Reconstruction of the Oral Cavity

1
Reconstruction of the Oral Cavity

• Michael Underbrink, M.D.
• Anna Pou, M.D.

2
Introduction

• Difficult challenge
• Complex anatomy and function
• Goals
• Restore preoperative function
• Cosmesis
• Patient status is important consideration
• Variety of reconstruction options

3
Anatomy

• Vermilion to junction of hard and soft palate
  superiorly
• Inferiorly to circumvallate papillae
• Structures lips, alveolar ridges, buccal
  mucosa, retromolar trigone, hard palate, floor of
  mouth, mobile tongue
• Functions speech, mastication, bolus
  preparation and initiation of deglutition

4
Functional Considerations

• Oral sphincter
• Speech, mastication and deglutition
• Provides a watertight closure for bolus
  preparation
• Prevents escape of saliva

5
Functional Considerations

• Alveolar Ridges
• Covered with thin, adherent mucosa
• Elevated above floor of mouth
• Lingual and buccal sulci direct the flow of food
  and saliva during bolus processing

6
Functional Considerations

• Floor of the mouth
• Allows unrestricted mobility of the oral tongue
• Collects food and saliva (bolus preparation)

7
Functional Considerations

• Oral (mobile) tongue
• Speech and deglutition
• Mobility allows for
• Articulation of speech
• Bolus manipulation in preparation for deglutition
• Sensory functions proprioception, pain, taste
• Assists in mastication and bolus processing

8
Functional Considerations

• Hard palate
• Opposes tongue
• Important for speech and bolus preparation

9
Functional Considerations

• Buccal Mucosa
• Lines the cheek
• Functions in mastication and deglutition
• Allows expansion for mastication
• Thin to avoid restriction of dental closure

10
Functional Considerations

• Base of tongue
• Often involved with oral cavity defects
• Participates in taste, deglutition and speech
• Must occlude oropharynx during deglutition
• Some consonants require BOT to touch hard palate

11
Patient Factors

• Individualize options
• Type of tissue
• Anticipated functional gain
• Anticipated donor morbidity
• Need for innervation
• Success rate
• Intraoperative positioning
• Operative time
• Dental restoration
• Overall medical status

12
Patient Factors

• Preoperative counseling
• Complete medical history
• Diabetes, atherosclerosis, previous radiation
• Cardiopulmonary status (operating time,
  aspiration risk)
• Smoking history
• Patient expectations and motivation are very
  important

13
Floor of Mouth Reconstruction

• Requires soft and mobile tissue
• Allow mobility of oral tongue
• Avoid scar contracture (i.e., secondary
  intention)
• Avoid bulk (glossoptosis, obliteration of lower
  lip sulcus)

14
Floor of Mouth Reconstruction

• Smaller defects
• Split thickness skin graft
• Harvest from lateral thigh at 0.017 in
• Provides water-tight closure, no hair
• Stabilize with bolster
• Survives over muscle and cancellous bone (via
  imbibition and neovascularization)
• Also good for lateral FOM and retromolar trigone

15
Floor of Mouth Reconstruction
16
Floor of Mouth Reconstruction

• Moderate defects involving a larger portion of
  mylohyoid
• Nasolabial flap
• Based on angular artery
• Better for older patients with lax skin
• Requires two stages and temporary fistula
• Bite block necessary

17
Floor of Mouth Reconstruction
18
Floor of Mouth Reconstruction

• Moderate defects (continued)
• Regional flaps
• Forehead flap (rarely used)
• Platysma flap
• Facial artery musculomucosal flap (FAMM)
• Deltopectoral flap (historical significance)

19
Floor of Mouth Reconstruction

• Forehead flap
• Superficial temporal artery
• Reliable 2/3 across the forehead
• Tunneled into cheek below zygoma
• Requires orocutaneous fistula
• Obvious donor site (skin graft)
• Second stage to inset flap

20
Floor of Mouth Reconstruction

• Submental artery island flap
• Thin, supple skin
• Submental branch of facial artery
• Primary closure of donor site
• Poor reliability if
• Facial artery sacrificed
• Irradiated necks

21
Floor of Mouth Platysma Flap Reconstruction
22
Floor of Mouth Reconstruction

• FAMM flap
• Branch of facial artery
• Contains mucosa, buccinator muscle, and fat
• 2 x 8 cm flap without injury to facial nerve

23
Floor of Mouth Reconstruction
24
Floor of Mouth Reconstruction

• Deltopectoral Flap
• Axial distant flap
• First four perforators of internal mammary
• Deltoid portion is random
• Preliminary delay procedure
• Creates dependent orocutaneous fistula

25
Floor of Mouth Reconstruction

• Fasciocutaneous free flaps
• Thin nature and pliability
• Radial forearm has low incidence of failure to
  this site
• Provides tongue mobility and free movement of
  food during deglutition

26
Floor of Mouth Reconstruction

• Radial forearm free flap
• Based on radial artery
• Outflow two venae comitantes, basilic vein,
  cephalic vein
• Long vascular pedicle with dependable supply
• Potential sensation (posterior cutaneous nerve
  anastomosed to lingual)
• Disadvantage donor site morbidity (STSG,
  potential loss of thumb and index finger,
  potential decreased forearm function)

27
Floor of Mouth Reconstruction
28
Anterior Tongue Reconstruction

• Very difficult to reconstruct
• Complex intrinsic musculature and function
• Redundancy is advantageous
• Near hemiglossectomy does not significantly alter
  function

29
Anterior Tongue Reconstruction

• Defects lt50 can be closed primarily /- STSG
• Larger or composite defects require more bulk
  (i.e, fasciocutaneous free flap)
• Lateral arm free flap is good for defects
  including posterior aspect of tongue/FOM

30
Anterior Tongue Reconstruction
31
Anterior Tongue Reconstruction
32
Anterior Tongue Reconstruction

• Lateral Arm free flap
• Posterior radial collateral artery
• Paired venae comitantes
• 12 x 18 cm paddle possible (6 x 8 cm allows for
  primary closure)
• Potential sensate flap (posterior cutaneous
  nerve)
• Disadvantages donor site appearance, hair
  growth, elbow pain, lateral forearm numbness

33
Anterior Tongue Reconstruction
34
Buccal Cavity Reconstruction

• Small defects primary closure possible
• Larger superficial defects
• Quilted skin/mucosal grafts
• Temporoparietal fascial flap (STSG for lining)
• Large full-thickness defects
• Pectoralis major myocutaneous flap
• Latissimus dorsi myocutaneous flap
• Fasciocutaneous free flaps

35
Buccal Cavity Reconstruction
36
Mandibular Reconstruction

• Goals
• Reconstitute mandibular continuity
• Allow for future dental restoration
• Anterior defects
• Worst functional defects
• Andy Gump deformity
• Lateral defects
• Easier to reconstruct
• Less functional problems

37
Mandibular Reconstruction

• Fibula osseocutaneous free flap ideal for
  anterior defects (minimal soft tissue defect)
• Based on peroneal vessels
• Multiple osteotomies allowable (for contouring)
• 25 cm of bone available (entire defects)
• Sensate (lateral cutaneous nerve)
• Reliable for osseointegrated dental implants

38
Fibula Free Flap
39
Fibula Free Flap
40
Mandibular Reconstruction

• Scapular free flap for anterior defects with
  massive soft tissue loss (i.e., total
  glossectomy)
• Circumflex scapular artery and vein
• 14 cm of bone available (lateral aspect)
• Allows osseointegrated implants
• Long pedicle to axillary artery
• Multiple fasciocutaneous/musculocutaneous flaps
  available (scapular, parascapular, latissimus
  dorsi, serratus anterior)
• Major drawback patient positioning

41
Scapula Free Flap
42
Mandibular Reconstruction

• Lateral mandible defects
• Regional/Distant/Free flap with mandibular swing
• Low profile reconstruction plate with soft tissue
  coverage
• Patient factors which prevent dental restoration
• Plate exposure rate of about 5
• Compared to anterior exposure rate near 20
• Osseocutaneous free flaps (iliac, scapular,
  fibula)

43
Mandibular Reconstruction
44
Mandibular Reconstruction

• Iliac crest free flap for lateral defects
• Internal oblique musculature included
• Contour similar to native mandible
• Reliable for osseointegrated implants
• Deep circumflex iliac artery
• Disadvantages (difficult harvest, donor site
  deformity, abdominal weakness, postoperative
  hematoma, lateral thigh pain/anesthesia)
• Split inner cortex modification reduces morbidity

45
Mandibular Reconstruction
46
Mandibular Reconstruction
47
Special Considerations

• Total Glossectomy Defects
• Often accompany oral cavity defects with
  extensive disease
• Require bulk for reconstruction
• Goals
• Direct secretions laterally
• Provide contact of neo-tongue with palate
• Use flaps which will not atrophy over time
• Palatal drop prosthesis

48
Special Considerations

• Total Glossectomy Defects
• Rectus abdominis free flap
• Inferior and superior epigastric arteries
• Motor nerve (intercostal) anastomosis retains
  bulk
• Latissimus dorsi myocutaneous free flap
• Thoracodorsal artery
• Motor nerve (thoracodorsal)
• Pedicled flaps (PMMF, latissimus dorsi)

49
Special Considerations

• Total glossectomy with laryngeal preservation
• Select patients
• Good health without cardiopulmonary disease
• Can tolerate aspiration
• Disease does not involve valleculae or
  preepiglottic space
• Must maintain intact superior laryngeal nerve
• Laryngeal suspension lessens aspiration

50
Decision Making in Oral Cavity Reconstruction
Defect Type
Bone
Soft Tissue
Floor of Mouth
Tongue
Buccal Mucosa
Superficial Primary Closure Skin/Mucosal
Grafts Full Thickness Regional
Flaps Fasciocutaneous Free Flaps Large Full
Thickness Fasciocutaneous Free Flaps Pedicled
musculocutaneous flaps
Anterior Defect
Lateral Defect
Osseocutaneous free flaps
Regional/Distant Flap and Mandibular
Swing Reconstruction Plate and Regional/Distant
Flaps Osseocutaneous Free Flaps
Small STSG Moderate Regional Flaps Fasciocutaneous
Free Flaps Large Pedicled Fasciocutaneous
flap Fasciocutaneous free flaps
lt50 Loss Primary Closure Skin Graft Combined
Defects Fasciocutaneous free flaps Total
Glossectomy Myocutaneous free flaps Pedicled
musculocutaneous flaps
51
Conclusion

• Multitude of reconstructive options
• Remember functional characteristics of tissue
  involved
• Various patient factors to consider
• Preoperative counseling essential
• High success rates possible with proper patient
  selection

52
References

• Fong BP, Funk GF. Osseous free tissue transfer
  in head and neck reconstruction. Facial Plast
  Surg. 1999 15(1) 45-59
•  
• Liu R, Gullane P, Brown D, Irish J. Pectoralis
  major myocutaneous pedicled flap in head and neck
  reconstruction retrospective review of
  indications and results in 244 consecutive cases
  at the Toronto General Hospital. J Otolaryngol.
  2001 Feb 30(1) 34-40
•  
• Abemayor E, Blackwell KE. Reconstruction of soft
  tissue defects in the oral cavity and oropharynx.
  Arch Otolaryngol Head Neck Surg. 2000 Jul
  126(7) 909-12
•  
• Berenholz L, Kessler A, Segal S. Platysma
  myocutaneous flap for intraoral reconstruction
  an option in the compromised patient. Int J Oral
  Maxillofac Surg. 1999 Aug 28(4) 285-7
•  
• Burkey BB, Coleman JR Jr. Current concepts in
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  North Am. 1997 Aug 30(4) 607-30
•  
• Wells MD, Edwards AL, Luce EA. Intraoral
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  1995 Jan 22(1) 91-108
•  
• Hausamen JE, Neukam FW. Resection of tumors in
  tongue, floor of the mouth, and mandible
  possibilities of primary reconstruction. Recent
  Results Cancer Res. 1994 13425-35
•  
• Boyd JB. Use of reconstruction plates in
  conjunction with soft-tissue free flaps for
  oromandibular reconstruction. Clin Plast Surg.
  1994 Jan 21(1) 69-77
•  
• Yousif NJ, Matloub HS, Sanger JR, Campbell B.
  Soft-tissue reconstruction of the oral cavity.
  Clin Plast Surg. 1994 Jan 21(1) 15-23