Neck Surgery Uniformed Services University of the Health Sciences
University of Washington Facial Plastic and Reconstructive Surgeon
Seattle, Washington Daparbnent of Otolaryngology-Head and Neck Surgery
National Naval Medical Centar
Allan M. Goldstein, MD
Bethesda, Maryland
Associate Professor of Surgery
Harvard Medical School Mark L. Urken, MD, FACS
Associate Visiting Surgeon Professor
Department of Pediatric Surgery Department of Otorhinolaryngology-Head and NeckS urgery
Massachusetts General Hospital Albert Einstein College of Medicine
Boston, Massachusetts Chief of Head and Neck Su11ical Oncology
Continuum Cancer Centers of New York
Tessa A. Hadlock, MD
Division of Head and Neck Surgery
Diracmr Department of Otolaryngology
Facial Nerve Centar Beth Israel Medical Canter
Department of Omlaryngology-Head and Neck Surgery New York, New York
Massachusetts Eye and Ear Infirmary
Associata Professor
Harvard Medical School
Boston, Massachusetts
vi
Foreword
D esearch in vascular surgery was markedly enhanced of the 1980s and 1990s brought many more surgical
~s a result of the work of Carrell and Guthrie in innovations and new microsurgical flap designs includ
the early 1900s in which they performed replantations ing such important ones as the scapular flap, fibula oste
and transplantations of several composite tissues. Hepa ocutaneous :flap, and the radial forearm flap.
rin was discovered in 1916.T he ability to control blood A number of regional flaps were coming into use
cloning was an essential step forward in the develop for head and neck reconstruction at the same time as
ment of microvascular surgery, as was the use of the the emergence of clinical microvascular surgery. Most
operating microscope that was initiated by Nylen and important was the pectoralis major myocutaneous :flap.
Holmgren for ear and eye surgery in the early 1920s at The use of microsurgical tissue transfer for reconstruc
the Karolinska Medical School in Stockholm, Sweden. tion of the head and neck was undoubtedly delayed
Jacobson and Suarez in 1960 wt:re the first to use the somewhat by the popularity of the pectoralis major
operating microscope to perform anastomoses of 3-mm myocutaneous flap and the belief that it represented the
arteries using 7-0 braided silk. Thus was bom microvas answer to virtually all of the reconstructive challenges
cular surgery. Technical improvements in microsurgi in head and neck reconstruction. The failure of the pec
cal instruments, suture, and the operating microscope, toralis major flap to reliably transfer vascularized bone
including coaxial illumination, motorized zoom, and for mandibular reconstruction and the difficulties in
binocular viewing enabled multiple surgeons to simul tubing this flap to reconstruct the pharyngoesophageal
taneously begin to investigate experimental extremity segment led to renewed interest in the role of free tissue
replantations throughout the world. transfer as a potential solution.
Success with replantations led to efforts to perform It was in the 1970s that otolaryngologists who per
reconstructive microvascular surgery. During the 1960s, formed reconstructive surgery, like myself, became
Buncke experimented with replanting and transplant interested in microvascular surgery. As a 2nd year house
ing tissues in laboratory animals. He developed many officer in the Department of Otolaryngology, Maxillo
important principles and techniques and is considered facial Surgery at the University of Iowa, William Panje,
by some to be the founding father of microvascular sur MD, traveled to New York to take a 1-week surgical
gery. The first reported experimental microsurgical skin course to learn the techniques of microvascular surgery.
flap transplantation was reported by Krizek and associ When he returned from the course, he was kind enough
ates. Abdominal skin baaed on the superficial epigastric to teach me the techniques. We dissected donor :flaps
vascular pedicle was successfully transferred in dogs. in cadavers and practiced anastomosing 1-mm blood
During the decade of the 1970s, there were numer vessels in rats. Once we were consistently successful in
ous advances in experimental microsurgical tissue trans anastomosing these small blood vessels, we attempted
fer and later in the decade, the emergence of clinical the transfer of a free groin flap based on the superficial
microvascular surgery. Although human tissue transfer circu.m:fla iliac artery and ~in to the anterior floor-of
was accomplished as early as 1957, when Sam and Sei mouth in order to repair a defect resulting from removal
denberg reconstructed an esophagus with a free jejunal of a large squamous cell carcinoma. The vascular pedi
segment, it was not unti11972 that the first human free cle was only 3 em in length. Much to our delight, the
skin flap transfer ofscalp tissue using microvascular sur flap survived and it was reported in 1975 as the world's
gery was reported by Harii and colleagues. A year later, first successful intraoral microsurgical flap. Bill and I
Daniel and Taylor reported the successful transfer of a were in our 3rd year ofr esidency at the time.W e contin
groin flap. The first revascularized fibular transfer was ued to perform other microsurgical reconstructive cases
reported byT aylor and colleagues in 1975.T he decades together during our senior year of residency at Iowa.
vii
VIII FOREWORD
In 1977, I completed my residency and began an a highly illustrated and in-depth discussion of both
academic career in the Department of Otolaryngol normal and abnormal anatomy of donor sites, the most
ogy-Head and Neck Surgery at the University of common designs of flaps, and their major applications
Michigan. At this time, there was concern among some for head and neck reconstruction. The book details the
head and neck surgeons that otolaryngologists were not surgical techniques of dissecting and transferring flaps,
being trained to perform microvascular surgery and potential pitfalls when harvesting flaps, and preopera
that this aspect of head and neck reconstruction would tive and postoperative surgical care. The Adas provides
be lost to our specialty. Dr. Krause, Chairman of the a comprehensive review of flaps used for head and
Department of Otolaryngology in Michigan, convened neck reconstruction and is divided into two pans. Part
an impromptu meeting of young academic otolaryngol I discusses regional flaps including muscle and mus
ogists with an interest in head and neck reconstruction culocutaneous and fascial and fasciocutaneous flaps.
at the fall meeting of the AAO-HNS in 1978. Attend An additional chapter explores the palatal island flap.
ees concluded that the most effective way of securing Part II deals with a large selection of microsurgical flaps
microvascular surgery as pan of the expertise of otolar and nerve graft donor sites. Photogmphs of detailed
yngologists was to teach young academic otolaryngolo flap dissections in fresh cadavers are supplemented with
gists the techniques of microvascular surgery and the beautiful anatomic illustrations. New to this edition and
anatomy of the various donor flaps. These individuals ofg reat value is the inclusion ofd etailed cadaveric dissec
could, in turn, teach fellows and house officers in their tions that show the insetting and orientation of flaps to
respective residency programs. The first microvascular reconstruct some of the most common defects encoun
training course for otolaryngologists was directed by tered by reconstructive surgeons. The book is a valuable
myself and Charles J. Krause, MD, in 1979 at the Uni and timeless contribution to the medical literature.
versity of Michigan. In 1989, I published the first text Microvascular surgery has revolutionalized head
book solely devoted to microsurgical aspects of head and neck reconstruction over the last three decades.
and neck reconstruction. Surgeons can replace missing segments of the mandi
Dominant among these early surgical leaders is Mark ble and maxilla with vascularized bone grafts in which
L. Urken, MD, who has had a prominent role in teach osteointegrated dental implants can be incorporated.
ing microvascular surgery to otolaryngologists through Patients undergoing partial or total glossectomy are
courses he conducts, the fellowship progmm he directs, reconstructed with innervated musculocutaneous flaps.
and textbooks he has written and edited. Young leaders Sophisticated techniques in transplanting skin, muscle,
such as those who have contributed to the second edi bone, mucous membrane, and nerve enable the head
tion of this outstanding adas continue to innovate and and neck surgeon to repair patients suffering from
expand the clinical applications of microsurgical recon great deformities and dysfunction as a result of soft tis
struction of the head and neck. sue and bony defects of the head and neck. The level
The second edition of the Atlas of Regional and Free of functional and aesthetic restoration of such patients
Flaps for Head and Neck Reconstruction represents the was not possible before the development of microvas
culmination of the experience and knowledge in micro cular surgery. This Atlas clearly provides an insight to
vascular and regional flap reconstruction of the head the impressive gains made in head and neck reconstruc
and neck gained over the last 30 years. The contem tion by enumerating and carefully describing the many
porary head and neck surgeon must have a thorough microsurgical and regional flaps available to the con
understanding of the anatomy of microvascular and temporary head and neck surgeon. It will be an invalua
regional flaps and their applications for head and neck ble resource for both the beginning and the experienced
reconstruction. They must also be familiar with the head and neck surgeon.
donor site morbidity resulting from their use. Micro
vascular surgery requires specialized surgical skills and Shan R. Baker, MD
detailed understanding of anatomy. This atlas provides Universi'ljl of Michigan