Color Atlas of Head and Neck Surgery - A Step-By-Step Guide [2015][UnitedVRG]

Siba P. Dubey Charles P. Molumi

Color Atlas of Head and Neck Surgery A Step-by-Step Guide

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Color Atlas of Head and Neck Surgery

Siba P. Dubey • Charles P. Molumi

Color Atlas of Head and Neck Surgery A Step-by-Step Guide

Siba P. Dubey University of Papua New Guinea and Port Moresby General Hospital Boroko, National Capital District, Papua New Guinea

ISBN 978-3-319-15644-6 DOI 10.1007/978-3-319-15645-3

Charles P. Molumi Port Moresby General Hospital Boroko, National Capital District, Papua New Guinea

ISBN 978-3-319-15645-3

(eBook)

Library of Congress Control Number: 2015938239 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any o ther physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com)

Everyday, we learn from our patients; this book is dedicated to them.

Foreword I

The range of conditions treated by Otolaryngology Head & Neck (OHN) Surgeons is very broad. In the developing world, the whole range of head and neck conditions are seen, frequently in an advanced state and often with complications of late presentation. This is particularly so in Papua New Guinea (PNG). I have come to know Professor Siba P Dubey during my regular visits to Port Moresby as visiting surgeon and external examiner for specialist surgical qualifications. I have great admiration for the work he has done over the last 20 years in treating many thousands of patients from all over PNG, in training almost a generation of OHN Surgeons for the country and its near neighbours and in gathering his dedicated team together at the Port Moresby General Hospital. Dr Charles P Molumi trained under Professor Dubey and has joined him in the challenge of treating the diverse and complex array of OHN diseases. Drs Dubey and Molumi have amassed a vast surgical experience whilst improving patients‘ lives and their long-term outcomes. T hey have prospectively collected their data, published numerous journal articles in peer-reviewed journals on advanced disease and its management, and have now produced a fine operative surgical atlas. The book covers a very wide range of rhinological, otological, head and neck oncological and reconstructive procedures illustrated with high-quality photographs. It displays the authors’ comprehensive surgical abilities across all areas of OHN surgery. The open procedures and more traditional reconstructive techniques will be useful to those places where there is a lack of availability of high-technology equipment, a dedicated plastic and reconstructive service and poor patient follow-up. The atlas is a testament to what can be achieved in an under-resourced environment, with sound surgical ability and a dedication to caring for patients whose life and its quality are jeopardised by advanced disease processes. It will be of interest to all OHN surgeons and trainees, opening the eyes of those practising in the developed world and inspiring those in developing countries. Dr Dubey and Dr Molumi are to be congratulated. December, 2014 Melbourne, Australia

Vincent C. Cousins, BMedSci, MBBS, FRACS

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Foreword II

When I met Dr. Siba P. Dubey at the IFOS Congress in Rome in 2005 and again at the Salivary Gland Congress in Paris in 2008, who would have predicted that these brief meetings would eventually lead to the honor of my being invited to write the Foreword to this remarkable book Color Atlas of Head and Neck Surgery: A Step by Step Guide by Drs. Siba P. Dubey and Charles P. Molumi. Dr. Dubey trained and qualified in Otolaryngology–Head and Neck Surgery in India and has spent the last 20 years operating on a vast number of patients, many if not most of whom have advanced cancer of the head and neck. Dr. Dubey and Dr. Molumi are consultants at Port Moresby General Hospital, the tertiary referral center of the country and the teaching hospital of the School of Medicine and Health Sciences, University of Papua New Guinea where Dr. Dubey is an Honorary Professor and Dr. Molumi is an Honorary Lecturer, respectively. When Confucius said “A picture is worth a thousand words” he must have been thinking of this book. This book is unique in that the techniques of surgery of all of the anatomic sites in the head and neck are presented in a series of astonishingly high resolution intraoperative photographs accompanied by brief figure legends highlighting the key features of the technique presented in the photos. Presenting the important elements of each operation graphically without having to wade through a great deal of t ext will certainly appeal to residents and fellows in training whose time to read is limited by their heavy work load. This book will prepare them well for their real-life experiences in the operating room. I congratulate the authors for producing this unique contribution to the literature in head and neck surgery. As we are well into the high technology age, I found it refreshing to have a low technology go-to text as a quick reminder of how to do it. January 2015 Pittsburgh, PA, USA

Eugene N. Myers, MD, FACS, FRCS Edin (Hon)

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Preface

The surgery of the head and neck region requires a great degree of expertise due to the presence of a large number of vital structures in a very compact area. This book is comprised of several chapters, namely, the nose and paranasal sinuses, larynx, thyroid, salivary glands, mandible, temporal bone malignancy, facial plastic surgery, neck dissections and surgery of the lip and oral cavity. Sections deal with (i) r adical and conservative (organ preservation) surgeries, (ii) aesthetic and reconstructive surgeries, and (iii) surgeries of the skull base. Preservation of function has led to the development of a number of organ preservation procedures, namely, different types of laryngectomies, maxillectomies and neck dissections. The most attractive and challenging feature of head and neck reconstruction is the complexity of the functional and aesthetic requirements. Goals are achieved with the help of a number of axial and microvascular free flaps. The surgery of the skull base deserves special mention as it is performed within the confines of the narrow spaces, often surrounded by sensitive neural and vascular structures. We hope that otolaryngologists, head and neck surgeons, plastic surgeons, maxillofacial surgeons and surgical oncologists will be benefitted by this book where step-by-step operative descriptions will act as quick references. The authors wish to express their sincere gratitude to late P rofessor Wolfgang Draf, Fulda, Germany, for his encouragement to publish this book. Our special thanks to Professor Vincent C Cousins, Melbourne, Australia, and Professor Eugene N Myers, Pittsburgh, USA, for going through the manuscript, providing editorial assistance, and writing the forewords for this book. We also appreciate the secretarial help of Jackie Lynch, Pittsburgh, USA. We are thankful to Professor Herwig Swoboda, Vienna, Austria, for his constructive advices from time to time, and to Professor John D Vince, Associate Dean, School of Medicine and Health Sciences, University of Papua New Guinea, for his advices during preparation of the manuscript. We very much appreciate the help we received from all our professional and administrative colleagues within Papua New Guinea. We are very grateful to Ms. Sandra Lesny, Ms. Martina Himberger and to the entire team at Springer for their superb help in all the stages of production of this book. Boroko, National Capital District, Papua New Guinea

Siba P. Dubey, MS Charles P. Molumi, MMed

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Contents

1

Nose and Paranasal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Sublabial Approach for Maxillary Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Midfacial Degloving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 Lateral Rhinotomy with Medial Maxillotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4 Transpalatal Approach by Palatal Osteomucoperiosteal Flap . . . . . . . . . . . . . . . 1.5 Total Maxillary Swing (For Advanced Nasopharyngeal Angiofibroma) . . . . . . 1.6 Total Maxillectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7 Total Maxillectomy with Orbital Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . 1.8 Extended Total Maxillectomy with Cheek Skin Excision . . . . . . . . . . . . . . . . . 1.9 Craniofacial Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 1 3 5 8 11 17 21 25 27

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Larynx and Trachea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Arytenoidectomy and Lateralization of Vocal Cord (Modified Woodman’s Technique). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Frontolateral Vertical Partial Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 Supracricoid Laryngectomy with Cricohyoidoepiglottopexy . . . . . . . . . . . . . . 2.4 Supraglottic Horizontal Partial Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 Total Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6 Total Laryngopharyngoesophagectomy with Gastric Pull Up. . . . . . . . . . . . . . 2.7 Upper Tracheal Resection and Anastomosis for Trachea Stricture . . . . . . . . . .

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Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Sistrunk Procedure for Thyroglossal Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Hemithyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Total Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 65 67 70

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Salivary Glands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Submandibular Sialoadenectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Superficial Parotidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Superficial Parotidectomy with Deep Lobe Resection . . . . . . . . . . . . . . . . . . . 4.4 Total Parotidectomy with Facial Nerve Graft with Sural Nerve and Blind Sac Closure of External Auditory Canal for Malignant Parotid Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 Temporoparietal Facial Flap (TPFF) and Abdominal Fat Graft for Prevention of Frey’s Syndrome Following Parotidectomy . . . . . . . . . . . . .

73 73 77 80

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31 35 38 42 48 56 58

82 85

Repair of External Nose Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 5.1 Repair of Alar Defect with Full Thickness Skin Graft . . . . . . . . . . . . . . . . . . . 89 5.2 Superior Based Nasolabial Flap for Reconstruction of Alar Defect . . . . . . . . . 91 5.3 Modified Reiger Glabellar Rotation Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 5.4 Island Forehead Flap for Reconstruction of External Nose Defect . . . . . . . . . . 95 5.5 Schmid-Meyer Frontotemporal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 5.6 Oblique Forehead Flap for Basal Cell Carcinoma of Nasal Dorsum. . . . . . . . 101 5.7 Anterior Scalping Flap for Nose Reconstruction. . . . . . . . . . . . . . . . . . . . . . . 103 xiii

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Contents

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Axial and Free Flaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Facial Artery Musculomucosal (FAMM) Flap . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Palatal Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 Submental Artery Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 Nasolabial Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 Trapezius Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.6 Lattismus Dorsi Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.7 Pectoralis Major Myocutaneous Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 Radial Forearm Free Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107 107 112 115 121 122 124 126 130

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Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 Mandibulotomy for Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Segmental Mandibulectomy and Reconstruction with Stabilizing Plate and Screw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3 Segmental Mandibulectomy and Reconstruction with Rib Graft . . . . . . . . . . 7.4 Bilateral Hemi Mandibulectomy and Reconstruction with Fibular Graft Microvascular Anastomosis . . . . . . . . . . . . . . . . . . . . . . . .

133 133

8

Lips and Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 Repair of Lip Defect with Abbe-Estlander Flap . . . . . . . . . . . . . . . . . . . . . . . 8.2 Repair of Full Thickness Lip Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3 Repair of Near Total Lop Defect by Karapandzic Flap . . . . . . . . . . . . . . . . . . 8.4 Repair of Medial Canthal Defect with Split Forehead Flap. . . . . . . . . . . . . . . 8.5 Deep-Plane Cervicofacial Rotation-Advancement Flap . . . . . . . . . . . . . . . . . 8.6 Temporalis Muscle Flap Transposition Technique for Paralysed Face . . . . . . 8.7 Pedicled Calvarial Bone Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

141 141 143 145 146 147 149 152

9

Temporal Bone Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1 Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy . . . . . . . 9.2 Subtotal Petrosectomy with Excision of Pinna . . . . . . . . . . . . . . . . . . . . . . . .

155 155 158

10

Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1 Excision of Lipoma Over Parotid Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2 Excision of Sebaceous Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.3 Excision of Parapharyngeal Neurofibrosarcoma . . . . . . . . . . . . . . . . . . . . . . . 10.4 Excision of Neck and Mediastinal Neurofibroma . . . . . . . . . . . . . . . . . . . . . . 10.5 Supra Omohyoid Neck Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6 Modified Radical Neck Dissection. Accessory Nerve Preserved . . . . . . . . . .

159 159 161 162 164 166 172

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

177

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

179

135 136 138

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Nose and Paranasal Sinus

1.1

Sublabial Approach for Maxillary Cyst

Fig. 1.1 Right nasolabial swelling due to cyst in the maxillary sinus

Fig. 1.2 The incision begins 0.5 cm above the junction of the gingivolabial sulcus mucosa. It extends from the canine to the first molar tooth. The incision is made bone deep. The superior mucosal flap is raised preserving the neurovascular bundle in the infraorbital foramen

S.P. Dubey, C.P. Molumi, Color Atlas of Head and Neck Surgery: A Step-by-Step Guide , DOI 10.1007/978-3-319-15645-3_1, © Springer International Publishing Switzerland 2015

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Fig. 1.3 A small gouge is placed at the canine fossa and hammered till the maxillary sinus antrum is entered taking care not to damage the root of the tooth. The opening is enlarged by nibbling the bone edges with a

1


Kerrison rongeurs till adequate exposure is attained. In cases where the bone is thinned out by the tumor, this might not be necessary

Fig. 1.4 The tumor is removed and the cavity is packed with an acroflavin pack. An inferior meatus antrostomy is made. The end of the pack is kept in the nasal cavity and removed on the third post operative day. The sublabial incision is closed in layers

1.2

1.2

Midfacial Degloving

3

Midfacial Degloving

Fig. 1.5 After oral intubation, patient is placed in head extended position. The nasal vestibular hairs are trimmed off and the nose is prepared with cophenylcaine spray and lignocaine with adrenaline infiltration. Bilateral tarsorrhaphies are done. A columella clamp is used to retract the columella. A total transfixation incision is marked out on each side at the junction between the stratified squamous and respiratory columnar epithelium

Fig. 1.7 A sublabial incision is made from the first molar of the ipsilateral side to first molar of the contralateral side. The incision is deepened to the periosteum of the canine fossa

Fig. 1.8 The nasal vestibule is released circumferentially by a through and through incision made down through the periosteum of the pyriform margin and the nasal floor

Fig. 1.6 The transfixation incision is extended from the tip of the nose onto the nasal floor

4

Fig. 1.9 Through the sublabial incision, the upper lip and the columella are elevated exposing the anterior end of the septal cartilage and marking over the lower lateral cartilage at the junction between the stratified squamous and columnar epithelium for the intercartilagenous incision

Fig. 1.10 An intercartilagenous incision is made to join the superior end of the transfixation incision medially (joining to the septal incision) (arrow) and the nasal floor laterally ( arrow head )

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Fig. 1.11 Dissection is continued through the intercartilagenous incision exposing the dorsum of the upper lateral cartilage and then to the nasal bones. The periosteum is incised with a curved Joseph knife, and the soft tissue is separated from the nasal bones. The elevation is continued laterally to the nasomaxillary suture line and superiorly to the glabella. Soft tissue over the anterior maxilla is elevated with a periosteal elevator in the subperiosteal plane to the zygoma and the infraorbital rim. The neurovascular bundle in the infraorbital foramen ( arrow) is carefully preserved

1.3

1.3

Lateral Rhinotomy with Medial Maxillotomy

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Fig. 1.14 The periosteum is elevated from the lateral nasal wall and the anterior wall of the maxilla preserving the infraorbital foramen with its neurovascular bundle. The periosteum over the inferior orbital margin is elevated. The lacrimal sac can be divided. The frontoethmoidal suture is identified

Fig. 1.12 Moure’s incision begins below the medial aspect of the eyebrow and curves downwards and forwards to the medial canthus. The incision extends to the nasofacial junction and along the nasal alar rim ending within the nostrilla

Fig. 1.15 The nasal alar is mobilized by carrying the Moure’s incision through the entire thickness along the pyriform aperture

Fig. 1.13 The incision is carried to the bone. The angular vessels are coagulated

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Fig. 1.16 The periosteum is elevated from the lateral nasal wall and the anterior wall of the antrum preserving the infraorbital foramen with its neurovascular bundle. The periosteum over the inferior orbital margin is elevated. The frontoethmoidal suture is identified and osteotomy done obliquely along the nasomaxillary suture line, vertically medial to the infraorbital foramen and horizontally above the level of the dental roots and the pyriform aperture

Fig. 1.18 The tumor is removed accordingly

Fig. 1.17 The bone (medial wall of maxilla) is removed and preserved in saline for reinsertion later. The lacrimal sac and duct is mobilized from their bony bed and retracted laterally. The maxillary sinus is inspected

1.3


Fig. 1.19 After hemostasis the nasal cavity is packed with gauze and the bone placed back and fixed with miniplate and screws

Fig. 1.20 The nasal alar is returned and the skin closed with interrupted sutures

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8

1.4

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Transpalatal Approach by Palatal Osteomucoperiosteal Flap

Fig. 1.21 A 5 cm gingivolabial sulcus incision is made equally on either side of the midline. The incision is made bone deep and the nasal mucoperioseal floor is elevated from the pyriform aperture to the posterior end of the hard palate and side to side as much as possible. With a heavy scissor, the junction of the maxillary crest and septum is cut all the way from its anterior end to the posterior end. A space is created between the bony and soft tissues of the nasal floor where a malleable copper retractor is placed. This is done to prevent injury to the nasal floor mucoperiosteum during subsequent osteotomy of the hard palate

Fig. 1.22 A incision is made on the hard palate from the last molar tooth of the pathological side to the junction between the contralateral canine and first premolar tooth. It is made where the palatal mucoperiosteum meet the tooth. The palatal mucoperiosteum is elevated just medial to the greater palatine canal posteriorly and posterior to the incisive foramen anteriorly. The greater and lesser palaltine arteries are coagulated to reduce bleeding

Fig. 1.23 On the side of the lesion a inverted ‘J’ shaped cut is made on the bony hard palate. The side arms of the inverted ‘J’ is placed at the junction of the horizontal and vertical part of the hard palate. The summit of the inverted ‘J’ is located almost 2 cm posterior to the base of the central incisor tooth. By this way, the very thick palatal bone is avoided. The cut is made just medial to the greater palatine canal using a mastoid drill with a small cutting burr. The cut is made through and through the bony nasal floor

1.4

Transpalatal Approach by Palatal Osteomucoperiosteal Flap

Fig. 1.24 The contralateral palatal cut is made through the midline sublabial incision. A through and through osteotomy is done without injuring the palatal mucoperiosteum using a Joseph lateral osteotome (arr ow) which is used in rhinoplasty; the right one for the left palatal half and vice versa. The knob at the tip of the osteotome is felt through the palatal mucoperiosteum to prevent accidental injury or buttonhole of the palatal mucoperiosteum

Fig. 1.25 Pressure with a periosteal elevator from the nasal side towards the oral side opens up the palatal osteomucoperiosteal flap, (POMP flap) in the oral cavity like the lid of a box. The flap is pedicled on the mucoperiosteum of the normal side from the opposite premolar to the last molar tooth. This exposes the nasal floor mucoperiosteum on both sides. The POMP flap ( arrow) is retracted with a retractor or sutured and anchored with a weight at the non pathological side

9

Fig. 1.26 The nasal floor mucoperiosteum is cut open to expose the tumor

Fig. 1.27 The tumor is removed accordingly either in whole or in piece meal

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Fig. 1.28 After the tumor is completely removed, the nasal floor mucosperiostum is sutured together to closed off the nasopharynx

Fig. 1.29 The POMP flap is placed back. Three to four sutures are placed between the elevated palatal mucoperiosteum with mucoperiosteum of the gingivolabial sulcus across spaces between the teeth. The

sublabial incision is closed in two layers. A light nasal packing is done and kept for 3–4 days

1.5

1.5

Total Maxillary Swing (For Advanced Nasopharynge al Angiofibroma)

11

Total Maxillary Swing (For Advanced Nasopharyngeal Angiofibroma)

Fig. 1.30 After orotracheal intubation, the patient is placed in the head–extended position. The mouth is opened and the palatal mucoperiosteum (arrow head ) on the involved side is reflected down to the level of the hard and soft palate junction posteriorly and just beyond the midline medially. The greater and lesser palatine arteries are coagulated to reduce bleeding

Fig. 1.31 The anterior and posterior faucial pillars are incised and the soft palate reflected together with the hard palatal mucoperiosteum exposing the oropharyngeal extension of the tumor

Fig. 1.32 The operation is continued to the face. The Weber-Fergusson incision (without the gingivolabial component) is marked out on the face

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Fig. 1.34 The anterior lacrimal crest is drilled out to expose the lacrimal sac

Fig. 1.33 The facial incision is deepened to the bone. The ala is incised to the nasal bone and whole nose with alar are reflected medially and anchored with sutures. This exposes the nasal extension of the tumor. The periosteum over the orbital floor is elevated to the level to the infraorbital foramen exposing the site for osteotomy

Fig. 1.35 The lacrimal sac is transsected and anchored with sutures

1.5


13

Fig. 1.36 The orbital floor is elevated and the infraorbital nerve is sectioned as it enters the infraorbital foramen on the orbita floor. The periosteum of the orbital floor is elevated as far as the orbital apex

Fig. 1.37 Osteotomies are made at the frontal process of maxilla and maxillozygomatic suture with an oscillating saw and the maxilloethmoidal junction is separated with a small thin straight osteotome. A straight osteotome is placed between the arms of the small V- shaped

notch located on the anterior nasal spine in the midline at the inferior margin of the pyriform aperture. It is gently hammered in both anterior and posterior directions, which opens up the palatal halves in the line of fusion

14 Fig. 1.38 A curved osteotome is placed at the pterygomaxillary suture behind the last molar tooth and gently hammered to disarticulate the maxilla from the pterygoid processes

Fig. 1.39 A curved osteotome is used to separate the palatal halves and the entire maxilla with attached cheek tissue and skin is reflected outwards as in the opening of a swing door exposing the entire surgical field and the tumor

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1.5


Fig. 1.40 Any bleeding vessels are coagulated or ligated and the tumor is removed completely. Residual tumor in the pterygoid base, base sphenoid and sphenoid sinus is removed. Tumor extensions into the orbital apex and middle cranial fossa is removed by gentle traction downwards

Fig. 1.41 After satisfactory removal of the tumor and hemostasis, the orbit is lifted by placing a malleable retractor at its inferior aspect, and the maxilla is placed back as in closing of a swing door. The maxilla is fixed with miniplate and screws at the maxillozygomatic suture, the frontal process of the maxilla, and the intermaxillary suture at the inferior margin of the pyriform aperture. In patients less than 18 years of age, absorbable miniplates and screws are used

15

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Fig. 1.42 The tumor is removed with all its extensions

Fig. 1.43 The facial and palatal wound heals up without scaring

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1.6

1.6

Total Maxillectomy

17

Total Maxillectomy

Fig. 1.44 The patient is placed in the supine position and the orotracheal intubation is done and the tube is taped to the corner of the mouth opposite the side of the tumor. After the field is draped and prepared the eyelids are sewn together with a 6-0-nylon suture. The Weber-Fergusson incision is marked out and injected with 1:100,000 lignocaine with adrenaline

Fig. 1.45 The incision is made 1–2 mm from the eyelashes along the edge of the lid. The subciliary flap is raised above the level of the orbital fat till the infraorbital margin is reached. The periosteum over the infraorbital rim is cut and communicated with the medial canthal incision

Fig. 1.46 The sublabial part of the incision is extended from the midline to the third molar teeth and went round it. The incision begins in the upper lip. The cheek flap is raised by grasping the upper lip between the thumb and the index finger of the surgeon and the assistant puts the incision under tension and compress the superior labial artery. The gingival mucosa of the upper alveolus from the central incisor to the last molar of the involved side is reflected and elevated together with the cheek flap

18

Fig. 1.47 The palatal mucoperiosteum of the involved side (when hard palate is free of tumor) is elevated as described in total maxillary swing. The elevated gingivolabial mucosa is made continuous with the reflected palatal mucoperiosteum across to the last molar tooth on the involved side. The greater palatine artery is coagulated and cut in the process. The anterior part of the nasal septum is dislocated from the anterior nasal spine to expose the V-shaped notch located on the anterior nasal spine ( arrowhead )

Fig. 1.49 A curved osteotome is placed in the pterygomaxillary fissure behind the last molar with the concavity of the blade facing upwards and hammered to free the pterygomaxillary suture

1


Fig. 1.48 Osteotomies are performed at the zygomaticomaxillary suture line ( 1) and frontal process of the maxilla ( 2) using a oscillating saw. A straight osteotome is placed between the V-shaped notch located on the anterior nasal spine ( 3) and hammered in both anterior and posterior direction, thus opening the palatal halves in the midline separating the maxilla

1.6

Total Maxillectomy

19

Fig. 1.50 The whole maxilla with the nasal bone, ethmoid sinus and pterygoid plates are removed with the specimen Fig. 1.52 The muscle is sutured to the periorbita and to holes made in the remaining frontal process of the maxilla thereby supporting the orbit when the eye preserved

Fig. 1.51 After removal of the specimen, the full-length of the temporalis muscle raised. The anterior 40 % of the muscle is passed under the zygoma or alternatively the zygoma is removed and placed back with miniplate and screws after passing the muscle under the zygoma to the defect

Fig. 1.53 The posterior 60 % of the temporalis muscle is transposed and sutured to the margin of the anterior part of the temporal fossa to minimize temporal depression

20

1


Figs. 1.54 and 1.55 The removed specimen containing the tumor consists of the alveolar of the upper jaw with tooth, floor of the orbit, hard palate and the lateral nasal wall

Fig. 1.56 Dentures are constructed after the palate is healed

Fig. 1.57 The facial incision heals with minimal scaring and the temporal depression is minimal

1.7

1.7

Total Maxillectomy with Orbital Exenteration

21


Fig. 1.58 When orbital exenteration is considered a Dieffenbach extension alone the superior palpebral is added

Fig. 1.60 From there the orbital contents are dissected and retracted down from the roof of the orbit to the floor. Osteotomies are done as described in total maxillectomy. The maxilla is mobilized together with

Fig. 1.59 The upperlid incision is deepened to the periorbita of the superior orbital rim

the orbital contents inferiorly to the oral cavity exposing the ophthalmic artery and optic nerve. The ophthalmic artery and nerve are cut and ligated and removed together with the maxilla

22

1


Fig. 1.61 The specimen containing the eyeball soft tissues over the cheek when the anterior wall is involved by the tumor

Fig. 1.62 The postoperative cavity, which extends from the oral cavity to the superior wall of the orbit is cleared of tumor

1.7


23

Fig. 1.63 The exposure also allows for tumor extensions to the base of skull to be removed

Fig. 1.64 The full length of the temporalis muscle is raised to obliterate the cavity and achieve oronasal separation

Fig. 1.65 The temporalis muscle is sutured to the periosteium of the supraorbital rim and tissues of the medial canthal and incised muscles of the nose. The gingivolabial mucoperiosteum and the palatal mucoperiosteum are sutured with the buccal fat and the inferior end of the temporalis muscle in between thereby separating the oral cavity from the nasal cavity. The cheek flap is placed back and the Weber – Dieffenbach incision is closed

24

Fig. 1.66 The facial incision heals with minimal scaring

1


1.8

1.8

Extende d Total Maxillectomy with Cheek Skin Excision

25

Extended Total Maxillectomy with Cheek Skin Excision

Fig. 1.67 In cases where the cheek skin is to be removed, the lip s plit is avoided. The cheek skin instead of reflecting is removed with the specimen

Fig. 1.69 The defect consisted of a open maxillary cavity

Fig. 1.70 The cavity is obliterated with temporalis muscle Fig. 1.68 The postoperative specimen consists of the eye and cheek skin with the maxilla

26

1


Fig. 1.71 A appropriate flap with skin (as described in Chap. 6) is placed over the temporalis muscle to replace cheek skin

1.9

1.9

Craniofacial Resection

27


Fig. 1.74 The frontal sinus is mapped out with X-ray templates of X-rays taken at 6 ft anterior posterior view of skull prior to surgery Fig. 1.72 A bicoronal incision is made and a scalp flap is raised anteriorly

Fig. 1.73 A separate pericranial flap is raised for later use on cranial base

Fig. 1.75 Burr holes are made on each side just above the frontal sinus border. A craniotomy is done using a giggly saw or stricker saw

28

1


Fig. 1.76 The bone flap is removed and kept in saline for later use

Fig. 1.78 The excised intracranial component of the tumor is removed through the extra cranial defect

Fig. 1.77 The dura covering the anterior cranial fossa is pressed down carefully with a malleable retractor and the cribriform plate inspected to assess the tumor extension. The area of the skull base around the cribriform plate is drilled and removed with the maxilla and orbit inferiorly

Fig. 1.79 After tumor removal the pericranial flap is draped over the defect in the skull base

1.9


Fig. 1.80 The bone flap is placed back and held in place with plate and screws

29

2

Larynx and Trachea

2.1

Arytenoidectomy and Lateralization of Vocal Cord (Modified Woodman’s Technique)

Fig. 2.1 A tracheoyomy is usually already performed at the beginning as most of the patients suffer from bilateral abductor palsy


31

32 a

2

Larynx and Trachea

b

Fig. 2.2 (a) Fiberoptic laryngoscopy shows vocal cords on inspitation and ( b) on expiration

Fig. 2.3 A 6–7 cm horizontal incision is given at the level of the lower border of the thyroid cartilage; it extends from the midline to the sternocleiodomasoid muscle laterally

Fig. 2.4 The strap muscles are identified and undermined in a superoinferior direction and retracted laterally

2.1

Aryte noidectomy and Lateralizati on of Vocal Cord (Modified Woodman’s Technique)

Fig. 2.5 The thyroid cartilage is rotated with the help of a sharp double pronged hook to expose the entire posterior border of the thyroid alar. The inferior constrictor muscle is incised along the entire length of the thyroid alar

33

Fig. 2.7 From this step, the operating microscope and the microsurgical instruments facilitate the subsequent steps. The arytenoid cartilage is identified by following the upper border of the cricoid cartilage posteromedially

Fig. 2.6 The inferior horn of the thyroid cartilage and the cricothyroid articulation are identified. The cricothyroid joint is disarticulated Fig. 2.8 The muscular attachments are removed and the laryngeal mucosa is reflected from the arytenoid cartilage with finer instruments and microscopic vision. The cricoarytenoid joint is disarticulated and the arytenoid cartilage is carefully retracted laterally to facilitate further separation of the remaining soft tissues from the arytenoid cartilage. The medialward dissection is done carefully to avoid accidental entry into the larynx

34

Fig. 2.9 A gentle lateral traction on the arytenoid cartilage exposes exposes the vocal process and the vocal ligament. A 4-0 nylon suture is passed through the substance of the vocal cord around the anterior end of the vocal process. The suture is fixed through a separate holes made at the posteroinferior posteroinferior aspect of the thyroid cartilage. At this stage the thyroid cartilage is returned to the neutral position and the assistant passes a fibreoptic nasolaryngoscope nasolaryngoscope to see the intercordal distance which, after tightening the sutures, should be between 4 and 5 mm. Endoscopic examination also confirm the extramucosal nature of the procedure

a

2

Larynx and Trachea

Fig. 2.10 A small knot is placed and the wound is closed in layers after placing a drain

b

Fig. 2.11 After healing when there adequate airway ( a) on expiration and ( b) on inspiration during fiberoptic nasolaryngoscopy, the tracheostomy tube is decannulated

2.2

2.2

Frontolateral Vertical Partial Laryng ectomy

35

Frontolateral Vertical Partial Laryngectomy

Fig. 2.12 The incision could be a small or a big apron-flap; it depends on the necessity of neck dissection. The tracheostomy could be performed at the beginning or at the end of the procedure

Fig. 2.14 The membrane and the perichondrium attached on the superior and the inferior border of the exposed thyroid cartilage is incised by a scarpal. With the help of a fine elevator, the inner perichondrium of the thyroid cartilage is elevated and the laryngeal soft tissues are separated from each thyroid alar. This step is continued till a paramedian tunnel is created between the upper and lower border of the thyroid cartilage

Fig. 2.15 An elevator is placed in the subperichondrial plane for protection of the laryngeal tissue underneath and a triangular portion of the thyroid cartilage is cut; the portion of the cartilage falls equally on either sides of the midline. The triangular portion of the thyroid cartilage is left attached to the underlying laryngeal soft tissues Fig. 2.13 The skin flap is elevated at the subplatysmal level. The strap muscles are separated in the midline. The muscles are retracted laterally using a self-retaining retractor to expose more than the anterior half of the thyroid cartilage

36

2

Larynx and Trachea

Fig. 2.18 The rest of the attachments of the tumor is cut with a strong curved scissors and the specimen ( inset ) is removed Fig. 2.16 The larynx is entered through the contralateral side (right in this patient) by cutting through the cricothyroid ligament at the inferior border of the thyroid cartilage. The distance of this incision from the midline depends on the extent of the tumor which now could be visualized through the aperture created

Fig. 2.17 Depending on the extent of the tumor, the inner perichondrium of the involved side is separated in an anteroposterior direction. With the help of a sharp scarple or sickle knife, the superior, the inferior and the posterior margins of the resection are delineated on the left side; it should roughly take the shape of an ‘U’ which opens anteriorly. The degree of posterior resection depended on the tumor extension towards the arytenoid cartilage

Fig. 2.19 The small raw area is expected to heal by granulation and epithelization

2.2

Frontolateral Vertical Partial Laryng ectomy

Fig. 2.20 Complete hemostasis is achieved and a tracheotomy is done in case it was not done at the beginning. To prevent the posterior retraction, the true and the false cords of the normal right side are pulled forward and sutured to the anterior border of the ipsilateral thyroid cartilage with fine sutures; these sutures are anchoreed to holes made on the thyroid cartilage with a fine diamond burr as the thyroid cartilage is friable

Fig. 2.21 The two halves of the thyroid cartilage are sutured together by a slowly absorbing thick suture material

37

Fig. 2.22 The strap muscles are reapproxmated and overlapped in the midline in a closed water-tight way over a suction drain. The rest of the incision is closed in two layers

Fig. 2.23 After 4 weeks the raw area is epithelized and the tracheostomy tube is removed

38

2.3

2

Larynx and Trachea

Supracricoid Laryngectomy with Cricohyoidoepiglottopexy

Fig. 2.24 A ‘U’ type incision is given. It is passed along the anterior border of the sternocleidomastoid muscles, down to the level of the cricoid cartilage. A subplatysmal skin flap is elevated at least 1 cm above the level of the hyoid bone. A functional neck dissection is performed at this stage

Fig. 2.25 The sternohyoid and thyrohyoid muscles are cut along the upper border of the thyroid cartilage. The former muscles are dissected downwards to expose the sternothyroid muscles. The muscles along the oblique line of the thyroid cartilage ( labelled C in the picture) are cut and the larynx is rotated by a hook

Fig. 2.26 The external thyroid perichondrium and the inferior constrictor muscles are cut along the posterior borders of the thyroid cartilage. Using a perichondrium elevator, the pyriform sinus mucosa is released. The superior laryngeal vessels are identified and ligated, and the internal laryngeal nerves preserved

Fig. 2.27 The sternothyroid muscles are dissected downwards beyond the cricoid cartilage thereby exposing the cricothyroid muscles. The muscles are carefully transected to expose the cricothyroid membrane. With the help of the perichondrial elevator, the subglottic mucosa overlying the cricoid cartilage is elevated on the side of the tumor. This step is necessary to achieve wider resection on the diseased side

2.3

Supracricoid Laryng ectomy with Cricohyoidoepiglottope xy

39

Fig. 2.28 The inferior horn of the thyroid cartilage is removed on the contralateral side to avoid injury to the recurrent laryngeal nerve during the removal of the thyroid cartilage Fig. 2.30 The periosteum of the hyoid bone ( arrow) is incised anteriorly and laterally using a periosteum elevator and the preepiglottic space is separated from the posterior surface of the hyoid bone

Fig. 2.29 The inferior horn on the ipsilateral side is disarticulated to allow the paraglottic space to be removed completely

Fig. 2.31 From the head end the larynx is opened just above the false vocal cord thus allowing good exposure of the extent of the tumor. At this stage, a tracheotomy is performed between third and the fourth tracheal rings through a separate incision. A tracheal intubation is done while the oroendotracheal tube is removed The larynx is entered through a inferiorly directed horizontal pharyngotomy ( arrow head ) thereby preserving the entire epiglottis

40

2

Larynx and Trachea

Fig. 2.32 The larynx is grasped with a Allis forceps and pulled in an anteroinferior direction to have maximum visualization. The endolaryngeal resection is performed under direct vision. On the contralateral side, a vertical prearytenoid incision is made from the aryepiglottic fold to the superior border of the cricoid cartilage with a scissors. The

entire paraglottic space is anterior to the cut while the pyriform sinus is behind it, and both are spared. The vertical prearytenoid incision and the medial transverse cricothyroidotomy are connected. This allows the lateral cricoarytenoid muscle to be spared on the contralateral side; so it will assist the anterior motion of the remaining arytenoid

Fig. 2.33 On the side (left ) of the tumor, the extent of resection is much wider. The cuts are made over the arytenoid, conserving the posterior mucosa, then continued vertically in the posterior subglottis through the

interarytenoid muscle. Subsequently, the cut on the tumor bearing side proceed anteriorly in the cricothyroid membrane and joined with the cut from the contralateral side. The specimen is removed and hemostasis is achieved

2.3

Supracricoid Laryng ectomy with Cricohyoidoepiglottope xy

41

Fig. 2.34 Before closure, it is made sure that the ventricular mucosa is removed entirely and there is no perforation of the pyriform sinus mucosa. The mucosa of the arytenoid cartilage is sutured covering the cartilage. The remaining arytenoid mucosa is sewn over the denuded

cricoid cartilage on the side of arytenoid resection. The remaining arytenoid cartilage is pulled forward to the posterolateral aspect of the cricoid cartilage to avoid the posterior sliding of the former

Fig. 2.35 Three thick sutures (‘0’ vicryl) are placed, one in the midline and one on either side 1 cm away from midline. They are passed to encircle the cricoid cartilage, cross the epiglottis and the base of the tongue and lastly, encircle the hyoid bone. The neck is flexed and the sutures are tied tightly leaving no gap between the cricoid cartilage and

the hyoid bone. The tension is less in the suture line as the previously released cervicomediastinal trachea moves upward. At this stage the final refinement of the tracheotomy is made. The previously sectioned sternohyoid muscles are sutured, drain inserted and the skin closed in two layers

42

2.4

2

Larynx and Trachea

Supraglottic Horizontal Partial Laryngectomy

Fig. 2.36 Following a ‘U’ incision, the flap is raised in the subplatysmal plane, exposing the underlying strap muscles and hyoid bone

Fig. 2.37 The internal laryngeal nerve is identified and preserved as it runs along with the superior laryngeal artery

2.4


43

Fig. 2.38 The superior horn of the thyroid cartilage is dissected out on both sides. This is done to preserve the pyriform sinus mucosa during removal of the specimen

Fig. 2.39 The sternohyoid, omohyoid, and thyrohyoid muscles are sectioned at their insertion along the margin of the hyoid bone and the hyoid bone is removed

44

2

Larynx and Trachea

Fig. 2.40 After removal of the hyoid bone, the thyrohyoid membrane and the thyroid cartilage are exposed by reflecting the thyrohyoid, sternohyoid and, omohyoid muscles inferiorly

Fig. 2.41 An incision is made across the superior border of the thyroid cartilage up to the base of each superior horn

2.4


45

Fig. 2.42 The perichondrium is elevated from the anterolateral surface of the thyroid cartilage and reflected inferiorly. After removal of the hyoid bone, the thyrohyoid membrane and the thyroid cartilage are

exposed by reflecting the thyrohyoid, sternohyoid and, omohyoid muscles inferiorly

Fig. 2.43 A plane of cleavage is established between the thyroid cartilage to be resected and the underlying perichondrium. With a Stryker saw, horizontal incisions are made across the thyroid cartilage midway

between the notch and the inferior border. The thyroid cartilage incision is continued superiorly at each side along the lines corresponding to the perichondrial incisions

46

2

Larynx and Trachea

Fig. 2.44 The thyroid cartilage above the horizontal incision is resected exposing the underlying perichondrium

Fig. 2.45 The pharynx is entered as described in laryngectomy. After exposure of the pharynx, the surgeon moves to the head end of the table. The tip of the epiglottis is grasped and retracted anteriorly and inferiorly. Depending on the extension of the tumor, the aryepiglottic fold is transected on each side by placing the blade of the dissecting scissors into the laryngeal ventricle below or above the false cord and the other blade in the pyriform sinus

Fig. 2.46 The repair begins by approximating the mucosa of the pyriform sinus to the margins of the resected false cords with 3-0 chromic catgut

2.4


Fig. 2.47 Laterally the base of the tongue is sutured to the inferior constrictor musculature with chronic catgut 3-0. Anteriorly, interrupted sutures are placed through the base of the tongue, the internal thyroid

47

cartilage perichondrium, the thyroid cartilage and the external thyroid cartilage perichondrium. The neck is flexed and the laryngeal mucosa and the tongue base mucosa are approximated together

Fig. 2.48 The strap muscles are sutured to the mylohyoid muscle. Guardian sutures are placed between the skin of the chin and the manibrum with two silk to prevent sudden over extension of the neck as described in Fig. 2.84

48

2.5

2

Larynx and Trachea

Total Laryngectomy

Fig. 2.49 A ‘U’ flap incision is marked out; extension could be made for neck dissection

Fig. 2.50 The flap consists of skin, subcutaneous tissue and platysma, elevated above to the level of the hyoid bone and stitched with the skin of the chin

2.5

Total Larynge ctomy

49

Fig. 2.51 The medial borders of the sternomastoid muscles are identified and dissected in its medial plane. The carotid sheath is identified and the common carotid artery, internal jugular vein and vagus nerve are retracted laterally. The superior belly of omohyoid muscle is incised

(arrow). The dissection is continued to the level of the clavicle below and hyoid above on both sides. The branches of anterior jugular vein are transsected and tied

Fig. 2.52 On the side of the tumor, appropriate neck dissection is done depending on the neck node metastasis. The superior and inferior thyroid arteries and veins, and middle thyroid vein are ligated; this helped easier removal of the corresponding thyroid lobe in continuity with the laryngeal specimen

Fig. 2.53 On the contralateral side of the tumor, the superior and inferior thyroid artery and vein are preserved

50

2

Larynx and Trachea

Fig. 2.54 The thyroid isthmus is divided. The thyroid gland on the contralateral side is peeled off from the trachea by blunt dissection and preserved

Fig. 2.55 The strap muscles attached immediately above the hyoid bone and the sternum are transsected. Incision of sternal attachment of the strap muscles exposed the trachea. The larynx is now free of muscular attachments

2.5

Total Larynge ctomy

51

Fig. 2.56 The superior horn of the thyroid cartilage on each side are removed

Fig. 2.57 A transverse pharyngotomy is made at the thyrohyoid membrane to enter the pharyngeal lumen in the area of the vallecula between the base of the tongue and the epiglottis. The surgeon with headlight moves to the head end of the table. Through the pharyngotomy, the epiglottis is grasped with Allis forceps and the pharyngeal mucosa is

cut with scissors laterally on each side of the epiglottis and then the cut follows inferiorly along the aryepiglottic folds on each side and turns medially just below the level of the superior border of the cricoid cartilage to join the incision from the opposite side

52

Fig. 2.58 The larynx is released by dividing the extramucosal tissues and any residual tissue of the inferior constrictor muscles along the same line of the mucosal cut. Both cuts are joined posteroinferior to the

2

Larynx and Trachea

cricoarytenoid articulation ( A) thereby keeping away from probable malignant spread to the latter

Fig. 2.59 The separation between the laryngotracheal and esophageal lumens are achieved with the help of gauze dissection on the posterior surface of the cricoid cartilage

2.5

Total Larynge ctomy

Fig. 2.60 The larynx with attached one thyroid lobe is removed. A new tracheostoma is made through the skin below the tip of the incision in patients who did not have any prior tracheostomy. The anesthetist gradually remove the orotracheal tube and the surgeon insert a new tube

53

through the tracheostoma. The shape of the tracheal cut is made so it extended backward and obliquely upward making the membranous part 5 mm higher than cartilaginous one

Fig. 2.61 After removal of the specimen the nasogastric tube is directed into the stomach

54

2

Larynx and Trachea

Fig. 2.62 A cricopharyngeal pharyngeal myotomy is made using a sharp knife till the mucosa is seen transparent

Fig. 2.63 The pharynx is closed by carefully apposing mucosal edges with the help of mucosal or extramucosal sutures from above downwards or vice versa. During this first layer of closure the mucosal edges

should be carefully inverted so that outer surface is apposed to outer surface when approximated. Usual pharyngeal closure line look like a straight line or ‘T’ shaped

2.5

Total Larynge ctomy

Fig. 2.64 In the second layer of pharyngeal closure are done by interrupted sutures so as to bury the first one; the pharyngeal wall is picked up with a fine, atraumatic round needle just lateral to the crease of the first suture line without penetrating the mucosa, and the knots are tied.

55

The third layer of the pharyngeal closure are made using pharyngeal constrictors and the preserved strap muscles of the neck. Particular attention is given to the suprastomal area; the commonest site of fistula formation

Fig. 2.65 At this stage, the patient head is made slightly flexed from extended position to lessen the tension on the suture lines. Using a heavy and fine sutures the peritracheal fascia is stitched to the subcutaneous tissues around the tracheostoma. Additional suturing of the skin to the mucosa above the tracheal cartilage is necessary to make the closure airtight. A suction drain is inserted and the skin flaps are sutured with the tracheostoma and with the rest of the cervical incision Fig. 2.66 The specimen is cut open and examined for tumor spread and sent for histopathological examination

56

2.6

2

Total Laryngopharyngoesophagectomy with Gastric Pull Up

Fig. 2.67 Procedure is same as described in total laryngectomy. Same time the stomached is mobilized endoscopically or by open abdominal surgery

Fig. 2.68 The esophagus is mobilized from above through the neck incision. By traction on the pharynx and esophagus the stomach is mobilized to the neck

Larynx and Trachea

2.6

Total Laryngop haryngoesopha gectomy with Gastric Pull Up

57

Fig. 2.70 The esophagus is excised at the gastroesophageal junction and removed with the pharynx and larynx specimen. The lumen is closed. An opening is created at the fundus of the stomach and anastomosed with the pharynx. After the posterior wall of the pharynx is sutured to the stomach a nasogastric tube is passed to the nose and directed to the stomach. Then the anterior wall of pharynx to stomach is closed. The wound is closed in layers

Fig. 2.69 Anchor sutures are placed through the muscular wall of the stomach and anchored to the paravertebral fascia

58

2.7

2

Larynx and Trachea

Upper Tracheal Resection and Anastomosis for Trachea Stricture

Fig. 2.71 Post intubation tracheal stricture at the first tracheal ring. Vocal cords and subglottis are normal. Patient is tracheostomised to relieve airway obstruction

Fig. 2.72 Patient is placed in neck extended position. Incision is marked out over the hyoid for hyoid drop and ‘U’ collar incision to approach the trachea

2.7


Fig. 2.73 Through the short transverse incision over the hyoid, the suprahyoid muscles attached to the hyoid are released

Fig. 2.74 The suprahyoid membrane is opened and preepiglottic space entered without opening the pharynx

59

60

2

Larynx and Trachea

Fig. 2.75 The digastric muscle sling attached to the hyoid is left intact. The hyoid bone is divided on both sides anterior to the digastric muscle attachments and lateral to the lesser cornu. A penrose drain is inserted and the incision is closed in layers

Fig. 2.76 Through the ‘U’ collar incision a subplatysmal flap is raised and the strap muscles exposed

2.7


61

Fig. 2.77 The strap muscles are divided below the level of the cricoid cartilage. Tracheal opening ( arrow) is made above the level of the stricture (between first and second tracheal rings). A catheter to be used as a ‘leader’ is passed from the mouth to the trachea to show where the stenosis begun

Fig. 2.78 The anterior wall of the trachea is split open to meet the previous tracheal opening for tracheostomy to show the stricture

62

2

Larynx and Trachea

Fig. 2.80 Lateral stay sutures are placed. The initial anastomotic suture is placed in the posterior midline so the knot is extraluminal. A hemostat holds the suture

Fig. 2.79 The stenosed circumference of the trachea is resected. A endotracheal tube is passed guided by the “leader” catheter

2.7


Fig. 2.81 The endotracheal tube in the tracheostoma is removed and the guided endotracheal tube is passed to the lower end of the trachea. The “leader”catheter is removed through the mouth. The anesthetic circuit is moved to the head from the neck to be connected to the endotracheal tube

Fig. 2.82 Multiple vicryl sutures passing from upper tracheal end to the inferior tracheostoma are placed. The vicryl sutures are started from the posterior surf ace of the trachea and preceded anteriorly

63

64 Fig. 2.83 The tracheal ends are approximated together and the vicryl sutures are tied. The stay sutures are tied together

Fig. 2.84 A sunction drain is inserted and the wound is closed in layers. Guardian sutures from the sternum to the chin are placed to prevent overextension. The patient is kept intubated for 5 days

2

Larynx and Trachea

3

Thyroid

3.1

Sistrunk Procedure for Thyroglossal Cyst

Fig. 3.1 A 5–6 cm transverse incision is made over the cyst; in case of a sinus the central part of the incision should encircle the opening of the sinus. The platysma muscle is cut and the dissection proceed cranially in the subplatysmal plane

Fig. 3.2 The sinus opening with the attached skin or the cyst is grasped and retracted superiorly taking care to preserve the integrity of the tract; dissection is continued till hyoid bone is reached


65

66

3

Thyroid

Hyoid bone

Fig. 3.3 The muscles attached at the superior and inferior border of the central part of the hyoid bone is cut while the thyroglossal duct is left attached with the specimen. The tract is followed through the hyoglossal muscle till the base of the tongue is reached

Hyoid bone

Fig. 3.4 A part of the tongue base around the foramen cecum is included in the specimen. The tongue base and its musculature are sutured together. A drain is placed in the subplatysmal plane and the platysma muscle reapproximated. The skin is closed

3.2 Hemithyroidectomy

3.2

67

Hemithyroidectomy

Fig. 3.5 Collar incision is marked out along the skin crease from anterior border of sternocleidomastoid muscle from one side to the other

Fig. 3.7 The facia over the strap muscles are incised and the muscles on each side are separated in the midline

Fig. 3.8 The thyroid tumor is exposed and the strap muscles are retracted laterally

Fig. 3.6 Subplatysmal flap is raised superiorly to the level of the hyoid bone and inferiorly to the suprasternal region

68

3

Thyroid

Fig. 3.9 The left recurrent laryngeal nerve running below the inferior thyroid artery in this case is identified

Fig. 3.11 The parathyroid gland is identified and separated from the thyroid gland with its vascular supply intact

Fig. 3.10 The left inferior thyroid artery is ligated

Fig. 3.12 The superior thyroid pedicle ( arrow) is ligated close to the gland and the tumor is removed in total

3.2 Hemithyroidectomy

69

a

b

Fig. 3.13 (a, b) The entire thyroid tumor is examined by sectioning and sent for histopathological examination

70

3.3

3

Thyroid

Total Thyroidectomy

Fig. 3.14 A collar incision is marked out along the skin crease extending between the lateral borders of sternocleidomastoid sternocleidomastoid muscles for neck dissection as well

Fig. 3.15 The recurrent laryngeal nerve on each side are identified and preserved. The tumor with neck dissection specimen is removed in one piece

Fig. 3.16 The tumor is removed and hemostasis is achieved. The right common carotid artery is exposed

3.3

Total Thyroidec tomy

Fig. 3.17 The intact specimen is sent for histopathological examination. The incision is closed as in hemithyroidectomy

71

4

Salivary Glands

4.1

Submandibular Sialoadenectomy

Fig. 4.1 The patient lies supine with the head slightly extended and tilted to the opposite side. The incisions lieds 2.5 cm below the mandible in the skin crease and curved upwards anteriorly


73

74 Fig. 4.2 Skin incision is carried below the platysma and subplatysmal flap raised exposing the submandibular gland with tumor. At the angle of the mandible, the facial artery and vein are identified, ligated and reflected upwards to protect the mandibular division of facial nerve. Elevation of the fascia over the submandibular gland further protects the nerve

Fig. 4.3 The upper border of the gland is dissected from the mandible and anterior part of the gland in the submental region. The lower part of the gland is elevated by following the hyoid posteriorly to free the part of the gland which curves backwards over the mylohyoid muscle. The anterior part of the gland is held with a Allis forceps and the facial artery and vein entering the lower border of the gland are ligated. The posterior border of the mylohyoid muscle is retracted anteriorly exposing the submandibular duct which pull the lingual nerve into view in a ‘V’-Shaped curve

4

Salivar y Glands

4.1

Submandibular Sialoadenec tomy

Fig. 4.4 The lingual nerve is dissected away from the gland and the submandibular duct is cut and ligated

75

76

Fig. 4.5 The submandibular gland is removed with the tumor. The specimen is examined in its entire form ( a) and (b) cut section and sent for histopathological examination

4

Salivar y Glands

4.2

4.2

Superficial Parotidectomy


Fig. 4.6 Modified Blair incision is marked out in the preauricular skin crease at the superior border of the helix and curried below the helix and below the lobule and then turned anteriorly to run horizontally in a skin crease approximately 2 fingerbreaths below the angle of the mandible

Fig. 4.7 The skin incision is carried to the subcutaneous tissue and platysma muscle. The greater auricular nerve as it runs over the sternocleidomastoid muscle is identified and preserved. The anterior flap is raised superficial to the greater auricular nerve and the parotid fascia. Elevation of the posterior and inferior flap exposed the tail of the parotid. The flaps are retracted with silk sutures. The tail of the parotid gland is dissected off the sternocleidomastoid muscle by dissection deep to the posterior branch of the greater auricular nerve

77

78 Fig. 4.8 The preauricular space is opened by dividing attachments of the parotid gland to the cartilagenous external canal with blunt dissection. This exposed the tragal pointer, which serves as the landmark for the facial nerve identification

Fig. 4.9 The parotid gland superficial to the facial nerve is divided and removed with the tumor

4

Salivar y Glands

4.2


Fig. 4.10 The parotid gland with the tumor is removed and a radivac drain inserted and the wound is closed in layers

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4.3

4

Superficial Parotidectomy with Deep Lobe Resection

Fig. 4.11 Skin incision is same as described in Fig. 4.6

Fig. 4.12 The anterior and posterior flaps are raised as described in Fig. 4.7. The greater auricular nerve is identified and preserved. The facial nerve trunk is identified as described in Fig. 4.8

Salivar y Glands

4.3

Superficial Parotidectomy with Deep Lobe Resection

Fig. 4.13 The parotid gland superficial to the facial nerve is dissected and removed. Then the deep lobe is dissected

Fig. 4.14 Nerves, blood vessels and muscles are preserved and hemostasis attained by bipolar diathermy at the end of the procedure. A sunction drain is inserted, the flap is returned and wound closed in layers

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82

4.4

4

Salivar y Glands

Total Parotidectomy with Facial Nerve Graft with Sural Nerve and Blind Sac Closure of External Auditory Canal for Malignant Parotid Tumor

Fig. 4.15 Total parotdectomy is performed as described in Sect. 4.3. The facial nerve trunk is also resected with the tumor when it cannot be separated from it. To have extra length for facial nerve anastomosis, mastoideectomy is done and the facial nerve is exposed from the fallopian canal. The sural nerve to be used for anastomosis is marked out as it runs along the lateral malleolar fold

Fig. 4.16 The sural nerve is exposed through its entire length

Fig. 4.17 The sural nerve with its branches is harvested to anastomose with the branches of facial nerve

4.4

Total Parotidectomy with Facial Nerve Graft with Sural Nerve

Fig. 4.18 Total parotidectomy is done and the facial nerve is resected. Canal wall down mastoidectomy is done. The facial nerve is freed from the fallopian canal. The internal jugular vein (arrow) and skeletonized lateral sinus ( arrow head ) in mastoid cavity are exposed. The branches of the sural nerve are anastomosed to the upper and lower branches and the main nerve anastomosed to the facial nerve trunk

Fig. 4.19 The temporalis muscle is transposed to cover the anastomosis and the defect after total parotidectomy

83

84

Fig. 4.20 Blind sac closure of external auditory canal is done and the wound is closed in layers

4

Salivar y Glands

4.5

4.5

Temporoparietal Facial Flap (TPFF) and Abdominal Fat Graft for Prevention of Frey’s Syndrome Following Parotidectomy


Fig. 4.21 A ‘Y’ or ‘T’ shaped incision is made from the cranial end of the parotidectomy incision. The upper end of ‘Y’ or ‘T’ reaches up to the superior temporal line

Fig. 4.22 The skin flap is raised in the subfollicular plane superficial to the superficial musculoaponeurotic system (SMAS). At this stage, injury to the hair follicles above and to the branches of the superficial temporal artery below is avoided. The elevation of the skin flap is carried out till the superior temporal line is reached and in both anterior and posterior direction till an adequate dimension of the flap to cover the raw area created by parotidectomy is reached

85

86 Fig. 4.23 The TPFF is separated from the underlying areolar tissue and f ascia covering the temporalis muscle. The branches of the superficial temporal artery are cut and ligated at the margin of the flap

Fig. 4.24 A abdominal incision is made from 3 o’clock to 9 o’clock running above the umbilicus to harvest abdominal fat graft

4

Salivar y Glands

4.5


Fig. 4.25 The abdominal fat is harvested superficial to the rectus abdominis muscle

Fig. 4.26 The harvested abdominal fat is trimmed to required size

87

88 Fig. 4.27 The harvested abdominal fat placed is over the parotid bed covering the facial nerve and secured with absorbable sutures

Fig. 4.28 The temporoparietal flap is placed over the fat graft. A drain is inserted and the incision closed in layers

4

Salivar y Glands

5

Repair of External Nose Defects

5.1

Repair of Alar Defect with Full Thickness Skin Graft

Fig. 5.1 Incision site is marked out for nasal basal cell carcinoma excision Fig. 5.2 The defect after excision


89

90

Fig. 5.3 Full thickness skin graft is harvested from the postauricular region

Fig. 5.4 Full thickness post auricular skin graft is used to close the nasal defect

5


Fig. 5.5 Wound heals without scaring, 10 weeks after operation

5.2

5.2

Superior Based Nasolabial Flap for Reconstruction of Alar Defect

Superior Based Nasolabial Flap for Reconstruction of Alar Defect

Fig. 5.6 The flap is marked out for reconstruct of alar defect using a superior based nasolabial flap

Fig. 5.7 A nasal dorsum turnover flap ( arrow head ) and a superior based nasolabial flap ( arrow) are raised

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5


Fig. 5.10 The donor area of the nasolabial flap is sutured; the nasal dorsum turnover flap forms the roof of the vestibule Fig. 5.8 The nasal dorsum turnover flap is reflected down

Fig. 5.11 The nasolabial flap is sutured with the nasal dorsum and with the turnover flap

Fig. 5.9 The nasal dorsum turnover flap is stabilized by suturing its lateral and basal sides with the respective parts of the vestibular skin

5.3

5.3

Modified Reiger Glabellar Rotation Flap

93

Modified Reiger Glabellar Rotation Flap

Fig. 5.12 The incision is marked out for reconstruction of the alar defect using a Reiger glabellar rotation flap

Fig. 5.13 The entire skin of the nasal dorsum including the glabella and part of the cheek is mobilised. The skin above the defect is used as rotation flap for inner lining

94

Fig. 5.14 The flap is transported to cover the defect

Fig. 5.15 Appearance of the patient 3 months after operation

5


5.4

5.4

Island Forehead Flap for Reconstruction of External Nose Defect

95


Fig. 5.16 A skin island forehead flap is marked out to be used for nasal defect

Fig. 5.18 A separate incision is given below the island. The skin is dissected out at the subdermal level and a pedicle is developed

Fig. 5.17 The flap is raised in the subgaleal plane

Fig. 5.19 A 2 cm cuff of subcutaneous tissue at the frontogaleal layer is raised along with the island of skin

96

5


Fig. 5.20 Between 2 and 2.5 cm above the supraorbital margin the periosteum is incised and the flap is dissected in the subperiosteal plane to include and protect the supratrochlear vessels. The flap is tunnelled subcutaneously to the defect. The donor area is closed

Fig. 5.21 A tunnel is created from the nasal defect to the forehead in the subcutaneous plane

5.4


Fig. 5.22 The flap is mobilized to the nasal defect

Fig. 5.23 The defect is closed and donor site closed with interrupted sutures

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98

5.5

5


Schmid-Meyer Frontotemporal Flap

Fig. 5.24 Defect on nasal tip and adjoining alar of both sides

Fig. 5.25 The flap is done in stages. First stage. This flap is based on supraorbital and supratrochlear arteries and had 2 pedicles which are label (A) and (B) in this picture

Fig. 5.26 The two flaps are raised from its bed and the non- epithialised surface covered with split-thickness skin graft. The flap is wider in deeper plane than superficial giving it a trapezoidal shape in cross section. The skin edges of the donor area of the flap are approximated. A 1 cm/2 cm piece of cartilage is implanted subcutaneously 1.5–2 cm lateral to the lateral end of the flap ( arrow); these measurements depends on the size of the defect

5.5

Schmid-Meyer Frontotemporal Flap

Fig. 5.27 Second stage: Begins 4 weeks after the first stage. A thin rubber tube is looped around the bridge of the skin between the lateral ends of the flap and medial to the cartilage implant thereby blood sup-

99

ply is occluded partially. The strangulation is gradually increased; subsequently the bridge of the skin in the loop is cut and it produced a free bipedicled flap with implanted cartilage at the lateral end

Fig. 5.28 Third stage: After 2–3 weeks of the second stage, the flap is strangulated at the tip in preparation for definitive transfer. This delay is continued until the blanching response of the flap tissue to finger pressure disappear within 3 seconds

100

5


Fig. 5.31 The patient appearance 6 months after operation

Fig. 5.29 The lateral end of the flap is cut and sutured to the defect at the nasal tip

Fig. 5.30 Fourth stage: Four weeks later the flap healed satisfactorily and its distal end is divided near the nasal tip. Pedicle of the flap is returned to the forehead; reimplantation of the pedicle is necessary to return a distorted brow line to its original position

5.6

5.6

Oblique Forehead Flap for Basal Cell Carcinoma of Nasal Dorsum

Oblique Forehead Flap for Basal Cell Carcinoma of Nasal Dorsum

Fig. 5.32 Basal cell carcinoma of nasal dorsum and adjoining medial canthus

Fig. 5.33 Defect after excision of the tumor

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5


Fig. 5.34 The oblique forehead flap is elevated and the flap is rotated to cover the defect. The donor area covered with split thickness skin graft

5.7

5.7

Anterior Scalping Flap for Nose Reconstruction

103


Fig. 5.37 The anterior scalp flap is completely elevated

Fig. 5.35 The anterior scalping flap marked for reconstruction of nose defect. The area to be refreshened around the nose defect is also marked out

Fig. 5.36 The skin of the forehead is elevated over the frontalis. After reaching the upper limit of the frontalis the dissection is done at the supraperiosteal plane

Fig. 5.38 The contralateral forehead is undermined to provide adequate mobility

104 Fig. 5.39 The septal columella ( arrow) and under surface of the nasal vestibule (arrow heads) is created

Fig. 5.40 The recipient site is refreshened

5


5.7


105

Fig. 5.41 The nasal columella created from the anterior scalping flap is sutured to the remaining columella on each side

Fig. 5.43 The flap 6 weeks later is ready to be divided

Fig. 5.42 The alar and rest of nasal defect is sutured to the flap and the donor site is covered with split skin graft

106

Fig. 5.44 The flap is divided and returned to the forehead

Fig. 5.45 The flap heals with patent nostril and the donor site heals with minimal scaring over time

5


6

Axial and Free Flaps

6.1

Facial Artery Musculomucosal (FAMM) Flap

Fig. 6.1 The airway is secured by nasal intubation. With the patient in supine position and the head extended, the face and head is prepared. The anterior incision lies 1 cm posterior to the oral commissure. The orifice of the parotid duct marks the posterior limit of the flap

Fig. 6.2 When incising the anterior border of the flap, the superior labial artery is identified. It is ligated and by following its proximal course, the facial artery is identified


107

108

6


Fig. 6.3 The flap is elevated in the layer underneath the facial artery including the overlying buccinators muscle and a small portion of the orbicularis oris muscle close to the oral commissure. The inferior labial artery is identified and ligated

Fig. 6.4 Dissection is continued underneath the facial artery to the neck over the mandible. The flap is completely mobilized from the neck with the facial artery and vein in view

6.1

Facial Arter y Musculomucosal (FAMM) Flap

109

Fig. 6.5 The flap is mobilized to the neck with its vascular pedicle

Fig. 6.6 The mandibular division of the facial nerve which runs over the facial artery and vein is dissected and preserved. The flap with its vascular pedicle is passed under the nerve to the neck

110

Fig. 6.7 With artery forceps, a tunnel is created communicating the floor of mouth and neck

Fig. 6.8 The flap is mobilized to the oral cavity

6


6.1

Facial Arter y Musculomucosal (FAMM) Flap

Fig. 6.9 The defect is closed with interrupted sutures

Fig. 6.10 The flap 6 weeks after operation

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112

6.2

6


Palatal Flap

Fig. 6.11 The patient is intubated with endotrachal tube in the midline and patient is placed in head extended position. The flap marked is out with interrupted diathermy point

Fig. 6.12 The palatal mucoperiosteal flap is elevated from the bony hard palate in the anteroposterior direction by blunt and sharp dissection from nonpedicle to the vascular pedicle side

6.2

Palatal Flap

113

Fig. 6.13 The posteromedial part of the greater palatine canal is drilled under microscope. This freed up the greater palatine vascular pedicle and flap becomes rotatable

Fig. 6.14 The flap is rotated to resurface the mucosal defect which was located in the retromolar trigone, posterior part of the inferior alveolus and adjoining part of the floor of mouth

114

6.3

6


Submental Artery Flap

Fig. 6.15 With the patient in supine position and head extended, the face and head are prepared. The upper limit of the flap is marked along the mandibular arch in the submental region from the ipsilateral angle

to a contralateral point across the midline. The inferior limit of the flap is outlined by an index finger-thumb pinch test to assess primary closure

6.3


Fig. 6.16 The flap is elevated from the contralateral side of the pedicle in the subplatysmal plane. When dissecting the upper margin of the flap, the marginal mandibular branch of the facial nerve which lies just

115

deep to the platysma and overlying the facial artery is identified and preserved. The dissection is continued till the midline is reached

Fig. 6.17 At the midline the dissection is continued to include the anterior belly of digastric muscle on the ispilateral side (i.e. the pedicle side). The dissection is proceeded towards the pedicle on the surface of the submandibular gland until the facial artery is reached

116

Fig. 6.18 The facial artery is traced proximally and downwards retraction on the gland reveals the submental artery

Fig. 6.19 The anterior belly of digastric muscle of the pedicle side is included in the flap

6


6.3


117

Fig. 6.20 The facial vessels and submental artery and vein are dissected from the submandibular gland and the mylohyoid muscle. Dissection is carried down to the origin of the facial artery and vein till a pedicle of desired length is obtained

Fig. 6.21 The submental flap is ready to be mobilized to the defect

118

6


Fig. 6.22 The pedicle is lengthened to desired length to reach the defect to be closed. In this case, it is used to close a large soft tissue defect that resulted in the postaural region. The flap with its pedicle is passed below the bridge of skin

Fig. 6.23 The flap covers the retro auricular defects; drain inserted and donor area closed

6.3


119

Fig. 6.24 For closure of defects in the tongue after glossectomy; the flap is passed into the oral cavity deep to the mandible and mobilized into the oral cavity

Fig. 6.26 A distally based reverse flow submental flap is able to reach defects in the hard palate following maxillectomy

Fig. 6.25 A distally based flap based on reverse flow is created by ligating the facial artery and vein proximal to the origin of the submental artery to cover the cranially located defect. The position of the mandibular branch of the facial nerve, which is the pivotal point for flap rotation restricts the distal dissection of the pedicle. The nerve is carefully dissected out and the flap is passed under it

120

6.4

6


Nasolabial Flap

Fig. 6.29 The donor site is closed

Fig. 6.27 Inferiorly based nasolabial flap is mobilized

Fig. 6.28 A tunnel is created in the cheek mucosa and flap directed into the oral cavity

Fig. 6.30 Gingivolabial defect closed with nasolabial flap

6.5

6.5

Trapezius Flap

Trapezius Flap

Fig. 6.31 The flap site marked out

Fig. 6.32 The feeding transverse cervical artery and vein are identified

121

122

Fig. 6.33 The flap with the feeding vessels attached is completely mobilized

Fig. 6.34 The flap used to close oral cavity defect

6


6.6

6.6

Lattismus Dorsi Flap

Lattismus Dorsi Flap

Fig. 6.35 The postoperative cheek defect to be closed with lattismus dorsi flap and an alternate flap

Fig. 6.36 The lattismus dorsi flap is marked out

123

124

Fig. 6.37 The feeding vessels of lattismus dorsi flap are identified

Fig. 6.38 The lattismus dorsi flap is mobilized with feeding vessels

6


Fig. 6.39 The outer cheek defect closed with lattismus dorsi flap. Inner mucosa is closed with a alternate flap

6.7

6.7

Pectoralis Major Myocutaneous Flap

125


Fig. 6.40 The clavicle and the approximate course of the vascular pedicle are marked out. The flap is marked out depending on the size of the defect to be reconstructed

Fig. 6.41 The skin of the lateral chest wall is undermined and the lateral border of the pectoralis major muscle is identified

126

Fig. 6.42 The pectoralis major muscle is separated from the pectoralis minor muscle

Fig. 6.43 The pectoralis major muscle is elevated off the chest wall

6


6.7


127

Fig. 6.44 The pectoral branch of thoracoacromial artery ( arrow) identified. Pectoral nerve ( arrow head ) exiting the pectoralis minor is identified and transsected

Fig. 6.45 The muscular attachment to the humerus is transsected and the flap is completely mobilized

128

6


Fig. 6.46 A tunnel is created for the passage of the pectoralis major muscle flap to the neck

Fig. 6.47 The pectoralis major myocutaneous flap is transferred to the neck superficial to the clavicle to be used to reconstruct defects as required

6.8

6.8

Radial Forearm Free Flap

129


Fig. 6.48 The radial forearm flap is marked out with the cephalic vein and the palpable pulse of the radial artery

Fig. 6.49 The dissection is began distally after exsanguination of the forearm through the use of an elastic bandage and raising the tornique to 250 mmHg. The distal skin incision is made to gain exposure of the

radial artery and cephalic vein. The cephalic vein and radial artery are transsected and ligated

130

6


Fig. 6.50 The dissection is done from the lateral to medial. The skin flap is elevated with the deep fascia

Fig. 6.51 The dissection is continued along the intermuscular septum till the point where the brachioradialis and the flexor carpi radialis overlap

6.8


131 131

Fig. 6.52 The proximal radial artery and cephalic vein are exposed by separating the brachioradialis from the flexor carpi radialis muscles

Fig. 6.53 The radial forearm free flap is ready to be divided when the vessels of the donor site to be anastomosed are ready. The tornique is released

7

Mandible

7.1

Mandibulotomy Mandibulotomy for Access

Fig. 7.1 The incision for midline mandibulotomy is marked out running in the midline of lower lip to the level of the hyoid and laterally to the anterior border of sternocleidomastoid muscle and up to the mastoid process. In the oral cavity the incision is made along the medial border of the mandible in the midline to the retromolar trigon area

Fig. 7.2 Mandibulotomy Mandibulotomy is done in the midline. The soft tissue attachments to the floor of mouth to the mandible are excised and the mandible is reflected laterally pivoting at the temporomandibular joint

S.P. Dubey, C.P. C.P. Molumi, Molumi , Color Atlas of Head and Neck Surgery: A Step-by-Step Guide , DOI 10.1007/978-3-319-15645-3_7, © Springer International Publishing Switzerland 2015

133

134

7

Mandible

Fig. 7.3 After the procedure, the temporomandibular joint is checked for dislocation and the mandible placed back in position and held together with mini plate and screws

7.2

7.2

Segmental Mandibulectomy and Reconstruction with Stabilizing Plate and Screw

135

Segmental Mandibulectomy and Reconstruction with Stabilizing Plate and Screw

Fig. 7.4 Through an incision two finger breaths below the angle of mandible, the mandibular tumor is exposed and marked out for segmental mandibulectomy

Fig. 7.6 Stabilization plate are placed and held in place with screws placed at the proximal and distal cut ends of the mandible

Fig. 7.5 The proximal and distal ends of the mandible are exposed after mandibulectomy and freed of any tissue attachments in preparation for plating Fig. 7.7 The excised specimen with mandible is sent for further examination

136

7.3

7

Mandible

Segmental Mandibulectomy and Reconstruction with Rib Graft

Fig. 7.10 The periosteum on the under surface of the rib is separated from rib. This separates the neurovascular structures deep to the rib Fig. 7.8 The 7th rib ( arrow head ) is palpated and marked out, the lower marking indicates the 12th rib

Fig. 7.9 A incision is made from thee skin to the bone. The outer periosteum reflected Fig. 7.11 The required length of the rib is measured and cut with a rib cutter

7.3

Segmental Mandibulectomy and Reconstruction with Rib Graft

137

Fig. 7.12 The rib graft is plated with plate and screws. A longer plate is used so it is plated to the excised ends of the mandible

Fig. 7.13 The rib graft is placed and secured to the excised ends of the mandible to hold it in place. The incision is closed. The gingivolabial and gingivolingual mucosa are close water tight to prevent saliva leak into the graft site

138

7.4

7

Mandible

Bilateral Hemi Mandibulectomy and Reconstruction with Fibular Graft Microvascular Anastomosis

Fig. 7.16 The end of the tumor on each side of the mandible is identified and the tissues over the tumor dissected off to expose the tumor

Fig. 7.14 Huge mandibular ameloblastoma involving both halves of the mandible requires hemimandibulectomy

Fig. 7.17 After exposure of the tumor, the tumor free part of the mandible on both sides is exposed to be cut

Fig. 7.15 The incision extends from the mastoid process of one side and curves over the tumor to the other side

7.4

Bilateral Hemi Mandibulectomy and Reconstruction with Fibular Graft Microvascular Anastomosis

Fig. 7.18 Saw cuts are made at the tumor free part of the mandible on both sides and the tumor is separated from the mandible; the ascending ramus on each side is visible ( arrows)

Fig. 7.20 The left f ibula is marked out for free fibular graft

139

Fig. 7.19 The excised tumor specimen is examined and sent for histopathological examination

140

7

Mandible

Fig. 7.21 Fibula graft harvested with attached vascular pedicle, the peroneal artery and vein ( arrow)

Fig. 7.22 The peroneal artery and vein is anastomosed with facial artery and vein ( arrow). Fibula graft is reinforced with mini plate and screws and attached to the remaining mandible on each side

8

Lips and Face

8.1

Repair of Lip Defect with Abbe-Estlander Flap

Fig. 8.1 The axial flap consists of skin, muscle and mucous membrane based on superior labial artery. It is used to reconstruct one-third of the excised lower lip. A ‘v’ shaped area of excision is marked out with 1 cm of normal tissue on either side of the squamous cell carcinoma in the lower lip. Similarly an equal triangular area is marked out in the upper lip whose length is equal to the half of the defect. The vermilion border of the lips also marked

Fig. 8.2 The pedicle of the flap is based medially and it contains the superior labial artery which runs 5 mm above the upper margin of the upper lip. Buccal aspect of the tumor shows minimal extension


141

142

8

Lips and Face

Fig. 8.4 The donor area is mobilized and closed in three layers. The lip commissure is formed in the process of flap rotation. The cut ends of the lip is sutured

Fig. 8.3 (a, b) Using a sharp cut, the tumor is excised. The medially based flap is designed, mobilized and rotated into the defect, and sutured in place in three layers, skin, muscle and mucosa

Fig. 8.5 After 4 weeks the wound heals with less scaring. The scar is eventually indistinguishable

8.2

8.2

Repair of Full Thickness Lip Defect

143

Repair of Full Thickness Lip Defect

Fig. 8.6 Full length mucosal lesion of the lower lip with cutaneous infiltration in the midline is marked out for excision

Fig. 8.7 The mucosal lesion is excised with a ‘V’ shaped cutaneous and mucosal incision in the midline

Fig. 8.8 The defect of the lip after excision

Fig. 8.9 The closure of the surgical defect is begun by placing sutures through the vermillion edge of the skin of the ‘V’ shaped defect for accurate approximation

144

Fig. 8.10 The skin, muscle and mucosal layers of the ‘V’ shaped defect is sutured

Fig. 8.11 The skin to mucosa of the lip margins are approximated

8

Lips and Face

8.3

8.3

Repair of Near Total Lop Defect by Karapandzic Flap

145

Repair of Near Total Lop Defect by Karapandzic Flap

Fig. 8.14 The skin and mucosal margins are closed. The oral sphincter function is maintained but significant microstoma resulted

Fig. 8.12 Full thickness of the lower lip involved by exophytic squamous cell carcinoma

Fig. 8.13 The tumor is excised creating a total lip defect. A crescentic incisions extending bilaterally from the nasolabial crease around the oral commissure and into or near the lower lip defect are made. The orbicularis oris muscle and labial artery pedicles are preserved; the gingivolabial and gingivobuccal mucosa of each side are also incised for adequate mobilization

146

8.4

8

Lips and Face

Repair of Medial Canthal Defect with Split Forehead Flap

Fig. 8.17 The flap and donor site heals well within 8 weeks

Fig. 8.15 The excision margin around squamous cell carcinoma of the medial canthal region and the flap which will be used to close the defect are marked out

Fig. 8.16 The post excision defect involved both upper and lower eyelids. The forehead flap is elevated and is splitted in the middle. The split flap is rotated to cover the defect. The donor area is also closed in layers

8.5

8.5

Deep-Plane Cervicofacial Rotation-Advancement Flap

147

Deep-Plane Cervicofacial Rotation-Advancement Flap

Fig. 8.18 The incision marking for excision of neurofibroma involving the midface and adjoining external nose

Fig. 8.19 Th neurofibroma is excised leading to the formation of a large defect in the midface, medial canthus and adjoining bridge of the nose

Fig. 8.20 A posteriorly based deep-plane cervicofacial rotation and advancement flap is raised with incision along the right nasolabial crease; the plane of dissection is made superficial to the facial muscles. Subsequently, the incision is extended to the upper part of the neck at a plane deep to the platysma

Fig. 8.21 This flap covers most of the raw area except in the medial canthus and adjoining nasal dorsum

148

8

Lips and Face

Fig. 8.22 On the right side, an appropriate size island flap (described in 5.4) is raised to cover the remaining defect in the medial canthus and adjoining nasal dorsum

8.6

8.6

Temporalis Muscle Flap Transposition Technique for Paralysed Face

149


Fig. 8.23 The patient had 3 years old post-traumatic facial paralysis; direct or indirect nerve reconstruction were not an option

Fig. 8.25 The middle third of the muscle (roughly 4 cm or two fingers breadth wide) is raised with a 2 cm strip of periosteum ( P) by which the muscle belly is pulled through to the incision lateral to the oral commissure. The periosteum at the tip of the muscle is split in the middle. The temporalis muscle is not elevated beyond the zygomatic arch to protect the neurovascular supply to it. The anterior third of the temporalis is elevated. This bulk of muscle is split into equal anterior and posterior parts or arms except for its cranial 2 cm. The anterior part or arm is detached from its proximal attachment leading to the formation of the word ‘V’

Fig. 8.24 Reanimation of the mouth. The incision for the temporalis muscle flap is marked out as a curved incision from the back of the ipsilateral pinna and followed to the superior temporal line anteriorly. The patient also needed mastoid exploration as a consequence of the trauma. Additional markings of incisions are made lateral to the oral commissure, lateral and medial canthus of the eye as well as middle of the upper and lower lids

150

Fig. 8.26 A 3 cm long incision is placed on the smile or lip-cheek crease of the paralysed side. The location of this line on the paralyzed side is determined before anesthesia during smile and compared with the normal side. Alternatively, it is ascertained by elevating the paralyzed angle of the mouth with fingers. The incision is deepened down to the muscle. The temporalis muscle is exposed. A subcutaneous tunnel is created by blunt dissection with forceps and fingers. In the temporal fossa the tunnel lies superficial to the superficial musculoaponeurotic system (SMAS). In the face, it lies between the fat and facial muscles layer. The middle and index fingers are passed through the tunnel to create adequate diameter

8

Lips and Face

Fig. 8.27 The anterior third of the muscle is brought out through the incision at the lateral canthus. The anterior third of the split muscle is now negotiated through the tunnels in such a way that the posterior part occupied the lower lid and the anterior one in the upper lid. The cranial part of the muscle lies at the medial canthus. The canthal and lid incisions helped in this process of adjustment. The lower ends of both the parts were stitched together at the lateral canthus. The temporalis muscle strips are stitched to the orbicularis oris and tarsal plates through the upper and lower lid incisions with the help of the fine absorbable sutures. Likewise, the tip of the muscle strip is attached to the medial canthal ligament

8.6


Fig. 8.28 All the incisions are closed and the suction drain inserted to the temporal wound

151

152

8.7

8

Lips and Face

Pedicled Calvarial Bone Graft

Fig. 8.29 Wide bony defect and soft tissue scaring resulted secondary to extensive cholesteatoma with complications

Fig. 8.30 The skin flap is raised above the superficial temporal artery (arrow head ). The posterior branch of the superficial temporal artery is identified (arrow) and traced in the posterosuperior direction till the part of the calverion overlying the posterior half of the parietal bone is reached

Fig. 8.31 Except for the inferior 20 % with vascular pedicle, the rest of the periosteum over the measured part of the bone is incised. Partial cut is made on the outer table of the compact calvarial bone with a saw. With a fine drill burr, ad holes are made at the proximal edge of the cut. With the help of sutures the periosteum is fixed with bone flap. The outer table of the calvarial bone is next cut using a curved osteotome till the cancellanous layer is reached

8.7

Pedicled Calvarial Bone Graft

Fig. 8.32 A tunnel is created between the periosteum and the bone flap at the inferior 20 % of the circumference. Using a mastoid drill and diamond burr this part of the bone is cut keeping the vascular pedicle intact and the bone flap with the covering periosteum are elevated with using a curve osteotome. The elevated bone flap covered by periosteum and pedicled on the posterior branch of superficial temporal artery is free to be mobilized

Fig. 8.33 The bone flap is rotated and it covered a wide defect of the temporo-occipital bone. The scar tissue is excised and split thickness skin graft placed on the periosteum of the bone flap

153

Fig. 8.34 The defect heals satisfactorily 3 months after operation

9

Temporal Bone Malignancy

9.1

Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy

Fig. 9.1 Postauricular incision used for elevation of anterior musculoperiosteal flap and identification of the facial nerve is marked out. The incision is extended into the neck for exposure of the great vessels and cranial nerves. The upper limb of the incision is marked out for temporalis muscle mobilization if needed after the procedure

Fig. 9.2 Anteriorly based mastoid musculoperiosteal flap is raised and left attached to the catalagenous canal to be used later for obliteration of the mastoid cavity


155

156

9


Fig. 9.3 Neck dissection is done and the facial nerve identified. The facial nerve is dissected into the parotid gland postauricularly and up to the point of second division. The sternocleidomastoid muscle is retracted posteriorly and common carotid artery, internal jugular vein

and vagus nerve identified. Cranial nerves XI and XII are also identified. Total parotidectomy is done. The tympanic segment of the facial nerve is removed as it is involved by the tumor. Radical mastoidectomy is done

Fig. 9.4 The tegmen, posterior fossa plate, sigmoid sinus from the sinodural angle to the jugular bulb is skeletonized. The mastoid segment of the facial nerve is dissected off the fallopian canal all the way

to the stylomastoid formen which is drilled out to mobilize the nerve for ene-to-end facial hypoglossal anastomosis. The sternocleidomastoid muscle is detached from the mastoid tip and tip removed

9.1 Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy

Fig. 9.5 The bony eustachian tube is drilled down to the isthmus. The carotid artery is exposed medial to the eustachian tube ( blue marker in the picture). The s tyloid process and lateral tympanic bone covering the

Fig. 9.6 The incision is closed and suction drain inserted in the neck

157

carotid foramen are removed. The upper cervical internal carotid artery, cranial nerve IX and internal jugular vein are exposed. The tumor is removed

158

9.2

9


Subtotal Petrosectomy with Excision of Pinna

Fig. 9.9 The defect is closed with pectoralis major myocutaneous flap with nipple

Fig. 9.7 Squamous cell carcinoma of the middle ear with pinna and posterior auricular extension

Fig. 9.10 The nipple is transferred back to the donor site on the chest after healing

Fig. 9.8 Defect after excision and subtotal petrosectomy, total parotidectomy and ascending ramus mandibulectomy ( arrow head )

10

Head and Neck

10.1

Excision of Lipoma Over Parotid Region

Fig. 10.1 Parotid lipoma before excision

Fig. 10.2 Raising the flap at the subcutaneous tissue level exposed the lipoma. It is easily excised by staying very close to the tumor


159

160

Fig. 10.3 The specimen is removed and sent for histopathological examination, a penrose drain inserted and wound closed

Fig. 10.4 A penrose drain is inserted and the wound closed

10

Head and Neck

10.2

10.2

Excision of Sebaceous Cyst

161

Excision of Sebaceous Cyst

Fig. 10.7 The intact specimen with intact capsule is removed and examined

Fig. 10.5 Submandibular sebaceous cyst before excision

Fig. 10.6 The skin flap is raised at the subcutaneous tissue plane exposing the cyst. Tissue attachments around the capsule are excised and the cyst removed

Fig. 10.8 The cyst opened exposing the sebaceous contents

162

10.3

10

Head and Neck

Excision of Parapharyngeal Neurofibrosarcoma

Fig. 10.9 Incision is marked out for mandibulotomy and inclusion of previous surgical scar for excision with the tumor

Fig. 10.11 The tumor is dissected away from the common carotid artery and followed to the angle of the mandible

Fig. 10.12 Dissection at the lateral border of the tumor shows involvement of the accessory nerve

Fig. 10.10 After mandibulotomy as described in Chap. 7, the entire tumor is exposed together with the neurovascular structures. The external jugular vein is ligated as it is involved by the tumor. The tumor is found to be arising from the vagus nerve

10.3

Excision of Paraphary ngeal Neurofibrosarcoma

163

Fig. 10.13 The tumor with the involved structures, the internal jugular vein, vagus nerve, accessory nerve, lingual nerve, hypoglossal nerve and external carotid artery are removed. The internal carotid artery is thinned out due to compression from the tumor

Fig. 10.14 Intact specimen with attached structures is examined

164

10.4

10

Head and Neck

Excision of Neck and Mediastinal Neurofibroma

Fig. 10.16 Orotracheal intubation is done; an inverted ‘L’ shaped incision given whose horizontal limb is on the upper part of the tumor and the vertical limb on the mediastinum

Fig. 10.15 The tumor occupied lower half of the neck and in the superior mediastinum

Fig. 10.17 The tumor is separated from skin and subcutaneous tissue, neck structures and clavicle. The vertical limb on the chest is cleared and sternum exposed for manubriotomy

10.4

Excision of Neck and Mediastinal Neurofibroma

165

Fig. 10.18 The sternum is retracted to expose the mediastinal extension of the tumor. The mediastinal extension of the tumor is removed together with the neck extension

Fig. 10.19 Operative field after excision of tumor exposing the neurovascular structures preserved

166

10.5

10

Head and Neck

Supra Omohyoid Neck Dissection

Fig. 10.20 Incision extends from the point of the chin, down to the hyoid bone and ends at the sternocleidomastoid muscle below the mastoid process

Fig. 10.21 Subplatysmal flap is raised superiorly to the level of the angle of mandible and inferiorly to the superior belly of omohyoid muscle. The area of dissection is marked out by methylene blue

10.5


Fig. 10.22 Superficial layer of deep fascia over the anterior border of sternocleidomastoid muscle is separated from the muscle

Fig. 10.23 The accessory nerve is identified

167

168

10

Head and Neck

Fig. 10.24 The accessory nerve is retracted anteriorly and Level IIb nodes are dissected

Fig. 10.25 After dissection of the nodes lateral to the accessory nerve, the dissected Level IIb nodes are passed under the nerve and retracted medially. The nerve is retracted laterally and rest of level IIb nodes dissected

10.5


169

Fig. 10.26 Investing layer of the deep fascia over the scalenus muscle is reflected exposing the upper trunk of brachial plexus and phrenic nerve

Fig. 10.27 The carotid sheath is opened exposing the contents

170

Fig. 10.28 Jugular nodes are dissected away from the carotid artery, vagus nerve and internal jugular vein

Fig. 10.29 The submandibular and submental nodes are dissected with the submandibular gland

10

Head and Neck

10.5


Fig. 10.30 Hemostasis of the surgical field is done at the end of the procedure, suction drain is inserted and the wound closed in layers

171

172

10.6

10

Modified Radical Neck Dissection. Accessory Nerve Preserved

Fig. 10.31 A Y- type incision marked out and injected with 1:100,000 lignocaine with adrenaline

Fig. 10.32 Superior and inferior subplatysmal flaps are raised

Head and Neck

10.6

Modified Radical Neck Dissection. Accessory Nerve Preserve d

173

Fig. 10.33 Accessory nerve supplying trapezius muscle is identified and preserved

Fig. 10.34 The dissection is began at the posterior triangle and proceeded medially. The upper trunk of brachial plexus and phrenic nerve identified; dissection continued to lateral border of sternocleidomastoid muscle

174

10

Head and Neck

Fig. 10.35 Clavicular and sternal attachment of sternocleidomastoid muscle ( arrow head ) is incised and internal jugular vein ( arrow) ligated

Fig. 10.36 Sternocleidomastoid muscle attachment to the mastoid process is divided, upper end of internal jugular vein ( arrow head ) is ligated and divided, accessory nerve supplying trapezius muscle dis-

sected away as it passes through the sternocleidomastoid muscle and preserved. Submandibular gland and submental nodes are dissected and specimen removed enbloc

10.6

Modified Radical Neck Dissection. Accessory Nerve Preserve d

Fig. 10.37 On the left side, the thoracic duct if identified is ligated to prevent chyle leak

175

References

Books Blitzer A, Lawson W, Friedman WH (1991) Surgery of the paranasal sinuses. WB Saunders, Philadelphia Butter CE (2009) Head and neck reconstruction. Saunders Elsevier, Philadelphia Donald PJ (1998) Surgery of the skull base. Lippincott – Raven, Philadelphia Dufresne CR, Carson BS, Zinreich SJ (1992) Complex craniofacial problems. Churchill Livingstone, New York Fisch U, Mattox D (1988) Microsurgery of the skull base. Georg Thieme Verlag, New York Genden EM (2012) Reconstruction of head and neck: a defect oriented approach. Thieme, Stuttgart Grillo HC (2004) Surgery of the trachea and bronchi. B C Decker Inc., Hamilton Jackson CG (1991) Surgery of the skull base tumors. Churchill Livingstone Inc., New York May M, Schaitkin BM (2000) The facial nerve: May’s second edition. Thieme, New York Melanna HM, Kian K (2012) Head and neck cancer recurrence: evidence-based multidisciplinary management. Thieme, Stuttgart Montgomery WW (2002) Surgery of the larynx, trachea, esophagus and neck. Saunders, Philadelphia Myers EN, Ferris RL (2007) Salivary gland disorders. Springer, Berlin Naumann HH (1998) Head and neck surgery, vol 1–3. Thieme, Stuttgart Rhoton AL, Natori Y (1996) The orbit and sellar region: microsurgical anatomy and operative approaches. Thieme, Stuttgart Rootman J, Stewart B, Goldberg RA (1995) Orbital surgery: a conceptual approach. Lippincott – Raven, New York Sekhar LN, De Oliviera E (1999) Cranial microsurgery: approaches and techniques. Thieme, Stuttgart Shah JP, Patel SG (2003) Head and neck surgery and oncology. Mosby Elsevier, New York Stell PM, Maran AGD (1978) Head and neck surgery, 2nd edn. Willium Heinemann Medical Books Ltd, London Strauch B, Yu H (1993) Atlas of microvascular surgery: anatomy and operative approaches. Thieme, Stuttgart Urken ML, Cheney ML, Sullivan MJ, Biller HF (1995) Atlas of regional and free flaps for head and neck reconstruction. Raven Press, New York

Journal Articles Ammirati M, Spallone A, Ma J, Cheatham M, Becker D (1993) An anatomicosurgical study of the temporal branch of the facial nerve. Neurosurgery 33:1038–1044

Arden RL, Nawroz-Danish M, Yoo GH, Meleca RJ, Burgio DL (1999) Nasal alar reconstruction: a critical analysis using melolabial island and paramedian forehead flaps. Laryngoscope 109:376–382 Ayad TA, Kolb F, Mones ED, Mamelle G, Temam S (2008) Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation. Head Neck 30:437–445 Bertotti JA (1980) Trapezius-musculocutaneous island flap in the repair of major head and neck cancer. Plast Reconstr Surg 65:16–21 Boyette JR, Vural E (2011) Cervicofacial advancement-rotation flap in midface reconstruction: forward or reverse? Otolaryngol Head Neck Surg 144:196–200 Casanova R, Cavalcante D, Grotting JC, Vasconez LO, Psillakis JM (1986) Anatomic basis for vascularized outer-table calvarial bone flap. Plast Reconstr Surg 78:300–308 Casler JD, Conley J (1991) Sternocleidomastoid muscle transfer and superficial musculoaponeurotic system plication in prevention of Frey’s syndrome. Laryngoscope 101:95–100 Coert JH, Dellon AL (1994) Clinical implications of the surgical anatomy of the sural nerve. Plast Reconstr Surg 94:850–855 Conger RT, Gourin CG (2008) Free abdominal fat transfer for reconstruction of the total parotidectomy defect. Laryngoscope 118:1186–1190 Conley JJ, Lanier DM, Tinsley P (1986) Platysma myocutaneous flap revisited. Arch Otolaryngol Head Neck Surg 112:711–713 Converse JM (1959) Reconstruction of the nose by the scalping flap technique. Surg Clin North Am 39:335–365 Converse JM, Wood-Smith D (1963) Experience with the forehead island flap with a subcutaneous pedicle. Plast Reconstr Surg 31:521–527 Curran AJ, Neligan P, Gullane PJ (1997) Submental artery island flap. Laryngoscope 107:1545–1549 Curry JM, Fisher KW, Heffelfinger RN, Rosen MR, Keane WM, Pribitkin EA (2008) Superficial musculoaponeurotic system elevation and fat graft reconstruction after superficial parotidectomy. Laryngoscope 118:210–215 Dubey SP, Molumi CP (2007) Critical look at the surgical approaches of nasopharyngeal angiofibroma excision and ‘total maxillary swing’ as a possible alternative. Ann Otol Rhinol Laryngol 116:723–730 Dubey SP, Molumi CP (2012) Transpalatal approach with pedicled palatal osteo-muco-periosteal flap. ANZ J Surg 82:439–442 Dubey SP, Molumi CP, Apaio ML (2011) Total maxillary swing approach to the skull base for advanced intracranial and extracranial nasopharyngeal angiofibroma. J Craniofac Surg 22:1671–1676 Guillamondegui OM, Larson DL (1981) Lateral trapezius musculocutaneous flap: its use in head and neck reconstruction. Plast Reconstr Surg 67:143–150 Heller L, Cole P, Kaufman Y (2008) Cheek reconstruction: current concepts in managing facial soft tissue loss. Semin Plast Surg 22:294–305

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Hill HL, Vasconez LO, Jurkiewicz MJ (1978) Method of obtaining sural nerve graft. Plast Reconstr Surg 61:177–179 Hivelin M, Wolkenstein P, Lepage C, Valeyrie-Allanore L, Meningaud JP, Lantieri L (2010) Facial aesthetic unit remodeling procedure neurofibromatosis type I hemifacial atrophy: report on 33 consecutive adult patients. Plast Reconstr Surg 125:1197–1207 Jeon SY, Jeong JH, Kim HS, Ahn SK, Kim JP (2003) Hemi degloving approach for medial maxillectomy: a modification of midfacial degloving approach. Laryngoscope 113:754–756 Jovett N, Mlynarek AM (2010) Reconstruction of cheek defects: a review of current techniques. Curr Opin Otolaryngol Head Neck Surg 18:244–254 Kline RM, Wolfe A (1995) Complications associated with harvesting cranial bone grafts. Plast Reconstr Surg 95:5–13 Koch WM (2002) The platysma myocutaneous flap: under used alternative for head and neck reconstruction. Laryngoscope 112:1204–1208 Kroll SS, Reece GP, Robb G, Black J (1994) Deep-plane cervicofacial rotation flap for reconstruction of large cheek defects. Plast Reconstr Surg 94:88–93 Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D (1990) Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope 100:735–741 McCarthy JG, Zide BM (1984) The spectrum of calvarial bone grafting: introduction of the vascularized calvarial bone flap. Plast Reconstr Surg 74:10–18 McGuirt WF, Mathews BL, Brody JA, May JS (1991) How I do it – platysma myocutaneous flap: caveats re-examined. Laryngoscope 101:1238–1244 Merten SL, Jiang RP, Caminer D (2002) The submental island flap for head and neck reconstruction. ANZ J Surg 72:121–124

References

Molumi CP, Dubey SP, Apaio ML (2012) Preservation of palatal mucoperiosteum for oronasal separation after total maxillectomy. Indian J Cancer 49:209–214 Newman MH, Work WP (1976) Arytenoidectomy revisited. Laryngoscope 86:840–849 Piquet JJ, Chevalier D (1991) Subtotal laryngectomy with cricohyoido-epiglotto-pexy for the treatment of extended glottis carcinomas. Am J Surg 94:357–361 Pribaz J, Stephens W, Crespo L, Gifford G (1992) A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 90:421–429 Psillakis JM, Grotting JC, Casanova R, Cavalcante D, Vasconez LO (1986) Vascularized outer-table calvarial bone flap. Plast Reconstr Surg 78:309–317 Ruark DS, McClairen WC, Schlehaider UK, Abdel-Misih RZ (1993) Head and neck reconstruction using the platysma myocutaneous flap. Am J Surg 165:713–718 Schuller DE (1982) Latissimus dorsi myocutaneous flap for massive facial defects. Arch Otolaryngol 108:414–417 Sharma RK (2011) Supratrochlear artery island paramedian flap for reconstructing the exenterated patients. Orbit 30:154–157 Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF (1996) The submental island flap. Br J Plast Surg 49:85–89 Taghinia AH, Movassaghi K, Wang AX, Pribaz JJ (2008) Reconstruc tion of the upper aerodigestive tract with the submental artery flap. Plast Reconstr Surg 123:562–570 Tan ST, MacKinnon CA (2006) Deep plane cervicofacial flap: a useful and versatile technique in head and neck surgery. Head Neck 28:46–55 Woods JE (1983) Parotidectomy: points of technique for brief and safe operation. Am J Surg 145:678–683

Index

A

Abbe-Estlander flap lower lip reconstruction, 141 upper lip reconstruction, 141 Advancement flap cheek reconstruction, 18, 24, 93, 121, 124, 125 Ala reconstruction Reiger glabellar rotation flap, 93 Anterior scalping flap nasal reconstruction, 103–106 Artery external carotid, 163 facial, 74, 107–111, 116–118, 120, 140 greater palatine, 19 internal carotid, 157, 163 lingual, 163 superficial temporal, 85, 86, 152, 153 superior thyroid, 49 transverse facial, 122 Arytenoidectomy with lateralization of vocal cord , 31–34

Fat graft, 85–88 Flap deltopectoral, facial artery musculomucosal (FAMM), 107–111 forehead island, 95–97 midline, oblique, 101–102 lattisimus dorsi musculocutaneous, 124, 125 nasolabial, 91–92, 121 pectoralis major myocutaneous, 126–129, 158 radial forearm free, 130–132 Schmid-Meyer, 98–100 submental artery, 115–120

G

Gillies advancement flap lower lip reconstruction, 141, 143, 145

L B

Deltopectoral flap, 128

Lacrimal sac and nasolacrimal duct, 5, 6, 13 Laryngectomy frontolateral partial of Leroux-Robert, 35–37 subtotal s upracricoid, 38–41 supraglottic horizontal partial, 42–47 total, 48–56 vertical partial, 35–37 Laryngopharyngoesophagectomy with gastric pull-up, 56–57 Lateral rhinotomy, 5–8 Lower lip primary closure, 15 reconstruction with flap Abbe-Estlander , 141 Gillies, Karapandzic, 145

F

M

Facial nerve anastomosis with hypoglossal nerve, 156 peripheral branches, reanimation by temporalis muscle transfer , 149

Mandibulectomy, 135–140, 158 Mandibulotomy, 133–134, 162 Maxillectomy, 18–27, 120 Midfacial degloving, 3–4

Bilateral hemimandibulectomy reconstruction with fibular graft, 138–140 Blind sac closure, 82–84

C

Calvarial bone graft, 152–153 Converse's forehead scalping flap reconstruction of nasal defect, 95–97 Cricopharyngeal myotomy with total laryngectomy, 54

D

S.P. Dubey, C.P. Molumi, Color Atlas of Head and Neck Surgery: A Step-by-Step Guide , DOI 10.1007/978-3-319-15645-3, © Springer International Publishing Switzerland 2015

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Color Atlas of Head and Neck Surgery - A Step-By-Step Guide [2015][UnitedVRG]

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