Disclosures. The Expanding Role of Microvascular Reconstruction. Overview. Things they are a Changing. Surgical Advisory Board, Genentech Corp

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and TORS are reducing the need for luminal/pharyngeal reconstruction HPV related oropharynx rarely needs reconstruction Prevalence of smoking is decreasing At the same time, Free flap success rates

1 Disclosures Surgical Advisory Board, Genentech Corp The Expanding Role of Microvascular Reconstruction P. Daniel Knott, MD FACS Associate Professor Director, Facial Plastic and Reconstructive Surgery UCSF Medical Center Oto Update 2013 San Francisco November, 2013 Things they are a Changing Overview ELM and TORS are reducing the need for luminal/pharyngeal reconstruction HPV related oropharynx rarely needs reconstruction Prevalence of smoking is decreasing At the same time, Free flap success rates are >98% Technology has significantly improved Two team concept shortens operative times ALT Flap: The game-changer Tongue reconstruction Pharynx reconstruction Early stage ORN Scalp reconstruction Contour restoration Midface Reconstruction Dental rehabilitation 1. Suh et al. Arch OtoHNS 2004 Aug. 2. Nuara et al. Arch FPS 2009 July. 3. CC Advances

What do we do well? Where do we fall short?

Noticeable scar on forearm with skin graft scar Need for immobilization

non-dominant hand for harvest Need a tourniquet (you are on the clock)

2 What do we do well? Where do we fall short? First Face Transplant in US What s wrong with the Forearm? Noticeable scar on forearm with skin graft scar Need for immobilization Sacrifice of 1 of only 2 arteries to the hand Need to organize OR around non-dominant hand for harvest Need a tourniquet (you are on the clock) Veins often damaged by successive venotomies Need for pre-op vascular testing Potential for neurosensory deficits 7 2

Anterolateral thigh flap (Song 1984) The Game The Changer Cost benefit analysis Perforator flap Versatile flap with minimal donor site morbidity

shape No tourniquet Vessels pristine Wong et al. Anterolateral Thigh Flap. Head & Neck.

001 Follow Up in Months (Range) Flap Size in cm 2 (Range)* Primary Closure N (%) Flap Failure N (%) ALT (n = 113) RFF (n = 113) 12 (1-42) 21 (1-64)

3 Anterolateral thigh flap (Song 1984) The Game The Changer Cost benefit analysis Perforator flap Versatile flap with minimal donor site morbidity Vascularized skin, fat, fascia, muscle Ample skin, linear closure Optimal two team site Allows near complete harvest without committing to size or shape No tourniquet Vessels pristine Wong et al. Anterolateral Thigh Flap. Head & Neck. April Fasciocutaneous Donor Site Morbidity Fasciocutaneous Donor Site Morbidity *p<0.001 Follow Up in Months (Range) Flap Size in cm 2 (Range)* Primary Closure N (%) Flap Failure N (%) ALT (n = 113) RFF (n = 113) 12 (1-42) 21 (1-64) 113 (8-375) 55 (6-198) 110 (97) 0 (0) 0 (0) 0 (0) Complication Wound Dehiscence* *p<0.001 ALT Number of Patients (%) RFF Number of Patients (%) 6 (5) 34 (30) Tendon Exposure N/A 16 (14.1) Seroma 6 (5) 2 (1.7) Hematoma 0 (0) 1 (1) Infection 2 (1.7) 3 (2.6) Total* 12 (12.3) 40 (35.4) 3

4 Reconstructive Trends 16 4

5 5

6 Voice Results: ALT v. RFFF 22 Voice Results: ALT v. RFFF 23 6

7 Prese ntatio Prese ntatio Prese ntatio 7

8 Infrastructure Maxillectomy Vascularized fat/fascia ALT flap Minimal donor site morbidity No atrophy Remucosalizes Maintains contour Prese ntatio Prese ntatio 8

Success of microvascular head and neck reconstruction

access approaches Peter C. Revenaugh, MD 1 ; Michael A.

Daniel Knott, MD 1 Presented, American Academy of

9 Success of microvascular head and neck reconstruction using small caliber anastomotic vessels and minimal access approaches Peter C. Revenaugh, MD 1 ; Michael A. Fritz, MD 1 ; Timothy C. Haffey, MD 1, P. Daniel Knott, MD 1 Presented, American Academy of Facial Plastic and Reconstructive Surgery, San Francisco, CA September,

Recipient Vessels Superficial Temporal Vessels Distal Facial Vessels

4 55.2 Gender (%female) 38% 36% Radiation therapy (pre or

3 107 Mean hospital length of stay (days) 5.8 6.

10 Recipient Vessels Superficial Temporal Vessels Distal Facial Vessels Vascularized Fascia Lata Number of flaps Mean age (range) Gender (%female) 38% 36% Radiation therapy (pre or post-operatively) 30% 42% Mean flap size (cm 2 ) Mean hospital length of stay (days) Post-operative facial nerve branch weakness 1 1 Flap loss 1 (total) 1 (partial) Fascia Lata for Scalp Reconstruction 40 10

11 41 11

$Exposed necrotic bone Pathologic fracture$ Fistula and infection Intractable pain Stage 1

asymptomatic, no infection Exposed necrotic

$bone, pathologic fracture, extraoral fistula,$ osteolysis extending to inferior mandible

Rigid + Surgical plate fixation debridement

12 Osteoradionecrosis (ORN) Osteoradionecrosis Exposed necrotic bone Pathologic fracture Fistula and infection Intractable pain Stage 1 Stage 2 Stage 3 Clinical Features Exposed bone, asymptomatic, no infection Exposed necrotic bone, symptomatic, infection Stage 2 + advanced disease complication (necrosis beyond alveolar bone, pathologic fracture, extraoral fistula, osteolysis extending to inferior mandible border) Recommended Treatment Oral antibiotic rinses (0.12% chlorhexidine)? + Oral antibiotic Segmental mandibulectomy + Rigid + Surgical plate fixation debridement without osseous reconstruction Photo from Marx RE, J Oral Maxillofac Surg 2009 ALT for Moderate ORN 12

Vascularized Nasal Lining Total or near-total nasal defect

layers: Internal nasal lining Subcutaneous cartilaginous and

most challenging layer to reconstruct Roles: Vascularized

13 Vascularized Nasal Lining Total or near-total nasal defect reconstruction is challenging Juxtaposed re-creation of nasal layers: Internal nasal lining Subcutaneous cartilaginous and bony nasal framework External skin covering Lining : Typically most challenging layer to reconstruct Roles: Vascularized surface to support nasal framework Allow for functional nasal airway 13

Vascularized Nasal Lining Free tissue transfer and nasal lining 1-3 Fasciocutaneous

- Flap thickness > - Redundant material needs repetitive debulking > - Harvest site

2) Walton RL, Burget GC, Beahm EK. Plast Reconstr Surg. Jun 2005.

14 Vascularized Nasal Lining Free tissue transfer and nasal lining 1-3 Fasciocutaneous free flaps effectively used for large defects Radial forearm free flap Limitations: > - Flap thickness > - Redundant material needs repetitive debulking > - Harvest site morbidity Vascularized Nasal Lining 1) Menick FJ. Plast Reconstr Surg. Oct ) Walton RL, Burget GC, Beahm EK. Plast Reconstr Surg. Jun ) Moore EJ, Strome SA, Kasperbauer JL, et al. Dec Vascularized Nasal Lining Vascularized Nasal Lining

15 Vascularized Nasal Lining Vascularized Nasal Lining Vascularized Nasal Lining Vascularized Nasal Lining

16 Brown Classification Brown JS and Shaw RJ, Reconstruction of the maxilla and midface: introducing a new classification, Lancet Oncol 2010;11:

17 Fibula Free Flap 17

18 18

19 19

20 Dental Rehabilitation Very few patients undergoing microvascular osseous mandible reconstruction undergo dental rehabilitation Very expensive Rarely covered by insurance Rehabilitation is even more important for edentulous patients Requires multiple stages with skin paddle thinning, vestibuloplasty, post placement, removal of hardware

21 The Future Composite Tissue Allotransplantation? Microvascular bioreactors? Thank you very much for having me Stem cell + tissue engineering? Knott: Facia 21

Fascia Lata Free Flap Reconstruction of Limited Hard Palate Defects

Open Access Original Article DOI: 10.7759/cureus.2356 Fascia Lata Free Flap Reconstruction of Limited Hard Palate Defects Rhorie P. Kerr 1, Andrea Hanick 1, Michael A. Fritz 1 1. Head and Neck Institute,