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UNIT IV HEAD & NECK

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29. SOFT TISSUE & SKELETAL INJURIES OF THE FACE.

Oct, 2012PI

Q10. A professional tennis player was hit by a tennis ball while playing a league match with bruising and swelling

over right orbital region. On examination of his eye, a subconjunctival hematoma with no posterior limit is noted.

a) What is your likely diagnosis?

b) How would you manage this injury?

MAR, 2011PI

Q.9 A 29 years old man presents to you with history of facial injuries which he sustained in a road traffic accident 2

weeks ago. He has complaints of diplopia, broad bridge of nose and depressed right cheek.

a) How will you evaluate this patient?

b) How would you manage the complaint of diplopia which was caused by blowout fracture of right side?

c) How would you manage the nasal deformity?

SEPT 2009

Q.2: A 30 year old man is involved in a motor bike accident and sustained a displaced fracture of the left zygoma

and depressed frontal bone and frontal sinus fracture. Movements of the left eye are restricted and the eye looks

smaller.

a) What consultation would you seek?

b) What is the best imaging method?

c) When the frontal bone fracture is being treated surgically by the neurosurgeon, what is the best way of treating

the frontal sinus fracture?

d) If not treated, what complications would arise from the frontal sinus fracture?

FEB 2007

Q.7:

a) How do you classify maxillary fractures according to the pattern of the fractures?

b) Give the emergency management.

c) Principles of definitive management.

MAR 2005, PII

Q.12 you are called to the emergency department to see a 21 years old man who has suffered facial injuries in a

road traffic accident. The casualty medical officer thinks he may have a zygomatic fracture.

a) List the clinical signs that would support such a diagnosis.

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b) What investigations would help in establishing the diagnosis and planning treatment?

c) Outline briefly the management plan.

SEP 2003PII

Q.14: A young man presents after a road traffic accident in the emergency room apparently bleeding from the

nose and the mouth and is getting suffocated.

a. How will you maintain the airway?

b. What are the different methods of arresting such bleeding?

MARCH 1998

Q.7: A young girl is involved in a head on collision in a car accident. She has suffered multiple injuries, including

lacerations, foreign body embedded in tissues, skin loss and fractures.

a) Discuss the injuries you would expect to see.

b) The management of this case.

c) Prevention of these drastic injuries.

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30. HEAD & NECK CANCER.

JULY 2017

Q2) A 40 year old lady has presented with a 2cm SCC of cheek mucosa. There is no neck involvement. Clinically you

don’t have facility for microvascular surgery.

a) What are the principles of excision?

b) Which pedicled flaps are of your choice, with justification, their importance and operative steps of flap

elevation.

JULY 2017

Q15) A 52 year old man presented with recurrent low grade fibrosarcoma of the right maxilla involving the anterior

wall and overlying skin. His right orbit is not involved, but the infratemporal fossa is reported to have the lesion on

CT scan.

a) What type of defect will be created after excision of this lesion?

b) Give 2 reconstructive options in this case for maxillary reconstruction.

c) How do you classify maxillary defects?

OCT 2013

Q13) A 55 year old man presents with a non-healing ulcer on the right cheek for 2 years. On examination there is a

6x4cm ulcer with induration on inner cheek mucosa and adherent to the retromolar area.

a) How would you evaluate this patient before undertaking excision and reconstruction? Enlist the investigations in

an order that you would like to perform.

b) With the description given of the lesion, what would be the likely defect after excision?

c) What are the reconstructive options, taking into consideration for the components essential for the

reconstruction?

Oct, 2012

Q.9 you are planning to operate on a 56 year old lady with an integral SCC that entails excision of the primary,

cervical lymph node dissection and microsurgical reconstruction of the intra oral defect.

a) Enumerate the major complications due to prolonged surgery that you should anticipate.

b) What steps would you take to prevent three of the major complications?

c) How does body temperature affect the microsurgical reconstruction?

MAR 2013

Q.13 A 56 year old female presents with a biopsy proven sebaceous carcinoma arising from the lateral canthal

region of the right eye and involving the whole lower eye lid.

a) What factors will you consider while planning the treatment?

b) If surgery is chosen, give your plan for complete management if this lesion

JUNE 2008

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Q.9 A 52 years old head mistress presents to you with a parotid swelling and facial nerve weakness of recent onset.

History reveals that she had a pleomorphic adenoma removed from the same site 20 years ago.

a) What is the likely cause of her problem and how will you assess her?

b) Give your treatment plan keeping in view her social obligations.

Q15) A 52 year old man presented with recurrent low grade fibrosarcoma of the right maxilla involving the anterior

wall and overlying skin. His right orbit is not involved, but the infratemporal fossa is reported to have the lesion on

CT scan.

a) What type of defect will be created after excision of this lesion?

b) Give 2 reconstructive options in this case for maxillary reconstruction.

c) How do you classify maxillary defects?

OCT 2013

Q13) A 55 year old man presents with a non-healing ulcer on the right cheek for 2 years. On examination there is a

6x4cm ulcer with induration on inner cheek mucosa and adherent to the retromolar area.

a) How would you evaluate this patient before undertaking excision and reconstruction? Enlist the investigations in

an order that you would like to perform.

b) With the description given of the lesion, what would be the likely defect after excision?

c) What are the reconstructive options, taking into consideration for the components essential for the

reconstruction?

Oct, 2012

Q.9 you are planning to operate on a 56 year old lady with an integral SCC that entails excision of the primary,

cervical lymph node dissection and microsurgical reconstruction of the intra oral defect.

a) Enumerate the major complications due to prolonged surgery that you should anticipate.

b) What steps would you take to prevent three of the major complications?

c) How does body temperature affect the microsurgical reconstruction?

MAR 2013

Q.13 A 56 year old female presents with a biopsy proven sebaceous carcinoma arising from the lateral canthal

region of the right eye and involving the whole lower eye lid.

a) What factors will you consider while planning the treatment?

b) If surgery is chosen, give your plan for complete management if this lesion

JUNE 2008

Q.9 A 52 years old head mistress presents to you with a parotid swelling and facial nerve weakness of recent onset.

History reveals that she had a pleomorphic adenoma removed from the same site 20 years ago.

a) What is the likely cause of her problem and how will you assess her?

b) Give your treatment plan keeping in view her social obligations.

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SEP 2000, PI

Q.5 A MIDDLE AGED WOMAN PRESENTS WITH AN INDOLENT ULCER 1.5 CM IN DIAMETER INVOLVING LEFT ANGLE

OF THE MOUTH AND BUCCAL MUCOSA. SHE IS A KNOWN PAN EATER FOR LAST 30 YEARS.

a) WHAT IS YOUR MOST LIKELY DIAGNOSIS?

b) DISCUSS ITS MANAGEMENT

MARCH 2000

Q.5: A 55 year old man presents with a hard palpable lymph node in the left cervical region of 2 months duration.

a) How will you assess this case?

b) How will you treat this case?

SEP 2003, PI

Q.6 List the important and specific complications of radical neck dissection?

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Orbital floor fracture: (Blowout fracture)

o Orbital floor can be divided into three main categories

Orbital floor

Medial wall and

Zygomatic

o Anatomy:

o Classification:

Orbital wall fracture:

Blow out fracture

Pure blow out fracture

Impure blow out fracture

Blow in fracture

Isolated orbital wall fracrture:

Roof

Floor

Medial wall

Lateral wall

o Floor (antral) Blow out #: can be further sub-classified

Type I: limited elevation of effected eye due to

mechanical limitation

Type II: limited depression due to IR palsy or flap

tear

Type III: limited elevation and depression due to mechanical restriction and/ or IR palsy

or flap tear

o White eye or trapdoor fracture:

Patient has a blowout with entrapment, but without many signs, such as swelling,

ecchymosis or hemorrhage the eye is “white and quiet” even in the presence of a

fracture

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Mostly occurs in children or young adults when bones are more flexible and they “snap

back” and cause entrapment of tissue or muscle.

o Management:

History: (standard history)

Mechanism of facial trauma

Size of object (mechanism/velocity)

Physical exam:

ATLS protocol

Full evaluation of globe + surrounding structure

Standard eye examination (vision, 6 cardinal gazes)

Neurosurgical consultation (CSF leakage,

pneumocephalus)/ ophthalmologist

Orbital floor:

Periorbital edema and ecchymosis

Palpable bony “step-off” fracture

Infraorbital nerve injury hyperesthesia, dyesthesia or hyperalgesia

Herteel ophthalmometry may demonstrate either proptosis or enophthalmos

Limited vertical movement entrapment of inferior rectus muscle (also check for

Oculocardiac (reflex also known as Aschner phenomenon, Aschner reflex, or Aschner-Dagnini reflex,

is a decrease in pulse rate associated with traction applied to extraocular muscles and/or compression

of the eyeball)

Media wall:

Remains undetected

Periorbital edema and ecchymosis

Subconjunctival hemorrhage

Subcutaneous emphysema (ethmoid air cells damage)

Pseudo-Daune’s retraction syndrome (On attempted

abduction a narrowing of the palpebral fissure and retraction of the

globe was observed) Zygomatic:

Significant malar depression with step defect at infraorbital rim, frontozygomatic

suture, and zygomatic buttress of maxilla intraorally

Zygomatic # evoke pain on palpation in 70% of patients

Paresthesia in distribution of infraorbital, zygomatic or zygomaticotemporal nerves

can be seen

Mandible movement disruption

Imaging: CT scan (thin 2-3mm cuts) is the imaging study of choice

Treatment:

Medial wall:

o Avoid blowing nose for several weeks

o Nasal decongestive spray

o Prophylactic antibiotic

o Steroids

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Surgical:

o Currently, three general guidelines are commonly agreed on for surgical

intervention

o Diplopia

o Enophthalmosgreater than 2mm after 2 weeks of trauma

o A fracture involving one half or more of orbital floor; especially when

associated with media wall defect usually leads to functional/cosmetic

deformity.

Approach:

o Conjunctival approach

o Cutaneous exposure

o Through a transantral approach

o Endoscopic approach via transmaxillary and transnasal

Complication:

o Failure to diagnose in time result in

Fibrosis

Contractures and

Unsatisfactory union

o Loss of vision

o Traumatic optic neuropathy

o Diplopia

o Overcorrection or under correction of

enophthalmos

o Lower eyelid retraction

o Bleeding

o Infection

o Extrusion of orbital implant

o Infraorbital nerve damage

Principle of definitive management of facial fractures: in summary

o Treatment of facial fractures requires a multisystem

approach

o All bony and soft tissue injuries should be diagnosed and

o Reconstruction of all tissue layers should be performed- if possible

o Rigid fixation of most facial fractures

o More precise stability and fixation of fractures

o Well planned incisions minimize scarring

o Adequate exposure, precise reduction and stable fixation remains the hallmark treatment of

facial fractures

o But the main principles in middle face trauma are:

An accurate and complete injury evaluation

MDT approach with ENT surgeon, maxillofacial surgeon, neurosurgeon and

ophthalmology surgeon; the result has to be “as well as we get”

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Maxillary Fractures: (Le Fort Fracture)extend through the pterygoid plate

Type of Fracture Features Approach/Incision

Le fort I injury Le Fort II injury Le Fort III injury

Classically passes through the maxilla transversely, somewhere between the tooth roots and the infraorbital rims, with preservation of integrity of infraorbital rims. Extends through the infraorbital rim and nose and is sometime, reffered to as a pyramidal fracture. Involves the zygomatic arch, lateral orbital wall and nasofrontal region

Upper gingivobuccal sulcus incison Lower lid incision (commonly used) Moderate impact injuries combination of sulcus and lower lid incision Severe injuries coronal approach for exposure of nasofrontal and medial orbital region and zygomatic arch

Emergency management:

o After standard ATLS protocol

o Following immobilization of all these fractures

o The patient should be placed in maxillomandibular fixation, the zygmaticomaxillary and

nasomaxillary buttresses stabilized with plates

o The goals of treatment should be restoration of

function and appearance.

Facial subunits:

1. Forehead:

1a-central

1b-lateral

1c-brow

2. Nose:

2a-Dorsum

2b-lateral wall

2c-ala

2d-tip

2e-columella

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3. Eyelid:

3a-upper

3b-lower

3c-medial canthus

3d-lateral canthus

4. Cheek:

4a-infraorbital

4b-zygomatic

4c-buccal

4d-parotid-masseter

5. Upper lip:

5a-philturm

5b-lateral

5c-vermillion

6. Lower lip:

6a-central

6b-vermillion

7. Chin

8. Ear:

8a- Helix

8b- antihelix

8c- triangular fossa

8d- cavum/concha

8e-ear lobule

9. Neck

Principle of tumor (malignant) excision:

o Surgical resection is the most common method of treatment for skin cancer of the head & neck.

o The physician should keep four goals in mind:

1. Total removal or destruction of cancerous tissue

2. Maximal preservation of normal tissue

3. Preservation of function

4. Optimal cosmesis.

o The most important principle of treatment is complete tumor excision because if this goal is not

achieved, the other goals cannot be achieved.

o Adequate margins of resection are necessary to achieve clear margins

o For majority of BCC and SCC cases 4mm margins are sufficient (if less than 2cm tumor size)

o However, if tumor is 2 cm or greater or in high risk area, is invading fat or is not well demarcated

or recurrent tumor than 6-10mm margin of excision is required.

o Other treatment modality: (mostly destructive)

1. Radiotherapy

2. Topical 5-fluorouracil

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3. Lasers

4. Photodynamic therapy

5. Interferon

6. Retinoids

7. Curettage and electrodissection

8. Cryosurgery

Neck lymph node level:

Neck dissection classification:

1. Academy classification (1991):

a. Radical neck dissection (RND)

b. Modified RND

c. Selective neck dissection

i. Supra-omohyoid type

ii. Lateral type

iii. Posterolateral type

iv. Anterior compartment type

d. Extended radical neck dissection

2. Medina classification (1989):

a. Comprehensive neck dissection (RND and Mod. RND)

b. Type I (XI preserved)-most important thing (Nerve)

c. Type II (XI, IJV preserved)- 2nd most imp things is vein

d. Type III XI, IJV and Sternocleiodmastoid muscle)- all three things preserved

e. Selective ND

i. Indication:

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1. Cancer arising in head and neck region, who are consider at risk of mets

2. Who have no evidence of clinical mets

3. Spiro’s classification:

a. Radical (4-5 nodes levels involved)

i. Conventional RND

ii. Modified RND

iii. Extended RND

iv. M & ERND

b. Selective (3-nodes level resected)

i. Supra-omohyoid ND

ii. Jugular dissection (level II-IV)

iii. Any other 3 nodes levels resected

c. Limited (no more than 2 nodes level resected)

i. Paratracheal node dissection

ii. Mediastinal node dissection

iii. Any other 1 or 2 nodes levels

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Types of neck incision

Adnexal tumor:

o Adnexal skin tumors are rare neoplasms that develop from hair follicles, sebaceous glands and

sweat glands. In the majority of cases these tumors are benign, although metastases have been

reported in rare occasion.

Hyperplastic and Hamartomatous lesions

Benign neoplasms

Malignant neoplasms

Hair and hair follicle

Basaloid follicular hamartoma

Basaloid epidermal proliferation

Overlying dermal mesenchymal lesions

Hair and hair follicle

Trichofolliculoma

Desmoplastic trichoepithelioma

Trichoblastoma

Trichoblastic fibroma

Trichoadenoma

Hair and hair follicle

Trichilemmal carcinoma

Trichoblastic carcinoma

Malignant proliferating trichilemmal cyst

Pilomatrix carcinoma

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Trichofolliculoma

Sebaceous trichofolliculoma

Folliculosebaceous cystic hamartoma

Trichodiscoma/ fibrofolliculoma

Pilar sheath acanthoma Sebaceous glands

Sebaceous hyperplasia

Nevus sebaceous of Jadassohn

Proliferating trichilemmal cyst/pilar tumour

Trichilemmoma

Desmoplastic trichilemmoma

Pilomatricoma/proliferative pilomatricoma

Sebaceous glands

Sebaceous adenoma

Sebaceoma/sebaceous epithelioma

Sebaceous glands

Sebaceous carcinoma

Basal cell carcinoma with sebaceous differentiation

General features comparing Basal Cell carcinoma with Trichoblastoma:

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35. RECONSTRUCTION OF THE CHEEKS.

JAN 2008, PII

Q.11 A 45 years old female underwent a free Bi-paddled radial forearm Flap for a composite cheek defect after

resection for cancer After 12 hours the flap is a little blue with brisk capillary refill.

a) What is the likely cause of this problem and what measures will you take to salvage the flap?

In case the flap fails, give 3 reconstructive options, giving your reasons for selecting one of them

MAR 25, 2009 PI

Q.2 A new born female is discovered abandoned in a dustbin with an animal bite to her face resulting in a full

thickness loss of most of the left cheek unit and entire lower lip.

a) How would you manage this patient initially in the first few days?

b) When and how would you reconstruct the above mentioned defect?

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Cheek reconstruction: (acquired defects)

Reconstructive options for cheek defects:

1. Healing by secondary intention (useful for less than 1cm)

2. Primary closure

3. Skin graft (good result if less than 5mm, when greater than

5mmpermanent contour deformity)

4. Local flaps:

a. Advancement flap (V-Y)

b. Transposition flap (banner, bi-lobed, rhomboid)

c. Rotation flap (cervico-facial, cervico-pectoral)

5. Local composite flaps:

a. Pectoralis major flap

b. Trapezius flap

6. Tissue expansion

7. Microvascular reconstruction:

a. Radial forearm flap

b. Parascapular flap

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c. Rectus abdominus flap

d. Anterolateral thigh flap

e. Fibulo-osteocutaneous flap

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33. NASAL RECONSTRUCTION

April 23, 2014-P11

Q.18: A 75 year old gentleman with a round BCC of 2 cm diameter of right ala of his nose involving the alar

cartilage comes to you for surgery.

a) What Local flaps are available to you for reconstruction after excision of BCC?

b) Give surgical details of two of these procedures?

c) What are common donor sites for cartilage graft in this case?

MAR 2009; FEB 2007

Q.18; Q.3: A 22 year old actress is attacked by a deranged man with a knife and she sustains total nasal

amputation.

a) What are the principles of total nasal reconstruction?

b) Give three options for nasal reconstruction which would be suitable in this patient.

c) Give advantages and disadvantages of each method

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Nasal Reconstruction:

o The nasal base plateform: Gillies/ Millard Fat Flip Flap

o Nasal Lining:

a. The composite skin graft: (defect less than 1.5cm)

b. Local hingeover lining flap:

c. Prelaminated skin graft and cartilage for lining under forehead

d. Intranasal lining flap:

i. Small unilateral defect: residual vesctibular skin

ii. Larger unilateral defect: ipsilateral septal

iii. Ant. Based septal composite mucoperichondrial flap

e. Skin graft for lining: (prelimaneted with forehead flap)

f. Folded forehead flap for lining

g. Microvascular lining: i.e. radial forearm

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o Nasal support:

a. If underlying normal bone and cartilage remain intact support replacement may be

unnecessary

b. Alar defect septal, ear, rib cartilage graft

c. In extensive midline defect septum may be absent several methods are useful

i. Septal composite flappivoted anteriorly, lining and central support are

positioned simultaneously out of piriform aperture

ii. This creates basic platform on which to rest other grafts a dorsal graft,

columellar strut, alar batters and sidewall grafts

iii. The dorsum can also be supported with cantilever dorsal graft of rib or cranial

bone fixed with a wire, screw or plate to nasal bones.

o Nasal cover:

a. Small superficial defect: less than 0.5 cm

primary closure

b. Defect less than 1.5 cm composite chondrocutaneous graft

c. Upto 1.5cm geometric bi-lobed flap, dorsal roataion advancement, single stage

superiorly based nasolabial flap

d. Large deep defect: two stage nasolabial, forehead flap (2/3 stages), distant flap (arm

flap, abdominal tube, DP or cervical) and free flap (RFFF)

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200

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37. RECONSTRUCTION OF THE MANDIBLE.

38. CRANIOFACIAL PROSTHETICS.

39. RECONSTRUCTION OF THE MAXILLA & SKULL BASE.

40. RECONSTRUCTION OF THE ORAL CAVITY, PHARYNX & ESOPHAGUS.

SEP2003PI

Q.4 Classify the lingual flap and describes briefly their likely uses?

MAR28, 2013PI

Q.5 A 23 year old female underwent right hemi-mandibulectomy and a neck dissection for a primary sarcoma of

the mandible 2 years ago. She had a post-operative radiation but no reconstruction was done. She now wants a

correction of her deformity.

a) What problems do you anticipate in the procedure and how can you avoid them?

b) Give 2 options for reconstruction and give reasons why you would choose a particular one for her?

MAR 25,2009PI

Q.8 A 23 Years old lady had a central mandibular defect measuring 11cm after firearm injury 6 months back. Her

soft tissue defect was repaired with a pedicle flap.

a) How will you prepare this patient for mandibular reconstruction?

b) How will you reconstruct this bony defect?

c) How will you check the viability of your transferred bone prior to any secondary procedure?

JAN 2008, PII

Q.13

a) How will you classify Maxillary defects?

b) A 50 years old man after resection of a Maxillary tumor came with a defect of right orbit maxillary area with

resection if right orbital contents and upper five walls of maxilla, sparing palate.

c) What are reconstructive options in this case? Which one will you choose and why?

JAN 2008, PI

Q.3 A 28 years old Pan-Masala user presents with a 4X6 cm ulcer over the left lateral order of the tongue. Biopsy

snows it to be a poorly differentiated squamous· cell carcinoma. He also has a 2X2 cm firm swelling in the left

submandibular region.

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a) How will you evaluate this patient?

b) Give your treatment plan keeping in view his age and histology of the tumor.

c) What would be your choice of reconstruction? Give reasons.

AUG 2007, PII

Q.15 Following a laryngectomy a patient starts having frequent coughing, foul smelling discharge from the wound

and wound dehiscence. There is also tachycardia & toxicity.

a) What is the likely diagnosis that has occurred? Give reasons

b) How will you evaluate the patient? Treatment plan.

March 20, 2012 PII

Q.15. Your ENT colleague is planning to a laryngopharyngectomy of squamous cell carcinoma in a 40 year old

obese female.

a) What factors will you consider while selecting a particular reconstructive procedure?

b) Give the advantages and disadvantages of three common forms of microsurgical reconstruction.

March 20, 2012 PI

Q.10: A 75 year old patient with well controlled diabetes was brought to you with extensive ulcerating lesion in sub

total destruction of her nose, upper lip, maxillary alveolus, left eye and cheek over a period of 7 years.

a) What is the most likely diagnosis?

b) How would you investigate this case?

c) How would you reconstruct the defect after resection?

MAR 17, 2010

Q.14 A young man received a shrapnel injury to the upper face during a terrorist bomb blast 2 hours ago The nose

upper lip, central upper alveolus and part of the hard palate are missing and the patient is bleeding profusely

a) What is the early management of this patient?

b) Outline the long term treatment plan.

c) Give in detail your plan for reconstructing his nose.

SEP 2005, PII

Q.20 A sixteen years old female presents with a suicidal shotgun wound of the lower face 3 hours after the

occurrence. This has resulted in loss of part of mandible, floor of mouth, and chin.

a) Outline initial assessment and treatment

b) Very briefly give one option for reconstruction and your reasons for choosing it.

AUG 2006, PII

Q.12. A 50 year old man had excision of major part of floor of mouth, partial mandibulectomy and radical neck

dissection. Enumerate the methods of reconstruction with pros and cons.

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Classification system for maxillary and Midfacial defects:

o Maxilla Anatomy:

It’s a pyramidal in shape having a base, an apex and four walls

Base: lateral wall of nasal cavity

Apex: directed laterally towards zygomatic process of maxilla

Anterior wall: facial surface of maxilla

Posterior wall: infratemporal surface of maxilla

Roof: floor of orbit

Floor: alveolar process of maxilla

o Cordeiro and Santamaira Classification

Type Features Reconstruction

Type I Limited Maxillary

Defects involve resection of one or two walls of the maxilla, excluding the palate

Scapular Parascapular ALT Rareedial forearm flap

Type II Subtotal maxillary IIa IIb

Defects include resection of the maxillary arch, palate and anterior and lateral wall with preservation of orbital floor Resection of less than 50% palate Resection of greater than 50% palate

Either a free flap or a combination of skin graft an obturator RFF If not free flap candidates that temporalis muscle flap Osteocutaneous radial free flap “sandwich”

Type III Total maxillary IIIa IIIb

Defects in middle resection of all six walls of maxilla Total maxillectomy with orbital preservation Total maxillectomy with orbital exentration

The rectus abd. Flap (single skin paddle) The temporalis muscle flap The fibula flap Rectus abd flap (3 skin paddle)

Type IV Orbitomaxillary

Defects include resection of orbital contents and the upper five walls of maxillar, sparing the palate

Rectus abd.flap in ideal (single islanded)

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Goals of maxillary reconstruction:

o Obliteration of the defect

o Restoration of essential

function of mid face

o Provision of adequate

structural support

o Aesthetic reconstruction of

external features

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206

Mandibular defect:

o Mandible is U-shaped bone o TMJ is a di-arthrodial joint o Types of defects: (Jewer Classification)

“C”-central defect including both

canines “L”-lateral segment, that exclude

condyle and don’t cross midline “H”- or hemi-mandibular- condyle is

resected together with lateral

mandible Eight permutations of these capital

letters including C, L, H, LC, HC, LCL, HCL and HH- are

most encountered for mandibular

defects o Mandibular defects may be congenital, acquired

(pathological or traumatic)

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A new classification for mandibular defects after

oncological resection

HCL (Boyd and colleagues classficiation):

o H-lateral defects of any length upto midline

including condyle

o C-defects involve central segment containing 4

incisors and 2 canines

o L-lateral defects excluding the condyle 3 lower

case letters describe soft tissue component

o- no skin or mucosa

s- skin

m- mucosa

sm-skin and mucosa and also some added

t-tongue

o Lateral defects can be reconstructed with a

straight segment of bone

o Central defect require osteotomies

o Anterior mandibular (C) defects require

absolute indication for reconstruction using vascularized bone

o Some center will reconstruct lateral (L) defects with vascularized bone, whereas other would

prefer to use soft tissues flaps with or without plates for reconstruction.

o Non-vascularized bone grafts (NVBGs) i.e. iliac crest, is another option for reconstruction of

small pure lateral mandibular defects.

Goals of mandible reconstruction:

o Restore form and function

o Restore bony contour of native mandible

o Restoration of mastication

Deglutition

Articulation

Maintenance of the airway

Condyle reoconstruction:

o Preserve condyle during resection

o Use as a non-vascularized bone graft

o Other options are:

Placing the flap into the fossa, interposing periosteum or temporalis muscle fascia.The

aim in this is to achieve a painless gap arthroplasty at the TMJ

Costochonral rib and Pure soft tissue reconstructio

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Commonly used free flaps for mandible reconstruction:

Free flap donor site Advantages Disadvantages

Fibula flap (gold standard) Based on peroneal a. Vascularized bone graft SizeTotal

native fibula length -12cm

Provide long segment of bone Multiple osteotomies without disrupting blood supply Ability to use a two team approach Good aesthetic and functional outcome

Limited height (double barrel fashion) Pain on ambulation Ankle instability Difficulty to closure donor site primarily (i.e. skin graft)

Iliac crest (2nd choice) Osteo-cutaneous flap Based on

DCIA Graft

length 6-16cm

Good bone height Donor site hidden under clothing Osteotomy can be done Ability to use a two team approach Primary closure of donor site

Poor color match of groin tissue Shaping the bone is difficult Bulky muscle, difficult to inset Risk of post op hernia Donor site pain limits gait and prevent early mobilization

Scapular free osteo-cutaneous flap Based on CSA Graft length ~14cm

Concealed donor site Large quantity of skin and soft tissues Support osseo-integrated implant

Lack segmental blood supply, doesn’t tolerate osteotomies Quality of bone is inferior to fibula and iliac crest Inability to use a two team approach Change of positioning during surgery Reduce range of motion of shoulder and difficulty lifting object

Radial forearm osteo-cutaneous flap Based on radial a Graft length ~14cm Prefabricated radial forearm flap

Large quantity of soft supple tissue Ability to use a two team approach Long pedicle

Short limited bone segment Doesn’t tolerate osteotomies Support osseo-integrated implant poorly Radius fracture risk (prevention: keel shaped osteotomy and prophylactic plating) Unsightly donor site as well as require volar splint + skin graft)

209

210

Osseo-integrated implant:

o Osseo-integration is defined as a time dependent healing process whereby clinically

asymptomatic rigid fixation of alloplastic materials is achieved, and maintained, in bone during

functional loading (Zarb &Albrektsson)

o Dental rehab is an important part of mandible reconstruction

o Use of Osseo integrated implant allows stable anchorage for placement of implant-borne

dentures, even in the absence of an alveolar ridge , allowing restoration of speech and

mastication and enhancing dental cosmesis

o Implants can be placed at the time of primary reconstruction or secondary with a delayed

procedures

o Pre-requisites for placement of osse-integrated implants:

An adequate vertical bone height

A minimum of 1mm of healthy bone surrounding the implants is also required

o Stages of Osseointegration:

Incorporation by woven bone formation;

Adaptation of bone mass to load (lamellar and parallel-fibered

bone deposition);

Adaptation of bone structure to load (bone remodeling)

o Recent advances:

Tissue engineering approaches to repair bone defect

Scaffolds ranging from collagen sponges to autologous autoclaved

bone have been together with bone marrow, derived stromal cells

and growth factors such as bone morphogenetic protein (BMP)-2

to facilitate osteogenic differentiation of implanted cells

o Soft tissue flaps:

The most commonly reported soft tissue flap used in combination with the fibula is the

radial forearm, but the ALT, rectus abd and pect.major flaps can be used as well as

pedicled flap like trapezius and pect.osteomyocutaneous flap.

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Reconstruction of pharynx: (larygnopharyngoplasty)

o Microvascular free flaps are largely replaced regional pedicled flaps, such as the PMMC flap, due

to their lower fistula rates.

o Free flap option include the jejunal free and fasciocutaneous free flaps, such as ALT and RFF free

flaps.

Flap donor sites Advantages Disadvantages

Jejunal free flap Vascular arcade via superior

mesenteric a 20-30 cm length (upper

ligament of treitz)

Avoidance of an additional suture line when reconstructing circumferential defects Lower fistula rates

Need of laparotomy Post op ilieus Anastomostic leakage Bowel obstruction

ALT free flap Minima donor site morbidity Lower fistula rates Can be used two skin paddle

Thick/ bulky flap Difficult to inset

PMMC (pectoralis major myocutaneous) flap

Large skin territory Rich vascular supply Large are of rotation No microvascular anastomosis Less time

Cosmesis Excessive bulk Breasat distortion in females

Lingual/ tongue flaps:

o First by Gersuny Eiselberg popularized in 1901

o One of the most versatile organ for obtaining tissue for transfer within the oral cavity of pharynx

o Its abundant blood supply permits the use of anteriorly/posteriorly based flaps, central island

flap and dorsal flap to transfer tissue

o Based on one or more branches of contralateral lingual vessel

Flap variation First described by Likely uses

Lateral-posterior tongue flap

Lexer Klopp & shurtev Conley Papioannau & Farr Ganguli & Villoria Chambens Som & Nusibaum Sessions

Repair defect of retromandiblar tonsil Repair defect of soft palate & tonsillar fossa Utilization tongue for closure of skeletal intraoral defects, creation of pharyngostomies and to protect carotid artery Reconstruction of floor of mouth Defects of cheek and tonsil Closure of defects of tonsillar fossa, buccal mucosa and retromandibular trigone Reconstruction of floor of mouth after marginal mandibulectomy Recommended ipsilateral hypoglossal nerve ligation to avoid flap pull away

Anteriorly based (set-back) tongue flap

De santo Defect of base of tongue

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Hemitongue advancement flap

Hovey Reconstruction of defect in patient who had undergone partial resection of anterior mobile tongue

Central island pedicled flap

Druck & Lorton Anterior floor of mouth defect recon (myomucosal flap)

Laterally based posterior tongue

Calcaterra

For pharyngeal closure For recon of hypopharynx

Tongue as transfer flap (dorsal tongue)

Guerrero-santos Reported use of these flaps to carry tissue to palate and lip

Sliding tongue flap Sisson For resurfacing hypopharynx

Splitting tongue Hiranandani Split the tongue and inferiorly advancement upper portion to reconstruct the pharynx

Sliding posterior tongue

Love Described use of a sliding posterior tongue flap for reconstruction following subtotal resection of hypopharynx

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32. RECONSTRUCTION OF THE EYELIDS & CORRECTION OF PTOSIS.

APRIL 2016

Q5) A 14 year old boy presents with the inability to lift both upper eyelids, requiring him to tilt the head upwards

for visualization. It is present since birth.

a) How would you establish your diagnosis, giving clinical evaluation.

b) Give an algorithm for upper eyelid ptosis.

c) What are the main complications of ptosis surgery, and how would you avoid them.

APRIL 2015

Q2) A 10 year old boy presents in the OPD with complaints of inability to open his eyes completely since birth.

a) What is your diagnosis?

b) How will you assess this patient?

c) Enumerate the reconstructive options according to severity of the condition.

MAR 2006, PII

Q.15 Briefly describe the various steps in orbital socket reconstruction following ablative surgery for tumor

excision.

a) Name two choices for lining of the orbital socket and the advantages and disadvantages of both; state your

preference

b) Name the commonest cause of a contracted eye socket unable to retain eye prosthesis?

MARCH 2006

Q.3 Enumerate the factors is preoperative evaluation of a patient with unilateral upper eyelid ptosis

Describe the two most important factors in deciding the type of operation to correct ptosis.

JAN 2008, PI

Q.8

a) Give the classification of Ptosis

b) A 52 years old lady develops ptosis after Botox injections. How will you manage this case initially? What will you

do if Ptosis persists after six months?

SEPT 2009

Q.8: With regard to upper lid ptosis:

a) Briefly describe how you would measure levator function.

b) Give the grades of levator function along with the measurement range of each grade.

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c) When the degree of ptosis is more than 3mm and levator function is more than 4mm, what type of operation

you would advise and why?

SEPT 2009

Q.1: Describe the methods of surgical reconstruction of lower eyelid defects following excision of tumor if the

lower eyelid defect is:

a) 0 – 25%.

b) 25 – 50%.

c) 50 – 70%.

d) over 70%.

SEP 2004, PI

Q. 10 A girl of 16 years presents with left sided ptosis.

a. How will you assess this patient?

b. Briefly discuss the surgical option available

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Upper eyelid ptosis:

o Blepharoptosis or ptosis is an upper eyelid malposition in which the upper eyelid falls below the

normal level of 1-2mm below the upper limbus

o Casues: number of anatomic problems involving

Levator palpabrae superioris muscle or

Its aponeurosis and or

Muller’s muscle.

Ptosis may be congenital or acquired

Congenital:

o Myopathic ptosis

o Blepharophimosis syndrome

o Marcus Gunn jaw winking synkinesis

Acquired:

o Aponeurotic ptosis: (involutional)most common

o Senile ptosis, post-operative edema, trauma

o Neurogenic:

o Third nerve palsy

o Horner’s syndrome

o Myogenic:

o Myasthenia gravis

o Chronic progressive external ophthalmoplegia

o Senile

o Mechanical ptosis:

o Excess weight due to edema, tumor, large chalazion etc

o Conjunctival scarring

o Symblepharon of the upper lid

o Pseudo-ptosis:

o Due to surgical anophthalmos, microphthalmos and phthisis bulbi

o Due to hypotropia

o Due to dermatochalasis

o Examination and evaluation:

Shaking hand (for myotonic dystrophy)

Standard History

Proper Examination:

Systemic

Local:

o Standard eye examination (vision, 6 cardinal gazes)

o Levator excursion

o Palpebral fissure measurement

o Ptosis grade measurement

o MRD

o Marcus Gunn jaw winking synkinesis

o Cover/uncover test and also Shirmer’s test

216

Surgical correction:

o Levator repair or resection with advancement

o Tarsoconjunctival mullerectomy (Fasanella-servat procedure)

o Frontalis sling

Autogenous (fascia lata and palmaris longus tendon)

Alloplastic (silicon)

Complications:

o Undercorrection:

Prevention & Tx: proper

planning, re-evaluation

and re-surgery

o Poor lid crease:

Prevention & Tx: proper

marking, suturing skin to

deep orbital septum and

levator aponeurosis and

back to skin

o Over-correction:

Prevention & Tx:

fastening, taking wound

closure nd cutting the

offending suture, and

should be treated with

massage

o Lagophthalmos

o Lid malposition

o Lid contour abnormalities

o Infection, hematoma, scarring,

contracture etc

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Reconstruction algorithm based on reconstruction zones:

218

31. RECONSTRUCTION OF SCALP, CALVARIUM & FOREHEAD.

JAN 2008, PI

Q.9 A medical officer from a small local hospital rings you to inform that he has a 15 year old patient with total

scalp avulsion sustained in a rotating machine one hour back.

What instructions will you give regarding transport of the Scalp tissue and the patient to you?

What are the principles of microsurgical replantation of the scalp?

MARCH 2009

Q.19: A 30 year old woman is referred to you with a sinus on the scalp, draining pus. She has a history of surgery

for brain tumor followed by radiation treatment 3 months ago. How would you evaluate and treat this patient?

March 20, 2012 PII

Q.11. A Young girl of 16 years had road traffic accident 2 years back in which she sustained scalp and facial injuries.

She presents with a bald patch of about 10x8 cm in left parietal and temporal region.

a) Name the most suitable reconstructive option.

b) How would you plan her reconstruction?

c) Enumerate the complications and how would you avoid them?

SEP 2005, PI

Q.6 A 32 years old farmer was electrocuted by high voltage tension wires 3 weeks back. His main wound requiring

your expert, help is over the occiput, measuring 13x11 cm. The occipital bone is exposed and occupies 2/3rd of the

area of this wound.

a) Order three investigations prior to surgery in this patient.

b) Enlist three- surgical options to repair the defect.

c) Name the most important complication you should try to prevent.

d) Name the most important long term complication in this case.

SEP 2004, PI

Q.6 A sixty years old man sustains electrical injury to scalp with necrosis of skin and calvarial bone over the right

parieto-occipital region.

a. What vessels supply the scalp?

b. What are the principles for managing acute scalp wounds?

c. What options are available for reconstruction of scalp bone defect?

219

Scalp:

Layers:

Blood and nerve supply:

220

Reconstruction of scalp:

o Primary closure up to 3cm

o Secondary closure

o Skin graft

o Dermal regeneration templates

o Local flaps

Partial thickness pericranial and glaeal

Full thickness an axial flap (based on major vessel)

For defects of 3-6 cm amenable to FTSG

For defects of 6-9cm large scalp flap (i.e. bucket handle for ant scalp defect)

Whichever flap design is chosen, the main reconstructive principles are

Mobilize as much scalp tissue as available to cover the primary defect (flap +

wide undermining) and to minimize the size of the secondary defect (wide

undermining) and

Plan the location of the secondary defect so as to maximize cosmetic and

functional results.

o Tissue expansion

o Regional flaps (trapezius and LD flap)

o Free tissue transfer: for defect greater than 9 cm

Musculocutaneous: (LD, RA, serratus anterior) muscle atrophy with passage of time

Fasciocutaneous (ALT) and

Omental flap (often becomes thin over time and may not be suitable for long-term

durable coverage)

Option available for reconstruction of scalp bone defect:

o Autogenous bone defect:

Calvarium, rib, and iliac crest

o Alloplastic material:

Titanium

Poly(methyl methacrylate) (PMMA)

Hydroxyapatite (HA)

Transport of Scalp Tissue: o Wash amputated part with water to remove gross

contaminants

o Wrap amputated part in moist gauze

o Place wrapped amputated part in dry plastic bag

o Place bag with amputated part in another plastic

bag with ice

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Principles of microsurgical replantation of scalp tissue: common principle are:

o Microvascular replantation should be attempted even in cases of prolonged ischemia time

o Careful cleaning and preparation of the scalp will help avoid the inclusion of hair and debris on

the underside of the flap

o One artery is all that is necessary for successful reperfusion, and it should be maximally

mobilized to avoid vein graft and

o One should attempt to re-anastomose at least two veins, ideally one in the occiput, to avoid the

common complication of venous congestion

Osteomyelitis:

o Has traditionally been classified into 3-categories

Hematogenous osteomyelitis through blood stream

Osteomyelitis due to spread from a contiguous focus of infection without vascular

insufficiency

Osteomyelitisdue to contiguous infection with vascular insufficiency

o Pathogenesis:

Norma bone is highly resistant to infection

Bacteria possess a variety of virulence

i.e. Protein (adhesin) which facilitate attachment to bone and ability to form

biofilm (a slim layer that shield bacteria from antimicrobial agent)

Inflammatory responses leads to increase intra-osseous pressureischemic necrosis

dead bone (sequestrum)

o Clinical presentation:

Depending on categories of infection, location, organism and host

Fever, chills, pain and sign of inflammation

Purulent discharge from wound

Physical exam: diminished pulses, poor capillary refill

o Evaluation and diagnosis:

Bone biopsy is the gold standard.

Routine exam and blood tests

Microbiology (blood cultures, wound C/S, bone biopsy)

Radiology: (plain radiographs, CT scan, MRI, Bone scan (3-phases), WBC scan

o Microbiology and treatment:

Basic principle of treatment:

A combined medical and surgical approach is usually needed

Dead- tissue must be removed

Poorly vascularized tissue is unlikely to heal

Empiric therapy not guided by culture results is more likely to fail

With few exception infection is very difficult to eradicate from prosthetic

material.

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Tissue expansion:

o Represents an invaluable asset in scalp reconstruction, allowing replacing like with like

o As much as 50% of the scalp can be reconstructed by expanding the remaining scalp

o Limitations:

The wounds need to be free of infection

Tissue o be expanded should be healthy and well vascularized

Expanding previously radiated tissue is not advisable

o Counselling:

The patient needs to be well informed preoperatively screened in regards to social

support, medical compliance, status of the underlying disease and its treatment course

and the will to endure the length expansion period, the consequent physical deformity,

and multistage reconstruction

Expander complication rates may be as high as 25% and include infection, exposure,

extrusion and device failure

o Principle of tissue expansion:

Correction of burn deformities using tissue expansion is a multistage process

Not only patient selection is crucial, so is individualized preoperative planning

The expectation of the patient and those of surgeon should match

Patient acceptance of weekly or bi-weekly injection process and the progressive

deformity cause by the expander is essential

Issues related to insertion process are less controversial when compared with the

details as to how this should be done

Incision:

Type of incision is still an issue

Proponents of paralesional incision (I.e. incision at the junction of normal tissue

and the scarred area) believe that minimal undermining of tissue is required for

insertion of expander

Implant:

Portal placement:

Several investigation have documented

safely in use of external ports

In pediatric population the use of

external port can alleviate pain and

anxiety associated with weekly

injection

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Expansion rates:

Can vary greatly

After healing of incision or

Anywhere from 1 week to 21/2 week after placement

Face and scalp expander may be easily inflated 2-3 times/week

Longer interval 7-10 days for extremities

Injection fraction vary, but 10% of volume per week is required to complete

expansion within 3 months period.

Overfilling/overexpansion by up to 50% of the estimated amount is necessary

o Techniques in tissue expansion:

Intraoperative consideration:

In most cases, expanders are placed below the galea or at the fascial layer,

depending on location

Meticulous hemostasis is crucial

Irrigation of expander pouted with antibiotic solution is also a common practice

Checking expander for leakage is an important part of procedure

Injection of air with the submersion of expander in saline is reliable for

detecting leaks

Alternatively, the use of methylene blue helps to identify expander leaks prior

to insertion

Operative technique;

Once the expander has been successfully inflated and ready for removal,

advancement or rotation of the flap has usually been decided

Hudson feels that the best method for maximizing the use of expanded tissue in

both vertical and horizontal direction is to add back cuts to the sides as well as

base of flap

Scoring the capsule to increase flap advancement has been touted by several

authors.

o Classification of burn alopecia:

Type Feature

Type I Type II Type III Type IV

Single alopecia segment a. Less than 25% of hair bearing scalp b. 25-50% of hair bearing scalp c. 50-75% of hair bearing scalp d. 75% of hair bearing scalp

Multiple alopecia segments amenable to tissue expansion placement Patchy burn alopecia not amenable to tissue expansion Total alopecia

224

o Complication: 1984, martin et al

Major complication (interrupt expansion process) Minor complication (resolve without interruption)

1.Infection 2.Expander exposure

Dehiscence of incision Erosion of envelope fold through skin Erosion of envelope or reservoir through

inadequate covering tissue Manipulated by psychiatric patient

3.Implant failure Removal of port connector Physician assembly may be faulty Injection port may lack proper back Envelope may be perforated by needle

4.Induced ischemia: Flaps may become ischemic when expanded Irradiated tissue may not survive elevation

1.Pain on expansion 2.Seroma and drainage after expander inflation 3.Dog-ear after advancement 4.Widening of scar with time

225

34. RECONSTRUCTION OF ACQUIRED LIP DEFORMITIES.

JUNE 25,2008PI

Q.3 A 55 years old male patient presents with squamous cell carcinoma of the lower lip, 1.5 cm wide and just 0.5

cm medial to the right commissure. The cervical lymph nodes are not involved.

a) Give two options for reconstruction of the defect after excision of this tumor.

b) Give advantages and disadvantages of each option.

MAR 2004, PI

Q.3: A 40 years old "naswar" user presents with a midline growth of the lower lip. Apparent changes are extending

to the mucosa of the adjacent alveolus.

a. Give the essential factors for the evaluation of this lesion.

b. Outline the treatment plan

SEP 2004, PI

Q.2 A 70 year old man presents with squamous cell carcinoma of central portion of lower lip of 2 cm size and

palpable sub mental N1 lymph node.

a. How will you investigate this case?

b. How will you treat this case?

226

Lip:

A reconstructive

algorithm for full

thickness acquired

defects:

227

Four pattern of lower lip excision for

Small full thickness lower lip defects.

Schematic of Abbe flap:

228

Schematic of B/L karapendzic:

229

Schematic of Modified Bernard flap:

Schematic of Estlander and Reverse estlander flap:

230

Schematic of Vermillion reconstruction:

231

36. FACIAL PARALYSIS.

April, 2016

Q.1) A 28 year old female developed a facial palsy after removal of an acoustic neuroma. How will you manage her

postoperatively, giving your reasons if she presents at:

a) 3 months.

b) 12 months.

c) 24 months.

OCT 2013

Q20) A 25 year old unmarried woman presents to you with right sided facial palsy following surgery for a CP angle

tumor 6 months back.

a) What are the possible options to reanimate this patient?

b) Which one would you choose, justifying your choice.

MAR 2004, PI

Q.9

What are the causes of post-operative facial nerve dysfunction?

Briefly describe Frey's syndrome and its management

AUG 2006, PI

Q.8 Enumerate the dynamic procedures for treatment of facial palsy (unilateral complete) with pros and cons of

each procedure

MAR 2005, PI

Q.5 A 25 year old unmarried woman presents to you with a right sided facial palsy following surgery for an acoustic

neuroma 6 months ago.

a) What are the possible means of correction of this deformity in this patient?

b)'Which one would you choose giving reasons for it?

SEPT 2010

Q.2:

a) Enumerate the causes of facial nerve dysfunction.

b) Enumerate various dynamic facial re-animation procedures.

c) Briefly describe Frey’s syndrome and its management.

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Facial nerve paralysis:

o Facial nerve: 7th cranial nerve and supplies 23 paired and one orbicularis oris muscle.

Segments:

Cisternal segment in CPA

Intracanalicular segment

Labyrinthine segment

Tympanic segment

Mastoid segment

Extracranial segment

Branches:

Geniculate ganglion: is location of 1st

three branches

Greater petrosal nerve

Lesser petrosal nerve

External petrosal nerve

In mastoid segment:

Nerve to stapedius

Sensory auricular nerve

Chorda tympani

Extracranial segment:

Posterior digastric

Stylohyoid

Posterior auricular nerve

Braches in parotid gland:

Temporal branch

Zygomatic branch

Buccal branch

Marginal mandibular

branch and

Cervical branch

Etiology of facial nerve palsy: May in

1981

Intra-cranial Intra-temporal Extra-temporal/Temporal

Vascular abnormalities Brain tumor-CPA Developmental abnormalities Agenesis of Facial nucleus Trauma Degenerative disorder of CNS

Developmental Infection Cholesteatoma Tumors of middle ear, mastoid Trauma (# temporal bone) Iatrogenic

Trauma Malignant tumor (parotid) Iatrogenic Bell’s pasly:-

Idiopathic Trauma, Infection & Tumor

233

o Aims of reconstruction:

Restore symmetry and coordinated dynamic animation with normal appearance at repose &

Symmetry during voluntary and involuntary expression

Competent oral and ocular sphincter

Preservation of existing facial function and

Minimal loss of function in other donor motor nerves should be the goal

o Pre-op examination:

Standard history and proper physical examination are imperative for establishing a

management plan

Local exam must include all cranial nerves, any scar, evaluation of facial expression, blowing,

forceful eye closure, whistling, clenching, parotid gland and any scar or mark over mastoid

area for exclusion of birth trauma etc

To detect anatomical site of lesion, tests such as the schirmer test, stapedius reflex, taste

examination and salivary flow test

Investigation: electroneurography, needle electromyography (EMG), nerve conduction

studies, blink reflex and nerve excitability testing , CT scan and MRI

o Operative technique:

Direct repair

Nerve grafting

Cross facial nerve graft up to 6 months (post injury)

Nerve transfer

The “Babysitter principle” 6 months to 2 ½ year (post injury)

Direct neurotization: not later than 2 years after injury

Muscle transposition in long standing injury (i.e. temporalis muscle innervate other than

facial nerve)

Free muscle transfer (i.e. gracilis, pect.minor, LD, serratus anterior, split rectus abd,

corachobrachilias, internal oblique, and extensor digitorum brevis muscle)

o Reanimation of upper, middle and lower face:

Reanimation of eye:

Primary aim is to:

Limit ocular exposure

Protect the eye

Restore eye closure and blink and

Improve appearance

Temporary measures:

Eye protection with tapes or other

occlusive measure during sleep, protective glasses and routine eye lubrication

Permanent solution:

Static maneuver:

o Gold weight insertion or eye spring for patient with partial blink

o Lower eyelid position can be improved with canthoplasty, tendon graft for

suspension or lid shortening

Dynamic maneuver:

234

o Primary repair of nerve (zygomatic branch)

o Direct neurotization via implantation of motor donor nerves via nerve

graft in orbicularis oculi muscleviable muscle fibers in eye sphincter

o Orbicularis oculi muscle: substitution are contralateral platysma and

frontalis muscle

o Mini-temporalis transposition: no synchronous blink

o Reamination of smile:

Use of regional msucles:

Partial or total transfer of masseter

Temporalis muscle

Free microneurovascular muscle transfer: involve

one or two stage

First two operation by CFNG and later free

microneruovascular muscle transfer gold

standard management for long standing

paralysis or developmental facial paralysis

(DFP) i.e. gracilis and pect.minor

One stage free tissue transfer:

Muscle recovery as early as 6 months after one stage procedure and successfully

treated children with hemifacial microsomia

Harii et al. give 2 explanation for rapid muscle re-

innervation

Retrograde blood flow

Single neurorrhaphy

o Reamination of lip depressor:

Lower lip paralysis traditionally managed with

Selective myectomy or

Neuroctomy on normal side

Botulinum toxin Type A

Dynamic restoration:

Mini-hypoglossal nerve transfer

Use of CFNGs

Direct neurotization

Regional msucles (ant.belly of diagastric or

lateral platysma muscle

Soft tissue rejuvenative technique:

Superficial musculoaponeuritic system

cervicofacial rhytidectomy, blepharoplasty,

browlift, and lower lid tightening can augment

aesthetic restoration.

235

Forehead Flap: surgical technique and design consideration

o General consideration:

This operation is performed under local, sedation or preferably with general anesthesia

Prior to designing the flap , primary defect must be

evaluated

In case where a combined defect of cheek and

nose is present, evaluate and fix cheek 1st

o Guiding principles for design and elevation include: (Modifications provided by masters like Burget and Menick have

only increased the utility of this exceptional flap)

Maintaining an axial pattern whenever possible

Utilizing the pedicle ipsilateral to defect

Extending the flap at right angle across the

forehead with caution and only when extra length

is necessary

Utilizing a reasonably narrow pedicle

Early sub-periosteal dissection

o Flap variation:

Paramedian forehead flap (Indiana)

Median flap

Lateral forehead flap

o Flap elevation:

Pedicle is located about 2 cm lateral to midline

near medial eyebrow

Base of flap is designed 1.5cm wide to include

pedicle

Modification include a narrower pedicle, axial pattern ipsilateral rotation, sub-periosteal

dissection with periosteal scoring and skin grafting at flap elevation

Avoidance of transferring of hair is best

Great care and operative time is put into correct flap dimension for coverage

Careful consideration is made for correct orientation

Remember that flap can be pivotal at a point below level of eyebrow

Avoid trauma to flap

Widening infiltration the surgical field will help define the surgical plane, and minimize

blood loss

Flap elevation begin distally

It is elevated thickly at level galea or 1cm below eyebrow, the dissection is carried sub-

periosteally and continued over the orbital rim

This captures sub-periosteal perforater and provide for very safe flap

If there is significant tethering or shorteness of flap, the periosteum can be scored,

dissected free, or the flap can be raised above periosteum

Tip of flap, for initial 1.5-2cm, is raised with subcut plane with removal fo sub fat and

underlying frontalis muscle.

236

o Flap inset:

If properly designed, insetting should be easiest part of case

Great care is taken to thin most distal ~1/8th of the flap

as this portion will never be re-evaluated

o Donor site closure:

Primary closure or left some area for secondary healing

or covered with skin graft

Important not to attempt to close the donor site at level

of rotation to prevent pinching and venous congestion

of the flap

o Post-op care:

Dressing

Can take shower- 3rd post op day

Removal of inset suture- 5-7th day

o Detachment: after 14-21 days

237

Nasolabial flap:

o Introduction:

The nasolabial flap is a hardy flap that finds its use in the everyday reconstruction of

various defects in the head and neck. The flap may be superiorly or inferiorly based. The

choice between the two will depend on the location of the defect and the arc of

rotation needed to reach it with the least amount of tension. The use of the nasolabial

flap varies. In broad terms, it is commonly used as a superiorly based flap to reconstruct

nasal defects and oral defects located in the upper sulcus or palate. When it is raised as

an inferiorly based flap, it is used most commonly to address lower lip defects or

intraoral defects such as floor of mouth, lower gingival sulcus, and buccal mucosa

defects. The nasolabial flap has found a unique role as one of the go-to flaps in the

reconstruction of buccal defects such as those encountered after the excision of scar

bands and or fibrosis secondary to betel nut chewing. Prior to the establishment of

microvascular transfer as a routine option in the reconstruction of head and neck

defects, the nasolabial flap was very popular for the repair of floor of mouth defects

created after excision of squamous cell carcinomas.

The main advantages of using the nasolabial flap for reconstruction of external skin

defects are the color and texture match to the defect site. Because of the proximity of

the donor site to the defect site, the use of this flap allows for a near imperceptible

reconstruction for these two factors.

The main disadvantage of the nasolabial flap is the scar at the donor site. The location of

the scar renders its use less than favorable to many patients. In some cases, when the

flap is utilized in younger patients and only on one side, there is a potential for

postoperative facial asymmetry. Lastly, in cases where the flap is needed for the

reconstruction of floor of mouth defects, the remaining dentition needs to be evaluated

to see if it will traumatize the flap when the patient is chewing and the reconstruction is

carried out in stages.

o Anatomy

The regional anatomy relevant to the nasolabial flap extends from about 5 mm inferior

to the medial canthus and extends inferiorly towards the inferior border of the

mandible.

The bulk of tissue available for use in a nasolabial flap is found along the area of the

nasolabial fold as it extends lateral to the ala of the nose to a few millimeters below the

lateral aspect of the oral commissure. The common design of the nasolabial flap would

include the tissues in the nasolabial fold and lateral to it and as it extends inferiorly, it

would include a small quantity of tissue just medial to the fold but with a greater

quantity on the lateral aspect.

The vascular anatomy of the periorbital and perinasal region comes mainly from the

facial artery, angular artery, and the nasal arteries.

The facial artery travels in a superior oblique direction once it emerges above the

mandible. Along its path it gives off a number of branches, those being the inferior and

superior labial arteries, and the lateral nasal artery before it becomes confluent with the

angular artery.

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The angular artery is a branch of the ophthalmic artery that joins the facial artery as it

descends inferiorly along the superior lateral aspect of the nose.

In the superior aspect of the nose, the ophthalmic artery also gives off the dorsal nasal

artery.

All of these arteries give off perforators to the skin, which are responsible for the

perfusion to the nasolabial flap. The main perfusion to the flap comes from the

perpendicular vessels originating from the facial artery and angular artery.

The venous supply to the flap is based on the accompanying veins.

The nasolabial flap may be raised as an axial flap, a random flap, or as an island flap. An

inferiorly based nasolabial flap has been raised in patients where the ipsilateral facial

artery has been ligated either at the time of surgery or in a previous surgical encounter.

o Flap harvest:

Superiorly based flap:

o Once the decision has been made to raise a superiorly based flap, the next decision

is to determine its width and length, and therefore the reach of the flap.

o The flap should be designed so that the inferior tip of the flap narrows down to a

point. This design will allow for the closure of the donor site with the least amount

of undermining and excision of dog ear. Equally, the flap design should place the

final scar within the nasolabial groove. The placement of the scar within this region

will give the least conspicuous

evidence of the surgery.

o The flap is elevated from the distal tip

towards the base by first making an

incision deep to the dermis along the

marked width of the flap.

o The flap is elevated in a plane

superficial to the muscles.

o Care should be taken to identify and

avoid injury to the perpendicular branches of the facial artery as they penetrate the

muscle on their way to perfuse the overlying skin.

o The surrounding area is undermined to

improve the rotation of the flap without

causing distortion of the tissues around the

base of the flap.

o In cases where the flap is to be used along the

nasal sidewalls, the flap is rotated to insure

the reach is adequate and without tension.

o The flap is contoured to the defect and inset

by placing one to two deep sutures along the

base to recreate the groove and the rest of

the flap is inset in the usual fashion as per the

surgeon’s routine.

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Inferiorly based flap

o The inferiorly based flap is designed with the superior medial border of the flap

running in the nasolabial fold and widening to incorporate the desired width of the

flap laterally along the cheek.

o In the inferior region of the flap, around the upper lip and towards the commissure,

the medial incision should extend about 4 mm medial to the crease.

o The inferior width of the flap should be about 1.5 cm in order to capture enough of

the perforating vessels and to allow for adequate perfusion to the distal tip of the

flap.The incision is made superiorly.

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Flap monitoring: 24-72 hours most failure occurs within first 48 hours

o Clinical evaluation:

By an experienced microsurgeon is considered the gold standard for perfusion assessment

Important physical sign:

Quality of capillary filling,

Bleeding from cut edge,

Tissue turgor and

Temperature

Arterial inflow problem: pale, cool, digit with rapid refill

Venous insufficiency: rigid, blue with rapid refill

o Monitoring device:

Surface or pencil Doppler

Temperature probe

Laser Doppler probe

Quantitative fluorometer

Implantable Doppler

Near infra-red spectroscopy

Qualitative indocyanin green

o Causes of failure: Vascular occlusion (venous congestion is more common than arterial)

o Salvage rates: From 28%-90% (venous has higher salvage rate)

o Managing flap failure:

The first step in managing flap failure is early recognition of a compromised flap. Clinical

observation + pin prick, temperature and surface doppler, upon suspicion of vascular

compromise, shift the patient to OR for re-exploration. Surgical method should be the first

choice, with re-exploration initial attention should be directed at vascular pedicle. Causes

of extrinsic compression i.e. hematoma, pedicle kinking or misconfiguration are easily

identifiable and potentially correctable. The arterial system should be examined under

magnification for vascular spasm, for which topical papaverine may be used. Arterial can be

assessed by looking for pulsation of the distal pedicle or use of intraoperative Doppler.

Milking of venous system using microsurgical instruments may be used to assess venous

outflow. Identification of thrombus should prompt opening the anastomosis and

evacuation of clot with heparinized saline irrigation or a fogarty catheter prior to careful re-

anastomosis. Thrombolytic agents i.e. streptokinase, urokinase or tissue plasminogen

activator can be used if a thrombosis is identified, particularly in venous system.The venous

anastomosis should be taken down prior to flushing the flap with any of these thromblytic

agents in order to avoid systemic effect. Systemic antithrombotic therapy with IV heparin

may be considered in select salvage cases of arterial or venous thrombosis where flow is

re-established, particularly if thrombosis formation rapidly occurs at time of re-

anastomosis. The initial recipient vein and/or artery may not be appropriate in which case

another should be chosen.

o Non-surgical management of compromised flap: In selected cases venous congestion can be

managed with application of leeches. Partial flap loss may be managed with conservative

treatment such as debridement and secondary healing.