Reconstruction of the Head and Neck
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Reconstruction of the Head and Neck A Defect-Oriented Approach
Eric M. Genden, MD, FACS Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York
Illustrations by Scott M. Kessler, MD
Thieme New York • Stuttgart
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Thieme Medical Publishers, Inc. 333 Seventh Ave. New York, NY 10001 Executive Editor: Timothy Hiscock Managing Editor: J. Owen Zurhellen IV Editorial Assistant: Elizabeth Berg Editorial Director, Clinical Reference: Michael Wachinger Production Editor: Barbara A. Chernow International Production Director: Andreas Schabert Senior Vice President, International Marketing and Sales: Cornelia Schulze Vice President, Finance and Accounts: Sarah Vanderbilt President: Brian D. Scanlan Illustrator: Scott M. Kessler, MD Compositor: Toppan Best-set Premedia Ltd. Printer: Leo Paper Group Library of Congress Cataloging-in-Publication Data Genden, Eric M. Reconstruction of the head and neck : a defect-oriented approach / Eric M. Genden ; illustrations by Scott M. Kessler. p. ; cm. Includes bibliographical references and index. ISBN 978-1-60406-576-3 I. Title. [DNLM: 1. Head–surgery. 2. Neck–surgery. 3. Reconstructive Surgical Procedures–methods. 4. Surgical Flaps. WE 705] 617.5′1059–dc23 2011049355 Copyright © 2012 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage. Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are encouraged to confirm the information contained herein with other sources. For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Printed in China 54321 ISBN 978-1-60406-576-3 EISBN 978-1-60406-577-0
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I dedicate this book to my patients and their families. It is my hope and expectation that this book will assist surgeons and surgeons in training to restore their patients to enjoy the quality of life they deserve. I also dedicate this book to my wife, Audrey, and my children, Eric Jr., Sophia, and Isabelle, for their support and love.
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Contents
Foreword by Richard E. Hayden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Biographies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Chapter 1: Oral Cavity Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Eric M. Genden, William Lawson, Andrew Sikora, Andrew Kleinberger, Vijay Mukhija, and Mark K. Wax Chapter 2: Oromandibular Complex Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Eric M. Genden Chapter 3: Palatomaxillary Complex Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Eric M. Genden Chapter 4: Cheek and Neck Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Stephen M. Weber, Mark K. Wax, and Eric M. Genden Chapter 5: Pharynx, Cervical Esophagus, and Hypopharynx Reconstruction . . . . . . . . . . . . . . . . . . . . . 92 Matthew Old and Theodoros N. Teknos Chapter 6: Skull Base Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 K. Kelly Gallagher, John R. de Almeida, Eric M. Genden, and Douglas B. Chepeha Chapter 7: Scalp Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Vivek V. Gurudutt and Eric M. Genden Chapter 8: Management of the Paralyzed Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Eric M. Genden Chapter 9: Pediatric Head and Neck Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Eric M. Genden and Marita Teng Chapter 10: Microvascular Reconstruction of the Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Brett A. Miles Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 vii
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Foreword
The evolution over the past four decades of head and neck reconstructive surgery began with a revolution in flap surgery. Any surgeons who had witnessed the plight of patients with large and complex defects of the head and neck before the “modern era” would agree that there was a need for change. There may, however, be some disagreement over the exact advent of the “modern era” of head and neck reconstruction. A few might feel that it began when Seidenberg reconstructed a total laryngopharyngectomy defect with a vascularized jejunal segment in 1959. That was indeed a milestone, but failed to translate into wide application for many years, even for this specific defect. Some would credit McGregor in 1963 and Bakamjian in 1965 with ushering in the modern era with the introduction of the first reliable axial pattern skin flaps from the forehead and shoulder respectively. These flaps were indeed used extensively by head and neck surgeons in the 1960s and 1970s for a wide variety of defects, but usually failed to duplicate the missing tissue. Others would cite Buncke’s microvascular transfer of omentum to cover a large full thickness scalp defect in 1972. Most historians would mention Taylor and Daniels. In 1973, their transfer of a microvascular free cutaneous groin flap to the sacral area was a watershed event in reconstructive surgery. The first application of a free cutaneous flap to the head and neck occurred in 1975 when Panje et al used a free groin flap for tongue reconstruction. Few would disagree that the predictable and reliable reconstruction of the mandible began in 1978 when Taylor demonstrated that the original free cutaneous flap—the groin flap—was incapable of successfully carrying iliac bone on its superficial circumflex iliac arterial pedicle. Instead he showed that the deep circumflex iliac arterial pedicle supplied the iliac crest and would carry the overlying skin in a predictable fashion. At that time, very few head and neck surgeons were performing microvascular free flaps, and the introduction of the pedicled pectoralis major flap a year later in 1979 did little to swell the ranks of free flap surgery advocates. As both a spectator and a participant in this change, I believe that the modern era could not be declared before the
majority of the head and neck surgeons were critically employing the wide spectrum of available modern surgical options. As such, I see this modern revolution in head and neck reconstructive surgery as akin to any social revolution. First, there is the idea and innovation phase. This is where the aforementioned authors and their contributions fall. There follows a debate phase, during which the original ideas are expanded and new ideas added. During the 1980s, a flood of new flaps were introduced. Every revolution has a phase of conflict. The 1980s and the early 1990s were a contentious period, when many surgeons clung tenaciously to specific flaps or reconstructive techniques often at the expense of progress. For years, the head and neck surgical community was split between the practitioners who utilized all available flaps but usually favored free tissue transfer and those who used pedicled musculocutaneous flaps for every reconstruction. All revolutions have a resolution when the phase of conflict winnows out the ideas that have the most traction. By the early 1990s, this had happened with head and neck reconstruction. Free tissue transfer offered the closest match of donor tissues with those missing in the head and neck defect. Consensus was established on a relatively small number of flaps and grafts. Then the inevitable overshoot happened, as happens in all revolutions. By 2000, we started to see, in some centers, complex microvascular free tissue transfer being employed to reconstruct small defects that could have been equally or in some cases even better repaired with simple local or regional flaps or even, in rare cases, healing by secondary intention. I am honored to write this foreword for Reconstruction of the Head and Neck: A Defect-Oriented Approach. Professor Eric M. Genden ranks as one of today’s foremost head and neck surgeons. Not only is he accomplished in conventional diagnostic and ablative techniques in the head and neck but he is also on the cutting edge of new and developing surgical strategies, such as transoral and robotic surgery. As a role model for the modern head and neck surgeon, Dr. Genden is equally facile as a reconstructive surgeon. He is accomplished in today’s conventional reconstructive techniques, microvascular free tissue transfer, and the still important
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Foreword local and regional flaps, while being an innovator exploring new strategies for reconstruction, such as transplantation and tissue engineering for tracheal replacement. Above all, he is a superb educator. This book is abundant evidence of his dedication to teaching. It is a superb addition to the literature and very timely. The current frontline techniques for dealing with defects of the head and neck are presented in a clear, concise and well-organized fashion. The reader is prompted to approach the repair of each defect with a graduated mindset from simple to complex. This book can serve
as a reference for the resident and the practitioner, for every surgeon who wants to perform head and neck surgery. Dr. Genden makes a great contribution to head and neck reconstructive surgery with this book. Richard E. Hayden, MD Professor and Chair Department of Otolaryngology–Head and Neck Surgery Mayo Clinic Arizona
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Preface
Reconstruction of the head and neck requires a profound understanding of the anatomy, physiology, and function of the upper aerodigestive system. The relationship between form and function makes reconstruction of the head and neck a unique challenge. This book is written as a defectoriented guide to reconstruction. Each chapter is devoted to a region of the head and neck. The chapters are further organized by specific defect, so that the reader can identify a defect and explore the reconstructive options. The approaches to reconstruction are covered in detail and are
designed to review the fine points that are often not addressed in general reconstructive texts. The order of events, the orientations of the flap, and the details that confer excellent functional and aesthetic results are covered in each section for each defect. Achieving optimal results in head and neck reconstruction requires attention to function and form. We hope this book will serve as a guide for the reconstructive surgeon and provide the finer points essential to achieving excellent longterm results.
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Biographies
Eric M. Genden, MD, is a graduate of Columbia University and the Mount Sinai School of Medicine, New York, New York, where he completed his degree with a distinction in Research. He then completed residency training in otolaryngology–head and neck surgery at Washington University, Barnes Hospital St. Louis, Missouri, and then completed fellowship training in head and neck oncology and microvascular surgery at The Mount Sinai Medical Center, New York, New York. Dr. Genden is nationally recognized as one of the country’s top head and neck cancer surgeons and is regularly listed as one of America’s Top Head and Neck Surgeons and America’s Leading Cancer Surgeons. His expertise in management of oral cancer and microvascular reconstruction of the head and neck has contributed to the national reputation for excellence at Mount Sinai Hospital. Dr. Genden has published more than 150 manuscripts and chapters and is the author/ editor of this book and two others: Head and Neck Cancer: A Multidisciplinary Approach and Free Flap Surgery.
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Scott M. Kessler, MD, is a Board Certified Otolaryngologist in private solo practice in New York, New York. He has been on the Attending Staff at Mount Sinai Medical Center, New York, for the past 28 years. He earned his medical degree at the Mount Sinai School of Medicine, and following a surgical internship at the Barnes Hospital in St. Louis, Missouri, he completed his residency in Otolaryngology at Mount Sinai Hospital in New York. He specializes in Care of the Professional Voice, and his patients include a wide diversity of performing artists from all aspects of theater, broadcasting, and the entertainment recording industry. He has lectured locally and internationally, and has been featured in journals, on radio and television, and in several documentary films as a prominent expert in the field of Performing Arts Medicine. Dr. Kessler’s interest in medical illustration began in medical school, where he drew for his professors and research fellows for journals. During his residency, his illustrations were published in hundreds of articles, and since then his work has appeared in textbooks, monographs, and journals. In addition to his detailed pen-and-ink drawings, he also enjoys painting large abstract-expressionist canvases and oversize botanical acrylics.
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Contributors
Douglas B. Chepeha, MD, MPH Department of Otolaryngology Microvascular Program University of Michigan Health System A. Alfred Taubman Health Care Center Ann Arbor, Michigan John R. de Almeida, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York K. Kelly Gallagher, MD Department of Otolaryngology University of Michigan Health System A. Alfred Taubman Health Care Center Ann Arbor, Michigan Eric M. Genden, MD, FACS Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York Vivek V. Gurudutt, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York Andrew Kleinberger, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York William Lawson, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York
Brett A. Miles, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York Vijay Mukhija, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York Matthew Old, MD, FACS Department of Otolaryngology–Head and Neck Surgery Ohio State University Medical Center Columbus, Ohio Andrew Sikora, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York Theodoros N. Teknos, MD Department of Otolaryngology Ohio State University Eye and Ear Institute Columbus, Ohio Marita Teng, MD Department of Otolaryngology–Head and Neck Surgery Mount Sinai School of Medicine New York, New York Mark K. Wax, MD, FACS Department of Otolaryngology–Head and Neck Surgery Oregon Health & Science University Portland, Oregon Stephen M. Weber, MD, PhD Lone Tree Facial Plastic and Cosmetic Surgery Center Lone Tree, Colorado
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