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 2005-2010 1
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 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 2010 10 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
Reconstructive Trends 16 4
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Voice Results: ALT v. RFFF 22 Voice Results: ALT v. RFFF 23 6
Prese ntatio Prese ntatio Prese ntatio 7
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 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, 2011 9
Recipient Vessels Superficial Temporal Vessels Distal Facial Vessels Vascularized Fascia Lata Number of flaps 42 54 Mean age (range) 67.4 55.2 Gender (%female) 38% 36% Radiation therapy (pre or post-operatively) 30% 42% Mean flap size (cm 2 ) 131.3 107 Mean hospital length of stay (days) 5.8 6.5 Post-operative facial nerve branch weakness 1 1 Flap loss 1 (total) 1 (partial) Fascia Lata for Scalp Reconstruction 40 10
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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 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 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 1998. 2) Walton RL, Burget GC, Beahm EK. Plast Reconstr Surg. Jun 2005. 3) Moore EJ, Strome SA, Kasperbauer JL, et al. Dec 2003. 54 Vascularized Nasal Lining Vascularized Nasal Lining 55 56 14
Vascularized Nasal Lining Vascularized Nasal Lining 57 58 Vascularized Nasal Lining Vascularized Nasal Lining 59 60 15
Brown Classification Brown JS and Shaw RJ, Reconstruction of the maxilla and midface: introducing a new classification, Lancet Oncol 2010;11: 1001-08. 16
Fibula Free Flap 17
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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 77 80 20
The Future Composite Tissue Allotransplantation? Microvascular bioreactors? Thank you very much for having me Stem cell + tissue engineering? Knott: Facia 21