Reconstructive Surgery

INTRODUCTION

When it comes to head and neck surgery, nothing is more important than experience in the operating room. We also provide cutting-edge reconstructive surgery to preserve both form and function for our patients.

CAUSES FOR HEAD AND NECK RECONSTRUCTION

 

• Defects from cancer removal
• Defects from blunt or sharp trauma
• Chronic wounds
• Chronic infections
• Congenital defects

 

INDICATIONS FOR RECONSTRUCTION

 

• Restoration of Head and Neck Functions (vary by region)

• Watertight internal lining (mucosa)
• Oral continence
• Facilitated deglutition/swallowing
• Restore Mastication
• Restore sensation
• Protect vital structures
• Comprehensible speech
• Prevent aspiration
  • Restoration of Form – Symmetry – Facial features, preferably in a single stage

 

AREAS FOR RECONSTRUCTION

 

• Scalp
• Eyelids
• Nose
• Ears
• Lips
• Cheecks

 

SPECIALTIES INVOLVED

 

Head and neck reconstruction can be very complicated and requires close cooperation of all specialties involved. It’s a mission that requires a coordinated, patient-centered effort from a team of specialists:

These can include:

 

• Plastic surgery
• Head and Neck surgery
• ENT
• Head and Neck Oncology
• Radiation Oncology
• Speech Pathology
• Oral surgery
• Physical therapy and rehabilitation
• Prosthetic dentistry

 

PREOPERATIVE TESTING AND EVALUATION

 

Diagnostic tests can include:

 

• CT scan with 3D reconstruction
• MRI of head and neck
• Angiography of the vessels of the head and neck area
• Electromyography
• PET CT scan

 

LOCATION

 

Most of these procedures are performed in a hospital surgical suite. Because they can be very complicated quite often the initial recovery starts in the Intensive Care Unit.

 

ANESTHESIA

 

Anesthesia for most of the cases is General Anesthesia.

 

TREATMENT

 

Traditionally, many treatments for head and neck cancers have been devastating to self-image and dignity: surgeries that leave patients disfigured or unable to speak clearly, and radiation treatments that wither salivary glands and make eating and swallowing difficult. But new approaches, many established here, focus on preserving appearance, function and sense of self, without compromising a patient’s chances for cure.

We offer the very latest surgical and non-surgical options, including:

• Sentinel lymph node biopsy – surgically removing lymph node tissue to determine if cancer has spread
• Minimally invasive surgery
• Transoral Robotic Surgeryto access more difficult-to-see sites, such as the throat, reducing the need for open surgery
• Microvascular reconstructive surgery using free tissue transfer – borrowing tissue, muscle or bone from another part of the body to replace what was lost from jaws, cheeks, tongues and more due to tumor removal

Reconstructive strategies involve

• Split thickness and full thickness skin grafting
• Local random skin flaps (rhomboid flaps, advancement flaps, transposition flaps ,etc.)
• Local axial skin flaps (nasolabial flaps, Rintala flaps, Karapandjic flaps, etc)
• Local island skin flaps (submental flap)
• Local mucosal flaps (FAMM flap)
• Regional skin flaps (cervicofacial flaps)
• Regional muscle / myocutaneous flaps (temporalis muscle flap, pectoral muscle flap, trapezius flap, latissimus dorsi flap)
• Free skin flaps (radial forearm flap, anterolateral thigh flap)
• Free muscle flaps (rectus abdominis flap, gracilis muscle flap)
• Free bone flaps (fibula flap)
• Bone grafts
• Nerve grafts

Depending on the type of the reconstruction needed the duration of a head and neck reconstruction procedure may last from one hour to twelve hours (in case of a microsurgical procedure)

RECOVERY

Rehabilitation begins with a preoperative evaluation and assessment by surgeons, dentists, and speech and swallowing pathologists to look at teeth and evaluate swallowing. After surgery, we work closely with speech and language pathologists for voice and swallowing function rehabilitation. Most patients recover their normal swallowing function. Even when a voice box has to be removed there are ways to rehabilitate the voice to reproduce a normal human voice. Nutritionists and social workers are also available to you. Our team mission is to provide all the services needed to get you as close to your pre-tumor state as possible.

RISKS

• Hematoma
• Infection
• Partial Flap necrosis
• Full flap necrosis
• Wound dehiscence
• Oropharyngeal fistula
• Hardware extrusion
• Scarring
• Need for revision surgery

RESULTS

Once healing is completed the results are usually permanent. In some cases revision surgery is needed, mainly scar revisions.

 

CASE 1

LEGEND: 64 year old male with previous radiotherapy to the scalp of the head as a young boy in order to treat a dermatologic condition, developed recurrent squamous cell cancer. The patient underwent wide excision of the lesion and reconstruction with local scalp flaps (rotation flaps).

 

CASE 2

LEGEND: 68 year old female with squamous cell cancer of the forehead. The patient underwent wide excision of the lesion and reconstruction with combination of local scalp flaps (unilateral H-Flap and an advancement flap).

 

CASE 3

LEGEND: 72 year old female with squamous cell cancer of the left cheeck. The patient underwent wide excision of the lesion and reconstruction with a cervicofacial rotation advancement skin flap.

INTRODUCTION

The ears are important not only in normal daily functions such as hearing, but the play an important role in our cosmesis. Patients with abnormalities or deficits in their ears gain invaluable improvement with expertly performed ear reconstruction. Reconstruction of the ears present a particular challenge.

CAUSES

Surgery of the external ear is commonly performed by plastic surgeons for a variety of reasons. Many conditions can result in the need for ear repair:

• Congenital malformations
• Removal of cancerous lesions.
• Trauma – dog or human bites, “cauliflower ears”
• Burns
• Injury from Chemicals
• Chondritis (inflammation of the cartilage which deforms the ears)
• Previous surgery

 

CONSULTATION

 

The plastic surgeon will evaluate you in clinic to decide whether surgery is an appropriate solution to improve your quality of life. If it is necessary he will consult with an ENT or Head and Neck Surgeon. At the time of your visit, please be prepared to have pictures taken of you for both insurance purposes and surgical planning.

In addition to medically necessary solutions, some patients decide to take advantage of their reconstructive surgery to also effect aesthetic changes, like a otoplasty.

You will meet with one of our surgeons in clinic to be evaluated for ear reconstruction. Please be prepared to discuss your medical history, including past surgeries, present and past health problems, and medications. The surgeon will perform a general head and neck exam, which will include a detailed investigation of your inner and outer ear. After the assessment, the surgeon will discuss the optimal procedure with you in detail, answering any questions or concerns you may have.

If you are taking any blood thinners, you should discuss with the prescribing physician whether you should discontinue them in preparation for surgery.

 

PREOPERATIVE TESTS

 

Potential tests include:

 

• Audiology evaluation to be sure that hearing is intact
• Doppler studies to evaluate the integrity of the vessels supplying blood to the ear
• For significant trauma or large invasive tumors, consider imaging studies to exclude involvement of adjacent structures, orbit soft tissue, orbital bones, nose, sinuses, and zygoma.
• CT scan of orbits and sinuses is the best imaging modality when looking at bony involvement.
• MRI is the best imaging modality when looking at soft tissue involvement.

 

LOCATION

 

Ear reconstruction procedures should be performed in the sterile environment of a state of the art surgical suite. Most reconstructions are one day surgery cases not requiring hospitalization.

 

ANESTHESIA

 

The majority of our patients have general anesthesia during their procedures to ensure that they are unable to remember or feel the procedure. For smaller defects local anesthesia or sedation can be used.

 

SURGERY

 

There have been many advances in EAR reconstruction surgical techniques in recent years.

 

Simple superficial defects in the ear may occur after minor trauma or removal of small growths. Many of these require nothing more than local wound care and will heal on their own in a week to 10 days. Some simple superficial defects may require a few sutures with the same local wound care.

Reconstruction after Trauma

Probably the most common types of ear procedures involve trauma – usually a cut to the ear. Surgery involves the careful attention to detail in repairing the skin and/or cartilage involved. Healing of the cartilage depends on the presence of healthy skin and soft tissue overlying it. Without this, the cartilage becomes necrotic and will wither away. “Cauliflower ears” are a type of post-traumatic ear deformity that is often seen with wrestlers. This is caused by bleeding of ear between the cartilage and the skin. This blood collection clots and is transformed into dense scar tissue that causes the appearance of a “cauliflower.” These difficult surgeries involve the tedious removal of scar tissue and re-sculpturing of the ear cartilage and skin.

In nearly all cases of ear loss the missing part of the ear can be reconstructed using a variety of local skin flaps and if needed sculpted rib cartilage. In many of these more complex cases, the surgeon will need to use transfer of adjacent tissues (what we call ”flaps”), or transfer of skin from other parts of the face or body (what we call “skin grafts”) to complete the reconstruction.

 

When cartilage is needed a three dimensional framework of the missing segment is carved and positioned under the adjacent skin to reconstruct the ear. This is a complex operation.

 

In case where partial loss or total loss of the ear is the case, then the reconstruction of the ear is performed in two stages. In the first stage the shape of the ear is recreated. This results in a normal looking ear, however, because of the shortage of skin the reconstructed ear will be attached to the side of the head and require separation in the second stage. This is performed six months after the first stage. The ear is elevated and a skin graft is applied to cover the back of the new ear.

Reconstruction after Cancer removal

 

The three most common cancers of the external ear are basal cell carcinoma, squamous cell carcinoma and melanoma. If you are only missing part of your existing ear then your solution might be straightforward. If the cancer surgery also involved a lymph node dissection or radiation therapy then your solution might be more complicated. Just like with trauma to the ear, we need to know if the vascular supply to the scalp fascia is intact.

A variety of skin grafts, local and regional skin flaps can be used to reconstruct the auricle.

It should be understood by the patient that many reconstruction surgeries in order to be effective and produce an optimal results, should be performed in two or even three stages, a few weeks apart from each other. The more complex the reconstruction the more likely it will need to be staged.

 

 

RECOVERY

Recovery is usually uneventful. Pain is minimal and easily controlled with simple pain killers. The wound care is easy with an antibiotic gel or crème. Most of our patients return to work or school after one week. You will need to come back to the office to have sutures by the surgeon or another member of our clinical support team. It is very important that you follow your surgeon’s discharge instructions after surgery to allow for the smoothest recovery.

 

RISKS

• Wound Infection
• Bleeding
• Flap or skin graft failure
• Delayed healing
• Wound dehiscence
• Chondritis – infection of the cartilage
• Diminished sensation
• Asymmetry
• Scarring
• Need for revision surgery

 

RESULTS

 

Once all stages of reconstruction and healing are completed then the results improve over time and are usually permanent. Revision surgery may be needed.

Both function and cosmesis measure outcome. The outcome is poorer with greater initial defect. However, in general, all of the procedures described in this article have adequate, if not excellent, outcomes, even for the larger defects, if meticulous attention to detail is taken in the repair.

 

CASE 1

LEGEND: 82 year old male with a BCC tumor of the anthelix of the ear (arrow left photo). Following excision the 2 cm defect was repaired with an Antia-Bush local skin flap in one stage

 

CASE 2

LEGEND: 34 year old female with staged reconstruction of the missing top of the ear after a dog bite. During the first stage a cartilage framework was created, implanted in a skin pocket behind the ear and after six months during the second stage operation the reconstruction was completed

 

CASE 3

LEGEND: 64 year old male with a BCC skin cancer of the ear (top left photo arrow). The cancer was excised (top middle photo arrow). A posterior auricular skin flap was designed (top right photo). The flap was raised (middle left photo) and passed through the ear to the anterior surface to close the defect (middle right photo arrow). Three months later the reconstruction is excellent (bottom photos)

INTRODUCTION

The eyelids are important not only in normal daily functions such as seeing, but also in emotional expressions. More importantly, fully functional eyelids are a prerequisite for normal sight. Patients with abnormalities or deficits in their eyelids gain invaluable improvement with expertly performed eyelid reconstruction or other type of eyelid procedures. Given the complexity of the function that the eyelids serve, reconstruction of the eyelids present a particular challenge.

CAUSES

Many conditions can result in the need for eyelid repair:

 

• Congenital malformations
• Removal of cancerous lesions.
• Trauma
• Burns
• Injury from Chemicals
• Facial nerve paralysis (refer to facial paralysis section)

 

 

CONSULTATION

 

The plastic surgeon will evaluate you in clinic to decide whether surgery is an appropriate solution to improve your quality of life. If it is necessary he will consult with an Opthalmologist or Head and Neck Surgeon. At the time of your visit, please be prepared to have pictures taken of you for both insurance purposes and surgical planning.

In addition to medically necessary solutions, some patients decide to take advantage of their reconstructive surgery to also effect aesthetic changes, like a blepharoplasty.

You will meet with one of our surgeons in clinic to be evaluated for eyelid reconstruction. Please be prepared to discuss your medical history, including past surgeries, present and past health problems, and medications. The surgeon will perform a general head and neck exam, which will include a detailed investigation of your orbit and eye. After the assessment, the surgeon will discuss the optimal procedure with you in detail, answering any questions or concerns you may have.

If you are taking any blood thinners, you should discuss with the prescribing physician whether you should discontinue them in preparation for surgery.

 

PREOPERATIVE TESTS

 

• Schirmer’s test:determines whether the eye produces enough tears to keep it moist.

 

• Lacrimal system exploration: Irrigation and possibly intubation may be necessary for protection or repair of the lacrimal drainage system, especially in medial trauma cases.

 

• For significant trauma or large invasive tumors, consider imaging studies to exclude involvement of adjacent structures, orbit soft tissue, orbital bones, nose, sinuses, and zygoma.
• CT scan of orbits and sinuses is the best imaging modality when looking at bony involvement.
• MRI is the best imaging modality when looking at soft tissue involvement.

 

 

LOCATION

 

Eyelid reconstruction procedures should be performed in the sterile environment of a state of the art surgical suite. Most reconstructions are one day surgery cases not requiring hospitalization.

 

ANESTHESIA

 

The majority of our patients have general anesthesia during their procedures to ensure that they are unable to remember or feel the procedure. For smaller defects local anesthesia or sedation can be used.

 

 

SURGERY

 

There have been many advances in eyelid reconstruction surgical techniques in recent years.

 

Simple superficial defects in the eyelid may occur after minor trauma or removal of small growths. Many of these require nothing more than local wound care and will heal on their own in a week to 10 days. Some simple superficial defects may require a few sutures with the same local wound care.

In some instances, such as after traumatic injuries or removal of larger growths or skin cancers, larger defects may extend through the entire lid. Many of these can be sutured together directly, but many others may require more complex reconstructions. In many of these more complex cases, the surgeon will need to use transfer of adjacent tissues (what we call ”flaps”), or transfer of skin from other parts of the eyelid face or body (what we call “skin grafts”) to complete the reconstruction.

 

Quite often for defects involving all layers of the eyelid (skin, tarsus, inner lining) we need to use cartilage grafts in order to restore the contour  of the eyelid and mucosal grafts from the mouth.

 

It should be understood by the patient that many reconstruction surgeries in order to be effective and produce an optimal results, should be performed in two or even three stages, a few weeks apart from each other. The more complex the reconstruction the more likely it will need to be staged.

 

One of the most important goals of the surgery is to preserve function to the circular muscle that closes the eye (orbicularis oculi).

 

 

The Upper Eyelid

A typical defect in the upper eyelid may affect as much as 50 percent of the central eyelid. Because the upper eyelid covers such a large part of the cornea, it is more important for protection of the eye. To surgically reconstruct the upper eyelid, we utilize a wide variety of techniques. For relatively small defects, a direct closure may be performed in which the inured tissue is excised and tissue is sutured. Other more involved techniques include:

• Lateral cantholysis
• Tenzel Flap
• Sliding or Free Tarsoconjunctival flap
• Temporal forehead flap

LEGEND: Example of upper eyelid defect reconstruction with cantholysis (b) and semicircular advancement flap (c)

 

The Lower Eyelid

Like the surgery for the upper eyelid, a direct closure procedure may be utilized in which the doctor removes injured tissue and closes the defect. For more involved cases, we may recommend one of the following techniques:

• Lateral antholysis
• Tenzel Rotational Flap
• Tripier flap
• Modified Hughes procedure
• Free tarsoconjunctival graft
• Rotational cheek flap
• Mustarde flap

LEGEND: Example of lower eyelid defect reconstruction with cantholysis, subsequent canthoplasty and a Mustarde rotational advancement flap

LEGEND: Example of lower eyelid defect reconstruction with a Tripier transposition flap from the upper eyelid

 

 

RECOVERY

Recovery is usually uneventful. Pain is minimal and easily controlled with simple pain killers. The wound care is easy with an antibiotic gel or crème. Usually for about a week the eye is covered with an eye patch.

Although it takes up to six months for your body to completely heal, most of our patients return to work or school after one week. You will need to come back to the office to have sutures by the surgeon or another member of our clinical support team. It is very important that you follow your surgeon’s discharge instructions after surgery to allow for the smoothest recovery.

 

RISKS

• Infection
• Bleeding
• Flap or skin graft failure
• Delayed healing
• Wound dehiscence
• Ectropion (outwards lower eyelid)
• Entropion (inwards lower eyelid)
• Droopy eyelids from injury to the levator muscle
• Lagopthalmus (inability to fully close the eye)
• Injury to the cornea
• Blurred vision
• Conjuctivitis
• Diminished sensation
• Asymmetry
• Scarring
• Need for revision surgery

 

RESULTS

 

Once all stages of reconstruction and healing are completed then the results improve over time and are usually permanent. Revision surgery may be needed.

Both function and cosmesis measure outcome. The outcome is poorer with greater initial defect. However, in general, all of the procedures described in this article have adequate, if not excellent, outcomes, even for the larger defects, if meticulous attention to detail is taken in the repair.

 

CASE 1

LEGEND: 65 year old man with a BCC skin tumor of the lower eyelid (left). The tumor was excised with 5mm margins (middle) and the defect was reconstructed with a semicircular rotation flap

 

CASE 2

LEGEND: 65 year old female with extensive basosquamous tumor of the lower eyelid and inner canthus (left). The tumor was excised (middle) and the defect was reconstructed with a combination of a glabellar flap and a mini Mustarde flap (right)

 

CASE 3

LEGEND: 32 year old female with a congenital melanocytic nevus of the lower eyelid. Underwent excision and reconstruction of the defect with a semicircular flap

INTRODUCTION

The lip is important not only in normal daily functions such as eating and speaking, but also in emotional expressions. More importantly, fully functional lips are a prerequisite for normal speech and swallowing. Patients with abnormalities or deficits in their lips gain invaluable improvement with expertly performed lip reconstruction or other type of lip procedures. Given the complexity of the function that the lip serves, the reconstruction of the lip presents a particular challenge.

CAUSES

Many conditions can result in the need for lip repair:

• Congenital malformations
• Removal of cancerous lesions.
• Trauma
• Facial nerve paralysis (refer to facial paralysis section)

Children born with congenital abnormalities such as a cleft lip need surgical repair within the first few months of life. Secondary cosmetic improvements of the lip can be performed when the child is older.

Individuals with trauma to their lips, such as lacerations or dog bites, must be treated expeditiously.

In patients with cancer involvement of the lip, reconstruction needs to be an integral part of overall treatment management.

 

CONSULTATION

The plastic surgeon will evaluate you in clinic to decide whether surgery is an appropriate solution to improve your quality of life. If it is necessary he will consult with an ENT or Head and Neck Surgeon. At the time of your visit, please be prepared to have pictures taken of you for both insurance purposes and surgical planning.

In addition to medically necessary solutions, some patients decide to take advantage of their reconstructive surgery to also effect aesthetic changes.

You will meet with one of our surgeons in clinic to be evaluated for lip reconstruction. Please be prepared to discuss your medical history, including past surgeries, present and past health problems, and medications. The surgeon will perform a general head and neck exam, which will include a detailed investigation of your oral cavity and the nasal airway. After the assessment, the surgeon will discuss the optimal procedure with you in detail, answering any questions or concerns you may have.

If you are taking any blood thinners, you should discuss with the prescribing physician whether you should discontinue them in preparation for surgery.

 

LOCATION

 

Lip reconstruction procedures should be performed in the sterile environment of a state of the art surgical suite. Most reconstructions are one day surgery cases not requiring hospitalization. For almost total or total lip reconstruction hospital stay is mandatory.

 

ANESTHESIA

 

The majority of our patients have general anesthesia during their procedures to ensure that they are unable to remember or feel the procedure. For smaller defects local anesthesia or sedation can be used.

 

SURGERY

 

There have been many advances in lip reconstruction surgical techniques in recent years.

 

A major concept in lip reconstruction involves the understanding of topographic regions of the face. The 3-dimensional anatomy of the face and lips results in “hills and valleys,” creating shadows that form distinct subunits in the face and within the lips (philtrum). Each subunit must be treated as a distinct entity and incisions must be placed at their borders without crossing into adjacent structures. This is particularly important in lip because the 3-D curvature, form, and anatomy must be preserved.

 

Another major concept in reconstructing lip defects is the notion of replacing tissue with tissue that is very similar. This is crucial in lip reconstruction, where the red part of the lip, the white part of the lip and the muscle of the lip have different properties, thereby requiring distinct reconstructive methods to address each layer.

LEGEND: For small defects of either the lower or the upper lip, borrowing tissue in the form of a flap from the other lip is the best way to achieve an excellent aesthetic result

 

Extremely important in lip reconstruction is prevention of functional deficits such as dysfunction of the lip muscle (orbicularis oris).

The surgeon will lift as per the plan of the surgery skin grafts, mucosal grafts and flaps of skin and soft tissue from the adjacent areas of the face in order to reconstruct the lip.

It should be understood by the patient that many reconstruction surgeries in order to be effective and produce an optimal results, should be performed in two or even three stages, a few weeks apart from each other. The more complex the reconstruction the more likely it will need to be staged.

Normally lip reconstruction involves several methods that essentially “borrow” from the adjacent skin and mucosal soft tissue. One major issue with these methods is that the mouth opening becomes smaller as a result. This problem can be particularly prominent if the amount of lower lip loss is significant.

LEGEND: Example of reconstruction of a lower lip defect with a flap from the area around the corner of the mouth and the check (Karapandjic flap)

A more complicated reconstruction method involves transplantation of the soft tissue from another part of the body with the accompanying blood vessels to reconstruct and build a new lip, also known as the free flap procedure or microvascular free tissue transfer. Forearm soft tissue is an ideal site given its thinness and pliability. The transplanted forearm tissue is folded and contoured to resemble the lip. In order to recreate the vermillion border, or the prominent front roll of the lip, a segment of the arm tendon is transplanted as well.

The transplanted forearm tissue requires constant supply of blood and nutrients as in any living tissue of the body. This requires connecting the blood vessels that have been transplanted from the forearm to blood vessels to those in the neck, which is done under microscope with ultra-fine sutures.

RECOVERY

Recovery is usually uneventful. Pain is minimal and easily controlled with simple pain killers. You can shower the very next day of the surgery and the wound care is easy with an antibiotic gel or crème.

Instructions for your diet should be followed closely in order to achieve fast healing. A mouthwash solution is usually prescribed for a few days in order to prevent injury with a toothbrush.

Although it takes up to six months for your body to completely heal, most of our patients return to work or school after two weeks of recuperation. You will need to come back to the office to have sutures by the surgeon or another member of our clinical support team. It is very important that you follow your surgeon’s discharge instructions after surgery to allow for the smoothest recovery.

 

RISKS

• Infection
• Bleeding
• Flap or skin graft failure
• Microstomia (smaller opening of the mouth)
• Delayed healing
• Wound dehiscence
• Drooling – oral incontinence
• Diminished sensation of the lips
• Asymmetry
• Scarring
• Need for revision surgery

 

RESULTS

Once all stages of reconstruction and healing are completed then the results improve over time and are usually permanent. Revision surgery may be needed.

CASE 1

LEGEND: 74 year old lady with squamous cell cancer of the lower lip. Underwent excision with 1 cm margins and reconstruction with local advancement flaps

 CASE 2

LEGEND: 64 year old male with right upper lip retraction upwards and asymmetry due to trauma to the upper lip (left photo). He underwent release of the scar and reconstruction with a local check flap and a full thickness skin graft (middle photo). The right photo shows correction of the defect and achieved symmetry.

 CASE 3

LEGEND: 54 year old male with lower lip defect and major saliva incontinence (drooling) and asymmetry due to major facial trauma. He underwent reconstruction with an ABBE flap from the upper lip. The right photo shows correction of the defect and achieved symmetry.

INTRODUCTION

Reconstructive oral surgery refers to the wide range of procedures designed to rebuild or enhance soft or hard tissue structures of the maxillofacial region. Ablative tumor surgery (benign or malignant) and traumatic injuries commonly demand reconstructive procedures to restore the functional and cosmetic deficit. Loss of soft or hard tissue secondary to infectious processes, or tissue injury due to radiation (e.g. osteoradionecrosis) may also require reconstructive measures. Oral reconstruction refers to reconstruction of the:

• Tongue
• The floor of the mouth
• The hard and soft palate
• Buccal areas – The inside surface of the cheeks
• The maxilla – upper jaw
• The mandible – lower jaw

CAUSES

• Tumor surgery benign or malignant (tongue cancer, floor of the mouth cancer, jaw cancer, palate cancer
• Massive Trauma to the face
• Chronic Infections
• Loss of soft tissue or bone due to irradiation (radionecrosis)

INDICATIONS FOR TRETAMENT

• Restoration of function (swallowing, mastication etc)
• Prevention of drooling
• Treatment of infections and fistulas
• Treatment of facial disfigurement
• Psychological reasons

CONSULTATION

Oral reconstruction surgery is a multidisciplinary procedure involving all the following specialties:

• Ablative Head and Neck Surgeon, ENT
• Plastic Surgeon
• Medical/ radiation oncologist
• Maxillofacial prothodontist
• Radiologist
• Pathologist
• Dietician, speech, occupational therapist and social worker
• Psychologist

The plastic surgeon will evaluate you in clinic to decide whether surgery is an appropriate solution to improve your quality of life. At the time of your visit, please be prepared to have pictures taken of you for both insurance purposes and surgical planning.

In addition to medically necessary solutions, some patients decide to take advantage of their reconstructive surgery to also effect aesthetic changes.

You will meet with the plastic surgeon in the clinic to be evaluated for oral reconstruction. Please be prepared to discuss your medical history, including past surgeries, present and past health problems, and medications. The surgeon will perform a general head and neck exam, which will include a detailed investigation of your oral cavity and the nasal airway. The consultation focuses in evaluating:

• Patient factors:
  • smoking, alcohol, medical co‐morbidities and prior irradiation
• The Defect:
  • size, location and dentition

 

After the assessment, the surgeon will discuss the optimal procedure with you in detail, answering any questions or concerns you may have.

If you are taking any blood thinners, you should discuss with the prescribing physician whether you should discontinue them in preparation for surgery.

DIAGNOSTIC TESTING

• CT scan with 3D reconstruction
• MRI
• Pet scan
• Angiography of the carotids

LOCATION

Oral reconstruction procedures should be performed in the sterile environment of a state of the art surgical suite. Most reconstructions require hospitalization for a few days to a couple of weeks.

ANESTHESIA

The majority of our patients have general anesthesia during their procedures to ensure that they are unable to remember or feel the procedure. For smaller defects local anesthesia or sedation can be used.

 PREPARATION FOR SURGERY

Pre-opereative planning includes:

• Optimize medical status of the patient in order to achieve fast healing and recovery
  • Cardiology, pneumonology and internal medicine referral
• Nutritional consultation. Quite often to facilitate healing and because feeding can be difficult a temporary feeding tube should be placed before surgery.
• Oral hygiene. Often prior to surgery a dentist needs to examine the patient and treat intraoral infections and perform dental extractions
• A temporary Tracheostomy may be needed before surgery in order to facilitate breathing after surgery

SURGICAL TREATMENT

 Soft Tissue Reconstruction

Surgeons may use a variety of approaches to reconstruct soft tissue, including skin grafts, local or free flaps, or nerve grafts.

Skin Grafts

Reconstructive surgeons can repair soft tissue in parts of the tongue, the lining of the mouth, and the lips using a portion of skin called a graft. Grafts may be taken from the abdomen or leg and used to repair small portions of the mucosa, which is the lining of the mouth.

Flap Tissue

Sometimes, larger areas of soft tissue that are removed from the oral cavity can be replaced with a portion of healthy tissue called a flap. This tissue may consist of skin, muscle, and fat.

Flaps can often be moved from nearby areas, such as the scalp, cheek, forehead, neck, or chest, without disconnecting the blood vessels that “feed” the flap.

Flap tissue may also be taken from a distant part of the body. This tissue is called a free flap. Doctors use microvascular surgery to cut through the attached blood vessels to remove the flap and reattach it at the site of repair. Physicians may transfer this tissue using microvascular surgery, in which they cut and sew together small blood vessels under a microscope. This helps restore blood flow to the tissue in the area of repair.

Microvascular reconstructive surgery is often used to rebuild structures that help with the mouth’s functions, such as chewing and swallowing food and speaking.

Being able to use a free flap from a distant part of the body gives surgeons more options for selecting tissue that best matches the site of repair in the oral cavity. Careful selection of tissue can help to restore function.

For example, doctors may remove forearm skin and underlying soft tissue to replace a missing portion of the tongue to help with speech and swallowing.

Nerve Grafts

Doctors may use nerve grafts—in which they remove a nerve from somewhere in the body where its absence isn’t noticeable—to restore sensation and movement to the tongue and lips. This allows for proper speech and swallowing.

Bone Reconstruction

The Plastic Surgeon will reconstructcthe upper and lower jawbones. Before surgery, we use CT scans of the tumor and jaw to create three-dimensional, computer-generated models of the areas to be reconstructed. We use these models to guide them as they make the incisions needed to remove the cancerous jawbone and construct the new jaw.

To rebuild the jaw, doctors may use a piece of the fibula, a bone from the lower leg. Other bones in the face can also be reconstructed. For example, the hard palate, or roof of the mouth, can be replaced with bone from other parts of the body, such as from the fibula or the scapula, which is also known as the shoulder blade.

Doctors ensure that the procedure does not create a disability in the area from which the bone is taken.

Dental Implants

After the jawbone is restored, periodontal surgeons may use dental implants and prosthetic teeth to restore the mouth’s appearance and your ability to chew.

Dental implants are small screws that are placed into the top or bottom jawbone to replace the root of a tooth. The screws are made from titanium, a metal that fuses with the surrounding jawbone over several months. After this process is complete, your surgeon attaches custom-made replacement teeth.

RECOVERY

Recovery time after reconstructive surgery varies. Minor reconstruction, such as when a skin graft is performed, may require only two or three days of recuperation in the hospital. If you need extensive reconstruction, such as the removal and replacement of the jaw or a large portion of soft tissue, you may need to stay in the hospital for up to a week or more. After surgery special speech therapists are available to help restore your speech and swallowing abilities. Rehabilitation Doctors may prescribe physical therapy to help with balance and walking, for example, if you had a bone from the leg removed. Instructions for your diet should be followed closely in order to achieve fast healing. A mouthwash solution is usually prescribed for a few days in order to prevent injury with a toothbrush. Although it takes up to six months for your body to completely heal, most of our patients return to work or school after two weeks of recuperation. You will need to come back to the office to have sutures by the surgeon or another member of our clinical support team. It is very important that you follow your surgeon’s discharge instructions after surgery to allow for the smoothest recovery.

RISKS

• Bleeding -Hematoma
• Partial Flap necrosis
• Full flap necrosis
• Wound Dehiscence
• Delayed healing
• Scarring
• Hardware extrusion
• Revision surgery

CASE 1

LEGEND: Reconstruction of superficial defect of the undersurface of the tongue with skin graft. Left photo shows defect (arrow). Right photo shows the skin graft (arrow).

CASE 2

LEGEND: Reconstruction of the right side of the tongue and the right floor of the mouth after partial glossectomy and removal of the right floor of the mouth due to cancer. Left photo shows defect (arrow). Middle photo shows a designed FAMM flap from the buccal mucosa Right photo shows the reconstructed floor of the mouth with the FAMM flap (arrow).

CASE 3

LEGEND: Reconstruction of marginal mandibulectomy and floor of the mouth with a radial forearm free flap. Left upper photo shows the cancer (arrow). The right upper photo shows the defect (arrow). Middle left photo shows a designed radial forearm flap. Right middle photo shows the connected arteries and veins of the flap to the arteries and veins of the neck (arrow). The bottom left photo shows the immediate result and the bottom right photo the result of reconstruction after one month. At six months the patient had dental implants.

INTRODUCTION

Nasal reconstruction is the restoration or refinement of nasal form and function.

CAUSES

There are a variety of causes of nasal abnormalities including, but not limited to:

• Congenital defects
• Blunt or sharp Trauma
• Cancer surgery
• Sport accidents
• Previous surgeries

 

CONSULTATION

 The plastic surgeon will evaluate you in clinic to decide whether surgery is an appropriate solution to improve your quality of life. If it is necessary he will consult with an ENT or Head and Neck Surgeon. At the time of your visit, please be prepared to have pictures taken of you for both insurance purposes and surgical planning.

In addition to medically necessary solutions, some patients decide to take advantage of their reconstructive surgery to also effect aesthetic changes to their nose (rhinoplasty).

You will meet with one of our surgeons in clinic to be evaluated for nasal reconstruction. Please be prepared to discuss your medical history, including past surgeries, present and past health problems, and medications. The surgeon will perform a general head and neck exam, which will include a detailed investigation of your nasal airway. After the assessment, the surgeon will discuss the optimal procedure with you in detail, answering any questions or concerns you may have.

If you are taking any blood thinners, you should discuss with the prescribing physician whether you should discontinue them in preparation for surgery.

 LOCATION

Nasal reconstruction procedures should be performed in the sterile environment of a state of the art surgical suite. Most reconstructions are one day surgery cases not requiring hospitalization. For almost total or total nasal reconstruction hospital stay is mandatory.

ANESTHESIA

The majority of our patients have general anesthesia during their procedures to ensure that they are unable to remember or feel the procedure. For smaller defects local anesthesia or sedation can be used.

SURGERY

There have been many advances in nasal reconstruction surgical techniques in recent years.

A major concept in nasal reconstruction involves the understanding of topographic regions of the face. The 3-dimensional anatomy of the face and nose results in “hills and valleys,” creating shadows that form distinct subunits in the face and within the nose. Each subunit must be treated as a distinct entity and incisions must be placed at their borders without crossing into adjacent structures. This is particularly important in nasal reconstruction because the 3-D curvature, form, and anatomy must be preserved.

Another major concept in reconstructing nasal defects is the notion of replacing tissue with tissue that is very similar. This is crucial in nasal reconstruction, where the nasal lining, cartilaginous framework, and external skin have different properties, thereby requiring distinct reconstructive methods to address each layer.

Extremely important in nasal reconstruction is prevention of functional deficits such as nasal airway obstruction.

The surgeon will lift as per the plan of the surgery skin grafts and flaps of skin and soft tissue from the adjacent areas of the face in order to modify your nasal bone, cartilage or a combination of both. Depending on the extent of the reconstruction, the surgeon may need to take cartilage from other parts of your body such as your ear or rib.

It should be understood by the patient that many reconstruction surgeries in order to be effective and produce an optimal results, should be performed in two or even three stages, a few weeks apart from each other. The more complex the reconstruction the more likely it will need to be staged.

LEGEND: Example of staged total nasal tip reconstruction with a forehead flap (Indian Flap)

After the procedure is complete, your surgeon will close any incisions with dissolvable or permanent sutures and may place a splint externally or internally. It is very important to follow the discharge instructions surrounding your splint because it is supporting your healing nasal septum.

 RECOVERY

Although it takes up to six months for your body to completely heal, most of our patients return to work or school after two weeks of recuperation. You will need to come back to the office to have sutures or your splint removed by the surgeon or another member of our clinical support team. It is very important that you follow your surgeon’s discharge instructions after surgery to allow for the smoothest recovery.

RISKS

• Infection
• Bleeding
• Flap or skin graft failure
• Nasal obstruction and breathing problems
• Asymmetry
• Scarring
• Need for revision surgery

 

RESULTS

Once all stages of reconstruction and healing are completed then the results improve over time and are usually permanent.

 

LEGEND: Example of reconstruction of the dorsal part of the center of the nose with a local skin flap (Rintal flap) after removal of a skin cancer

 CASE 2

 

LEGEND: Example of reconstruction of the right nostril of the nose with a local skin flap (Nasolabial flap) after removal of a skin cancer

 CASE 3

LEGEND: Example of reconstruction of the tip of the nose with a skin graft after removal of a skin cancer

INTRODUCTION

Abdominal wall reconstruction is a complex surgery typically used to correct abdominal weaknesses caused by recurring hernias, or open wounds that are not easily resolved by other specialties.

 

Normally, the first line of hernia correction is general surgery. However, if the repair breaks down after one or more tries, an alternative solution should be considered. In cases where traditional repair methods will likely fail due to scar tissue or an abdominal wall catastrophe, such as a pancreatic leak, a more involved approach may be needed from the outset. In those circumstances, plastic surgeons can be called on to perform abdominal wall reconstruction to dynamically restructure the abdomen at the time of closure. 

CAUSES

Possible causes of defects of the abdominal wall requiring reconstruction:

• Primary and Secondary hernias
• Massive weight loss
• Soft tissue tumors
• Soft tissue infection
• Traumas, injuries
• Chronic wounds
• Diabetic ulcers
• Vascular diseases
• Malformations

INDICATIONS

There are some circumstances that will not improve spontaneously. If a complex hernia or abdominal wound is left alone, the problem often tends to progressively worsen, which may result in drainage, sinus formation, fistula or other problem.

Abdominal wall reconstruction may be useful to a patient who has had previous unsuccessful attempts at hernia repair, or complicating circumstances such as a fistula, or a complex abdominal wound that other surgical teams cannot close. 

CONSULTATION

Abdominal reconstruction is a multidisciplinary endeavour. Many specialties may be involved:

• Plastic Surgery
• General Surgery
• Oncologists
• Radiotherapy Oncologists
• Infectious Disease Doctors
• Physical Medicine and Rehabilitation

The cause of the defect, the nature of the defect, the missing function, the general health and the expectations of the patient will guide the plastic surgeon to propose which reconstructive method will be the most appropriate.

Quite often the reconstruction needs to be performed in stages. Following a major reconstructive procedure minor ancillary procedures need to be performed in order to complete the reconstruction.

The Plastic Surgeon will review your postoperative care expectations and instructions specific to your reconstruction procedure so that you are prepared and know what to expect.

LOCATION

All of the procedures should be performed in state of the art surgical suites in order to avoid infection and to achieve the optimal result. Some minor procedures, such as skin grafting or minor skin flap surgery, do not require hospitalization. Most procedures depending on the severity of the case require a few days or even weeks of hospitalization and in some microsurgical cases, even recovery in an intensive care unit.

ANESTHESIA

Most of the surgical procedures that are used for the reconstruction require general anesthesia. Few procedures on a individual basis can be done under local anesthesia and sedation.

SURGERY

Abdominal wall reconstruction requires moving abdominal tissues to redistribute the abdominal muscles. This creates a dynamic repair that works to reinforce the abdominal wall. Patients report feeling as though they are wearing a girdle afterward — everything is tucked in — as the musculature is restored as close to the midline as possible. This helps to neutralize the reasons for an abdominal defect and makes a successful solution more likely. 

 Abdominal wall reconstruction entails making incisions in the abdomen, mobilizing the abdominal muscles, and moving them over to reshape the abdominal wall. This results in a dynamic repair that is more similar to the natural configuration of the abdomen compared to simply patching the gap. 

Plastic surgeons use a multidisciplinary approach, with general surgeons handling routine hernia repair and bowel issues, and plastic surgeons performing complex hernia and wound repair with abdominal wall reshaping. We use comprehensive approach to abdominal wall reconstruction, including the use of bioprosthetic materials when necessary and abdominal reshaping, using a minimally invasive technique, making abdominal wall reconstruction a solution to many problems that others may consider too challenging or too risky. 

In brief the various techniques involve 

• Wound closure devices – VAC (Vacuum Assisted Closure)
• Wound debridements
• Skin grafts
• Skin flaps
• Fasciocutaneous flaps
• Muscle flaps
• Myocutaneous flaps
• Tissue expansion
• Free tissue transfer, and microsurgery
• Compartment separation techniques

RECOVERY

Because of the multiple factors at play in abdominal reconstruction, and a corresponding variation in surgical approaches, postoperative care differs for every individual. Healing from reconstructive surgery can take up to weeks or even months depending on the severity of the injury it may be a year before the patient will be able to resume his/her pre-injury activity level. Physical therapy is of prime importance for faster recovery of function.

In case of post-oncologic reconstruction where postoperative radiation therapy, chemotherapy or immunotherapy is needed, usually 4 to 6 weeks after the surgery need to pass in order the wound healing process will be completed, so the therapies can begin.

Very often the patient is required to wear a postsurgical support garment for a month.

RISKS

The most common risks following abdominal reconstruction surgeries may include:

• Wound infection
• Hematoma
• Wound dehiscence
• Chronic wounds
• Delayed healing
• Partial or total flap necrosis
• Mesh infection and extrusion
• Need for further surgery
• Scar revisions
• Postoperative hernias

RESULTS

In a number of reports, the success rate of abdominal wall reconstruction has proven better than in repairs placing a mesh over the opening without correcting the underlying separation of tissue. Abdominal wall reconstruction with bio-prosthetic mesh is more robust in the face of infection and other complications. Once healing is completed the results are usually permanent.

CASE 1

LEGEND: 44 year old lady with abdominal wall desmoids tumor. Upper row shows the site of the tumor and the preoperative photos. The middle row photos show the desmoid tumor (left photo) and the reconstruction with an oblique abdominal muscle flap and a mesh (right photo). The bottom row shows the postoperative result 9 months later. The incision used was a typical abdominoplasty incision.

CASE 2

  

LEGEND: 49 year old lady with massive postoperative abdominal wall hernia. Upper row shows the preoperative photos. The patient underwent reconstruction of the abdominal wall with the mesh and the component separation technique. The bottom row shows the postoperative result 9 months later. The existing previous midline incision was used along with a previous Cesarean section incision.

INTRODUCTION

Chest wall reconstruction relates to all surgical procedures that aim to repair defects of the chest wall and the integrity of the chest wall (bones, muscles and skin).

When a patient undergoes major surgery to their chest or after major trauma to the chest, they can be left with wounds which are difficult or slow to heal, or which may be painful or prone to infection.

Chest wall reconstruction represents one of the most challenging tasks in plastic surgery. Over the past several decades, a more profound understanding of surgical anatomy and physiology along with tremendous advances in surgical technique have resulted in substantial improvements in postoperative outcomes.

CAUSES

The most common causes forest wall reconstruction surgery include treatment of:

• Pressure sores
• Chronic Infections
• Chronic wounds
• Trauma
• Irradiation
• Tumour resection
• Neurosurgery procedures of the spine
• Pectus excavatum
• Pectus Carinatum
• Poland’s syndrome

INDICATIONS FOR SURGERY

Chest wall defects can cause chest instability and communication with the lungs. Therefore reconstruction is important in order to:

• Help breathing
• Prevent infections
• Aesthetic reasons

CONSULTATION

Chest wall reconstruction is a multidisciplinary endeavour. Many specialties may be involved:

• Plastic Surgery
• Thoracic Surgery
• Cardiac surgery
• Oncologists
• Radiotherapy Oncologists
• Infectious Disease Doctors
• Physical Medicine and Rehabilitation

The cause of the defect, the nature of the defect, the missing function, the general health and the expectations of the patient will guide the plastic surgeon to propose which reconstructive method will be the most appropriate.

Quite often the reconstruction needs to be performed in stages. Following a major reconstructive procedure minor ancillary procedures need to be performed in order to complete the reconstruction.

The Plastic Surgeon will review your postoperative care expectations and instructions specific to your reconstruction procedure so that you are prepared and know what to expect.

You may need to be seen by your primary care physician and a pneumonologist prior to undergoing chest wall reconstruction. Your pre-operative clearance will include a discussion of your medical history and a physical exam. You may also be required to undergo several diagnostic tests, including:

• Blood Workup
• EKG
• CT Scan
• MRI Scan

 

LOCATION

All of the procedures should be performed in state of the art surgical suites in order to avoid infection and to achieve the optimal result. Some minor procedures, such as skin grafting or minor skin flap surgery, do not require hospitalization. Most procedures depending on the severity of the case require a few days or even weeks of hospitalization and in some microsurgical cases, even recovery in an intensive care unit.

ANESTHESIA

Chest wall surgery is performed under general anesthesia. 

SURGERY

• CHEST WALL RECONSTRUCTION

Most malignant as well as large benign tumors of the chest wall typically require thoracic surgery to cut away the abnormal growth. Chest wall resection involves the partial or full surgical removal of soft tissue, cartilage, sternum and/or ribs. Chest wall reconstruction, using manmade prosthetic materials such as artificial bone or titanium rib plating, may be employed to rebuild the skeletal structure of your chest wall after chest wall resection. Some chest wall disorders due to congenital conditions or trauma also benefit or require chest wall repair and reconstruction.

In brief the various techniques involve

 Wound closure devices – VAC (Vacuum Assisted Closure)

• Wound debridements
• Skin grafts
• Skin flaps
• Fasciocutaneous flaps
• Muscle flaps
• Myocutaneous flaps
• Tissue expansion
• Bone grafts
• Free tissue transfer, and microsurgery
• Compartment separation techniques

 

• PECTUS EXCAVATUM (Funnel Chest)

Introduction

Pectus Excavatum, also known as cobbler’s chest, sunken chest, funnel chest or simply a dent in the chest, is the most common congenital chest wall deformity, in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the anterior chest wall. Typically present at birth, this condition continues during the time of rapid bone growth and worsens until early teenage years. The severity of the defect and asymmetry of the chest widely vary. Pectus excavatum is often considered to be cosmetic, however it can impair cardiac and respiratory function, causing pain in the chest and back. People with the abnormality may experience negative psychosocial effects, and avoid activities that expose the chest.

Like pigeon breast, the causes of funnel chest are not entirely known, but may include syndromes like Marfan syndrome (a connective tissue syndrome) or genetic causes. Again, boys are far more likely to have funnel chest than girls.

Children with funnel chest may experience pain in that area, especially after vigorous exercise. Because the heart can be displaced by the sternum, the child might have palpitations or mitral valve prolapse. Sometimes lung capacity is reduced as well and the child might have asthma.

Treatment For Pectus Excavatum

1. The NUSS Procedure

Dr. Donald Nuss, based at Children’s Hospital of the King’s Daughters in Norfolk, Virginia, developed a technique to correct pectus excavatum in children. The Nuss procedure involves slipping in one or more concave steel bars into the chest, underneath the sternum through two small skin incisions along the axillary lines. The bar is flipped to a convex position so as to push outward on the sternum, correcting the deformity. The bar usually stays in the body for about two years, although many surgeons are now moving toward leaving them in for up to five years. When the bones have solidified into place, the bar is removed through outpatient surgery. The procedure is required to be done along with a thoracic surgeon.

1. Surgery with Silicone Implants (most popular procedure)

For male patients custom made solid pectoral implants made specifically for the area of depression is an impressive option for a better cosmetic result. Pectoralis implants can be used to augment the male chest wall. Implants can be used to provide additional projection of the chest wall enhancing the appearance and often times self image of the patient.

Initially, the plastic surgeon meets with the patient and after making close measurements of the defect he make the “moulage” for the custom silicone implant. The moulage and a chest CT scan is send to a specific company that creates the custom made solid silicone  implant to fit the patient (usually this takes 4 weeks).

The specifics of the operation vary from patient to patient. During the consultation with the patient, the plastic surheon discusses the amount of augmentation that the patient desires. The preferred shape of the chest wall is also discussed with the patient. Pectoralis implants have been very successful in allowing the patients to achieve increased fullness in the chest area.

The procedure takes 2 hours and is performed under general anesthesia. Generally, the procedure is done through an incision in the axillary (armpit) area or through a natural crease of the chest skin. The silicone implants are placed underneath the pectoralis muscle.

What to expect after surgery

After surgery, he requires his patients to get lots of rest. Expect the chest will feel somewhat sore for the first few days, but this should abate very quickly and by the end of the first week you should be comfortable. Patients are often back to work 1-2 weeks after the procedure.

• POLAND SYNDROME

Poland syndrome is a disorder where the muscles of the chest wall are underdeveloped or absent. Sometimes, on the side of the chest where the muscles are affected, the patient’s hand may have webbing between the fingers (syndactyly) as well. Poland syndrome appears more frequently in males than females, and the causes are unknown (and not genetically related).

Treatment for Poland’s Syndrome

Surgical treatment for patients with Poland syndrome can be done to create a more symmetrical look to the chest. Your specialist will discuss the best technique with you and your child to treat this syndrome.

LEGEND: example of custom made silicone implant

RECOVERY

After the procedure, your pain will be controlled using one of several methods: a pump that delivers pain medicine through your intravenous line at your demand, by a nurse administering medicine through your intravenous line at your request or through oral medicines. At the time of surgery, a long-acting anesthetic medication is placed directly into the space between your ribs by the surgeon. This pain-control method has been proven to significantly reduce post-operative pain.

Because of the multiple factors at play in chest wall reconstruction, and a corresponding variation in surgical approaches, postoperative care differs for every individual. Healing from reconstructive surgery can take up to weeks or even months depending on the severity of the injury it may be a year before the patient will be able to resume his/her pre-injury activity level. Physical therapy is of prime importance for faster recovery of function.

In case of post-oncologic reconstruction where postoperative radiation therapy, chemotherapy or immunotherapy is needed, usually 4 to 6 weeks after the surgery need to pass in order the wound healing process will be completed, so the therapies can begin.

After your discharge from the hospital, you will want to make arrangements to have someone with you for the first couple of days if you live alone. You will not be able to drive until you are off of pain medicines.

RISKS

The most common risks following abdominal reconstruction surgeries may include:

• Wound infection
• Pneumonia
• Empyema (pus collection in the chest)
• Mesh infection (in which case the mesh needs to be removed
• As the bioprosthetic mesh integrates into the body, however, the potential exists for softening or weakening of the mesh, which may produce laxity or bulging in some cases
• Hematoma
• Wound dehiscence
• Chronic wounds
• Delayed healing
• Partial or total flap necrosis
• Need for further surgery
• Scar revisions

CASE OF CHEST WALL RECONSTRUCTION

LEGEND: 36 year old male with extensive Neurofibroma of the chest wall and invasion of the chest cavity. Upper left photo shows the position of the patient on the OR table. The straight arrow shows the position of the neurofibroma. The curved arrow the designed latissimus dorsi muscle flap. The middle upper photo arrow shows the neurofibroma before excision. The excision involved excision also of three ribs. The upper right photo arrow shows the defect of the chest after the excision of the tumor and the exposed lung (pink tissues).

The bottom left photo arrow shoes the reconstruction with a mesh and a latisimmus dorsi muscle flap. The bottom right photo shows the thoracotomy scar two weeks after surgery.  

INTRODUCTION

Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum.

Not only the reconstructive method but also the timing of the reconstruction is crucial. In cases of post-resectional exposition of e.g., pelvic or femoral vessels or intrapelvic and intra-abdominal organs, simultaneous flap procedure is mandatory.

In particular, the reconstructive armamentarium of the plastic surgeon should include not only pedicled flaps but also free microsurgical flaps so that no compromise in terms of the extent of the oncological resection has to be accepted.

INDICATIONS FOR PERINEAL RECONSTRUCTION

• Pelvic exenteration
• Excision of the pelvic floor
• Anal excsision
• Vaginectomy / Vulvectomy
• Radionecrosis of the soft tissues
• Chronic wounds
• Non healing fistulas
• Wound dehiscence

GOALS OF RECONSTRUCTION

• Separation of the pelvic from the abdominal cavity
• Infection control
• Dead space obliteration
• Protection of the bowel
• Reconstruction of the pelvic floor
• Prevention of pelvic hernias
• Wound healing in order to start radiotherapy and chemotherapy
• Protection of urinary function
• Reconstruction in order to maintain sexual activity
• Aesthetic reconstruction

TIMING OF RECONSTRUCTION

ANESTHESIA

These surgeries are demanding and last for many hours and are performed under GENERAL ANESTHESIA. Anesthesia considerations are very important and the experience of the anesthesiologist is of prime importance.

LOCATION

These surgeries take place in state of the art surgical suites.

SURGERY

The reconstruction is performed with the use of various kind of flaps. Muscle and myocutaneous flaps are usually used for complex deep defects. Skin flaps are used usually for more superficial defects.

Common Muscle flaps

• VRAM – Vertical Rectus Abdominis flap (main muscle of the abdomen)
• TRAM – Transverse Rectus Abdominis flap (main muscle of the abdomen)
• Gracilis flap – One of the four muscle from the inside of the thigh
• Free Latissimus Dorsi flap – The flat muscle of the back of our chest

Reconstruction with the Rectus Abdominis Muscle flap

Common skin flaps

These flaps are usually harvested from the thighs and the buttocks

• Anterolateral thigh flap
• Gluteal flaps
• Pudendal flaps
• V-Y flaps

Reconstruction with regional skin flaps

RECOVERY

Recovery in the Intensive Care Unit is usually required for a few days. Usual hospital stay for these type of procedures can last between one and two weeks. Overall recovery depends on the general health status of the patients and may last a few weeks.

 RESULTS

Once all wounds are healed the results are usually permanent. If further  therapy for completion of the oncologic therapy is needed (chemotherapy, radiotherapy) this should be done 4-6 weeks following the reconstruction.

INTRODUCTION

The goals of lower extremity reconstruction are to restore limb function, cover vital structures, and maintain a satisfactory appearance following injury, infection, vascular or metabolic diseases, rheumatoid arthritis, and so on.

CAUSES OF LOWER EXTREMITY DEFECTS

Possible causes of defects of the leg requiring reconstruction are:

• Bone tumors
• Soft tissue tumors
• Soft tissue infection
• Osteomyelitis – bone infection
• Pseudoarthrosis – non healing fracture
• Traumas, injuries
• Chronic wounds
• Diabetic ulcers
• Vascular diseases
• Malformations
• Healing difficulties from arthroplasties
• Degenerative joint disease, rheumatoid arthritis
• Systemic lupus erythematosus

INDICATIONS FOR RECONSTRUCTION

The most frequent indication for lower extremity reconstruction is the need to replace or reconstruct an absent lower extremity function (i.e. sensation, motion) and reconstruct the form of the leg (thigh, tibia, foot).

CONSULTATION

Lower extremity reconstruction is a multidisciplinary endeavour. Many specialties may be involved:

• Plastic Surgery
• Orthopedic Surgery
• Vascular Surgery
• Oncologists
• Radiotherapy Oncologists
• Infectious Disease Doctors
• Physical Medicine and Rehabilitation

The cause of the defect, the nature of the defect, the missing function, the general health and the expectations of the patient will guide the plastic surgeon to propose which reconstructive method will be the most appropriate.

Quite often the reconstruction needs to be performed in stages. Following a major reconstructive procedure minor ancillary procedures need to be performed in order to complete the reconstruction.

The Plastic Surgeon will review your postoperative care expectations and instructions specific to your reconstruction procedure so that you are prepared and know what to expect.

LOCATION

All of the procedures should be performed in state of the art surgical suites in order to avoid infection and to achieve the optimal result. Some minor procedures, such as skin grafting or minor skin flap surgery, do not require hospitalization. Most procedures depending on the severity of the case require a few days or even weeks of hospitalization and in some microsurgical cases, even recovery in an intensive care unit.

ANESTHESIA

Most of the surgical procedures that are used for the reconstruction require general anesthesia. Few procedures on a individual basis can be done under local anesthesia and sedation.

THE PROCEDURE

Lower extremity reconstruction is complex because of the incredible variation of factors involved, including injury location and extensiveness, tissues types involved, and your medical background.

Surgical Techniques

Among the most commonly used surgical techniques are:

• Wound closure devices – VAC (Vacuum Assisted Closure)
• Wound debridements
• Skin grafts
• Skin flaps
• Fasciocutaneous flaps
• Muscle flaps
• Myocutaneous flaps
• Bone flaps
• Tissue expansion
• Free tissue transfer, and microsurgery
• Vein grafts
• Nerve grafts and Nerve transfers
• Bone grafts
• Amputations
• Lymph node biopsies and dissections

Surgery can take anywhere from one to several hours and will be conducted under general anesthesia.

RECOVERY

Because of the multiple factors at play in lower extremity reconstruction, and a corresponding variation in surgical approaches, postoperative care differs for every individual. Healing from reconstructive surgery can take up to 6 weeks (in some cases even more) and depending on the severity of the injury it may be a year before the patient will be able to resume his/her pre-injury activity level. Physical therapy is of prime importance for faster recovery of function.

In case of post-oncologic reconstruction where postoperative radiation therapy, chemotherapy or immunotherapy is needed, usually 4 to 6 weeks after the surgery need to pass in order the wound healing process will be completed, so the therapies can begin.

RISKS

The most common risks following lower extremity reconstruction surgeries may include:

• Wound infection
• Hematoma
• Wound dehiscence
• Chronic wounds
• Delayed healing
• Partial or total flap necrosis
• Hardware extrusion
• Need for further surgery
• Scar revisions

RESULTS

Once the healing process is completed the results are usually permanent.

CASE 1

LEGEND: 65 year old lady with sarcoma of the right calf. Left upper photo: MRI of the calf shows the tumor (arrow). Right upper photo shows the area to be excised with 3cm margins. Bottom left photo: Planned radial forearm free flap reconstruction. Bottom right photo shows transplanted free radial forearm flap 6 months later

CASE 2

LEGEND: 34 year old male with chronic ankle wound (left upper photo) secondary to fractured ankle joint, complicated by osteomyelitis and soft tissue necrosis. After multiple attempts to close the wound with debridements and skin grafts, the patient underwent reconstruction with a free lattissimus dorsi muscle flap from the back of the chest (upper right and bottom left photo). The bottom right photo shows the wound closed after one year.

WHY SCARS FORM

The formation of a scar is a natural healing process that occurs after you are injured. True scars are caused by a change to skin tissues, which is a part of the healing phase we previously mentioned. When white blood cells attack bacteria, they cause changes in the underlying skin cells present in the surrounding area. This causes the scar to become more visible.

The skin of younger individuals is resilient and elastic, compared to older people. Thus, an elderly person develops a more severe scar than a child would when recovering from the same type of injury. Elders should be very careful when looking after their wounds. Most importantly, anyone who is injured should resort to immediate treatment for best results.

Medicines and birth control drugs can make the appearance of a scar more apparent. Small blemishes that would otherwise not be so apparent often are more noticeable on those taking certain medicines, since they affect the pigmentation of the skin.

Factors that influence scar formation

• Size and depth of the incision or wound
• Location of the wound on the body
• Blood supply to the area
• Type, color, and thickness of the individual’s skin tone
• Direction of the scar
• Age of your skin.
• Medications you are taking.

TYPES OF SCARS

There are numerous kinds of scars, and all of them have a negative effect on the person who acquires them. Scars are usually a painful memory or a bad experience that can lower the self-esteem of a bearer, especially if the unpleasant scar is lodged on the face or another inconvenient location.

Below are listed various different kinds of scars that you must know about before you can treat yours effectively:

1. Atrophic Scars

Atrophic scars occur when the skin around a healing wound is put under tension during the healing process. This type of scarring may follow injury or surgery. Initially, the scar may appear normal but can widen and thin over a period of weeks or months. This can occur where the skin is close to a joint and is stretched during movement or may be due to poor healing due to general ill health or malnutrition. 

These are the type of scars that are depressed, serrated or flat against the upper layer of the skin.

2. Hypertrophic Scars

Such type of scars are elevated and raised in appearance. As compared to atrophic scars characterized by loss of tissue, hypertrophic scars occur because of the excessive tissue that develops over skin openings caused by infections or wounds.

Hypertrophic scars are somewhat similar to keloid scars in their characteristics and appearance; however, they form only on the areas of injury.

When a normal wound heals the body produces new collagen fibres at a rate which balances the breakdown of old collagen. Hypertrophic scars are red and thick and may be itchy or painful. They do not extend beyond the boundary of the original wound but may continue to thicken for up to 6 months.

Hypertrophic scars usually improve over the next one to two years but may cause distress due to their appearance or the intensity of the itching, also restricting movement if they are located close to a joint. 

Hypertrophic scars are more common in the young and people with darker skin. Some people have an inherited tendency to this type of scarring. It is not possible to completely prevent hypertrophic scars, so anyone who has suffered one should inform their doctor or surgeon if they need to have surgery. Scar Therapies are available which may speed up the process of change from a hypertrophic scar to a flatter, paler one. 

LEGEND: Hypertrophic scar from a previous C-section

3. Keloid Scars

Such types of scars appear when the skin goes through an aggressive healing phase. The result is a clustered and thick scar that appears darker than the surrounding skin. Keloids are caused by injuries, particularly when the body secretes excess collagen on the affected area, even after the original wound has healed and closed.

Like hypertrophic scars, keloids are the result of an imbalance in the production of collagen in a healing wound. Unlike hypertrophic scars, keloids grow beyond the boundary of the original wound. They can continue to grow indefinitely. They may be itchy or painful and may not improve in appearance over time. 

Keloid scars can result from any type of injury to the skin, including scratches, injections, insect bites and tattoos. Anybody can get a keloid scar and they can occur anywhere on the body. However, the young and people with darker skin are more prone to this type of scarring and they are more common on certain parts of the body e.g. ears, chest, shoulders and back. 

In simple words, keloids form when the healing phase has gone too far, and the body has done all the necessary repair beyond the damage. It is essential to note that in various cases, the extent of healing also affects the movement of the affected area. Keloids are often spotted on dark skinned people, as well.

It is easy to treat keloids through surgery. They can also be cured through the application of silicone sheets and steroid injections. Minor keloids are often treated by using liquid nitrogen applied on the affected area for quicker fading.

As with hypertrophic scarring, people who have developed one keloid scar are likely to be prone to this condition in the future and should alert their doctor or surgeon if they are likely to need injections or to have any form of surgery. 

LEGEND: Typical keloid of the sternum following sternotomy for heart surgery

4. Scar Contractures

Such type of scarring happens when you are burned. The burn is most often present on the joints and creases. Scar contractures tighten the affected skin and may affect your movement and flexibility.

These types of scars can make your skin look ruined. If the contracture scarring is deep, then it may also disrupt the normal functioning of your nerves and muscles.

5. Stretch Marks

Stretch marks are other types of scars that happen mostly to people who have experienced extreme weight loss and teenagers, as well as obese people and pregnant women. Stretch marks develop when the skin is stretched rapidly.

The skin tears, particularly on the buttocks, thighs and breast areas when a person grows or shrinks too fast. Initially, stretch marks may look red or purple in color, but over time they lighten, and look lighter or silver in color.

6. Acne Scars

Acne and pimples usually heal after some period of time, but the marks they leave make some unpleasant scars.

Acne scarring is caused as a result of severe acne. There are various forms of acne scars that differ in their type and depth. Also, the treatment of acne scars is dependent on the type of scars you have.

7. Ice Pick Scars

Ice pick scars are pores that are open and large. They are narrow and deep marks that go beyond the uppermost layer of the skin.

Ice pick scars are actually pores that form when acne infections reach the skin surface and destruct skin tissue along the way. These are generally found on the areas where the acne tends to break out more frequently. Ice pick scars are atrophic and may also happen when you pick on the blackheads and whiteheads. They can be either soft or hard, and have a tendency to prevail in the cheek area.

TREATMENT OF SCARS

There are numerous treatments available for various kinds of scars, ranging from over-the-counter remedies to clinical treatment options.

Once the scar type is identified, your doctor can find the proper treatment that is best suited for your scars and skin type.

Even though scars look ugly, the good news is that there are treatment options available for every kind of scar. Below are listed effective types of treatments that can treat each individual scar.

Most of the treatment methods described below can be used in combination in order to achieve the best result possible.

Most of the treatment methods are office based procedures with the exception of the surgical options.

• Massage 

Massaging a scar (especially hypertrophic or keloids) with specific gels, lotions and creams that are specifically formulated to eradicate or smoothen slight marks can be very effective.

Individuals who don’t have any concerns with allergies can safely use over-the-counter creams. However, if your skin is sensitive and subject to allergy and itching, prescription topical treatment is the one that you may need.

• Vitamin C

Experts indicate that vitamin C is an effective treatment for reducing the dark pigment that is caused due to scarring. Vitamin C serums are easily available on the market for fading stubborn scars on skin.

• Silicone Gel Sheets 

Silicone gel sheeting was developed in the 1980’s and has been used by over 1 million people throughout the world. Both waterproof and flexible, silicone gel sheets look and feel like transparent gelatine and work by flattening, softening and fading red and raised scars. Being flexible, they are comfortable to wear and easy to apply, even on awkward areas such as joints. The sheet is easily cut to fit the scar. 

Current research indicates that silicone gel sheeting works by moisturising and covering the scar area. This helps to reduce the size and improve the colour of a scar and can improve elasticity of the tissue. Research also indicates that improvements in the appearance of scars are permanent. 

• Pressure Garments 

Pressure Garments are only used under the supervision of a medical profession. They are most often used for Burn Scars and very often applied 3-4 weeks after the burn when the wound has healed. Pressure Garments are made to fit like a second skin of elastic fabric and are usually made to measure. They work best when worn 24 hrs a day for 6-12 month, and very often in combination with silicone gel sheeting. Mode of Action is not fully understood, though it may be that continuous pressure on the surface blood vessels play a part over a period of months, the scars become softer, flatter and become paler. Jobskin Made to Measure pressure garments have been used clinically for more than 30 yrs.  

• Cryotherapy 

Cryotherapy is a technique that uses liquid Nitrogen in the form of a spray to freeze the scar tissue. Research suggests that this technique is only effective in around 30% of cases and it is mainly used to improve scars on the shoulders or back. 

• Laser Surgery & Resurfacing 

Like surgery, the role of laser surgery in the management of scars is limited. The colour of a red scar may be improved by management with a vascular laser. It has also been suggested that removing the surface layers of the skin with a carbon dioxide laser may help to flatten scars. However, there are very few long-term studies to prove the effectiveness and safety of this therapy. It is important to establish that a fully trained medical practitioner carries out any laser therapy with experience in improving scars.

Laser therapy is also useful for restoring sun-damaged skin, wrinkles and aging skin. Even though laser therapy provides immediate results, it may have some severe side effects such as redness, superficial burns, and exaggerated acne that may take several weeks to heal.

• Dermabrasion 

Dermabrasion is a skin treatment that involves the removal of the uppermost layer of the skin. Also, known as abrasion, this treatment is very painful and requires anesthesia.

The practitioner makes use of a high-speed brush to sloughs off the uppermost layer of the epidermis of the skin.

Dermabrasion is an effective technique, which is very useful for treating shallow scars that are raised above the surrounding skin. This treatment is not effective for the treatment of sunken scars.

• Hyalorunic acid Injections 

Hyalorunic can be injected beneath a sunken scar or an acne  and ice pick scar, in order to build up the level of the skin. However, the effect is temporary and injections need to be repeated at regular intervals. There is also a risk of allergic reactions. 

• Steroid Injections 

A course of steroid (triamcinolone) injections will help to soften and flatten a hypertrophic or keloid scar. The steroid is injected into the scar itself and very little is absorbed into the blood stream, so side effects are minimal. Injections are repeated at 4 to 6 week intervals and are given under medical supervision. Three or four injections may be needed.

• Surgery 

Any surgical removal will always leave a new scar that will take up to two years to mature. Surgery will never remove a scar but can be used to alter its position, alignment or shape. Sometimes, surgery will actually make the scar longer; although its appearance is improved overall. This is particularly important to bear in mind when the scar is in a visible location (e.g. face). Surgery may be necessary to release a tight scar near a joint that is restricting movement. In the case of hypertrophic and keloid scars, there is a very high risk of recurrence of excessive scarring following surgery. 

Surgical techniques include:

• Excision of the scar and primary closure
• Serial excisions of the scars
• Excision and Skin grafting
• Excision and reconstruction with local and regional flaps
• Tissue expansion and flap surgery (staged operations)

 

CASE 1

LEGEND: Keloid revision surgery. The patient developed keloids of the face and forearm (upper row photos). After keloid excision and reconstruction with local flaps and multiple Z-plasties (bottom row photos)

CASE 2

LEGEND: Scar revision with fat transfer. Left photo shows depressed retracted scar (arrow) of the leg after excision of a melanoma. The scar is elevated and flat after fat transfer.