Zg13h.color.atlas.of.head.and.neck.surgery.a.stepby step.guide

123

Color Atlas of Head and Neck Surgery

Siba P. DubeyCharles P. Molumi

A Step-by-Step Guide


Siba P. Dubey • Charles P. Molumi


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

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

ISBN 978-3-319-15644-6 ISBN 978-3-319-15645-3 (eBook) DOI 10.1007/978-3-319-15645-3

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, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other 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 specifi c 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)

www.springer.com

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

vii

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, fre-quently in an advanced state and often with complications of late presentation. This is particu-larly 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 qualifi cations. I have great admi-ration 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. They have prospectively collected their data, published numerous journal articles in peer-reviewed journals on advanced disease and its management, and have now produced a fi ne 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 proce-dures 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 train-ees, opening the eyes of those practising in the developed world and inspiring those in develop-ing countries. Dr Dubey and Dr Molumi are to be congratulated.

December, 2014 Vincent C. Cousins, BMedSci, MBBS, FRACSMelbourne, Australia

ix

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 qualifi ed 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 pho-tographs accompanied by brief fi gure legends highlighting the key features of the technique presented in the photos. Presenting the important elements of each operation graphically with-out having to wade through a great deal of text 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)

Foreword II

xi

The surgery of the head and neck region requires a great degree of expertise due to the pres-ence 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, man-dible, temporal bone malignancy, facial plastic surgery, neck dissections and surgery of the lip and oral cavity. Sections deal with (i) radical 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 pro-cedures, 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 fl aps. The surgery of the skull base deserves special mention as it is performed within the confi nes 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 benefi tted by this book where step-by-step operative descriptions will act as quick references.

The authors wish to express their sincere gratitude to late Professor 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 col-leagues 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

Pref ace

xiii

1 Nose and Paranasal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Sublabial Approach for Maxillary Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Midfacial Degloving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.3 Lateral Rhinotomy with Medial Maxillotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Transpalatal Approach by Palatal Osteomucoperiosteal Flap . . . . . . . . . . . . . . . 8 1.5 Total Maxillary Swing (For Advanced Nasopharyngeal Angiofi broma) . . . . . . 11 1.6 Total Maxillectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.7 Total Maxillectomy with Orbital Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.8 Extended Total Maxillectomy with Cheek Skin Excision . . . . . . . . . . . . . . . . . 25 1.9 Craniofacial Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

2 Larynx and Trachea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 2.1 Arytenoidectomy and Lateralization of Vocal Cord

(Modifi ed Woodman’s Technique) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 2.2 Frontolateral Vertical Partial Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 2.3 Supracricoid Laryngectomy with Cricohyoidoepiglottopexy . . . . . . . . . . . . . . 38 2.4 Supraglottic Horizontal Partial Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . 42 2.5 Total Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 2.6 Total Laryngopharyngoesophagectomy with Gastric Pull Up . . . . . . . . . . . . . . 56 2.7 Upper Tracheal Resection and Anastomosis for Trachea Stricture . . . . . . . . . . 58

3 Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 3.1 Sistrunk Procedure for Thyroglossal Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 3.2 Hemithyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 3.3 Total Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

4 Salivary Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 4.1 Submandibular Sialoadenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 4.2 Superfi cial Parotidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 4.3 Superfi cial Parotidectomy with Deep Lobe Resection . . . . . . . . . . . . . . . . . . . 80 4.4 Total Parotidectomy with Facial Nerve Graft with Sural Nerve

and Blind Sac Closure of External Auditory Canal for Malignant Parotid Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

4.5 Temporoparietal Facial Flap (TPFF) and Abdominal Fat Graft for Prevention of Frey’s Syndrome Following Parotidectomy . . . . . . . . . . . . . 85

5 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 Modifi ed 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

Contents

xiv

6 Axial and Free Flaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 6.1 Facial Artery Musculomucosal (FAMM) Flap . . . . . . . . . . . . . . . . . . . . . . . . 107 6.2 Palatal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 6.3 Submental Artery Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 6.4 Nasolabial Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 6.5 Trapezius Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 6.6 Lattismus Dorsi Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 6.7 Pectoralis Major Myocutaneous Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 6.8 Radial Forearm Free Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

7 Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 7.1 Mandibulotomy for Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 7.2 Segmental Mandibulectomy and Reconstruction with Stabilizing

Plate and Screw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 7.3 Segmental Mandibulectomy and Reconstruction with Rib Graft . . . . . . . . . . 136 7.4 Bilateral Hemi Mandibulectomy and Reconstruction

with Fibular Graft Microvascular Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . 138

8 Lips and Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 8.1 Repair of Lip Defect with Abbe-Estlander Flap . . . . . . . . . . . . . . . . . . . . . . . 141 8.2 Repair of Full Thickness Lip Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 8.3 Repair of Near Total Lop Defect by Karapandzic Flap . . . . . . . . . . . . . . . . . . 145 8.4 Repair of Medial Canthal Defect with Split Forehead Flap. . . . . . . . . . . . . . . 146 8.5 Deep-Plane Cervicofacial Rotation-Advancement Flap . . . . . . . . . . . . . . . . . 147 8.6 Temporalis Muscle Flap Transposition Technique for Paralysed Face . . . . . . 149 8.7 Pedicled Calvarial Bone Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

9 Temporal Bone Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 9.1 Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy . . . . . . . 155 9.2 Subtotal Petrosectomy with Excision of Pinna . . . . . . . . . . . . . . . . . . . . . . . . 158

10 Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 10.1 Excision of Lipoma Over Parotid Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 10.2 Excision of Sebaceous Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 10.3 Excision of Parapharyngeal Neurofi brosarcoma . . . . . . . . . . . . . . . . . . . . . . . 162 10.4 Excision of Neck and Mediastinal Neurofi broma . . . . . . . . . . . . . . . . . . . . . . 164 10.5 Supra Omohyoid Neck Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 10.6 Modifi ed Radical Neck Dissection. Accessory Nerve Preserved . . . . . . . . . . 172

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Contents

1S.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

1.1 Sublabial Approach for Maxillary Cyst

Nose and Paranasal Sinus 1

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 gingivo-labial sulcus mucosa. It extends from the canine to the fi rst molar tooth. The incision is made bone deep. The superior mucosal fl ap is raised preserving the neurovascular bundle in the infraorbital foramen

2

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

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 acrofl avin 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 Nose and Paranasal Sinus

3

1.2 Midfacial Degloving

Fig. 1.5 After oral intubation, patient is placed in head extended posi-tion. The nasal vestibular hairs are trimmed off and the nose is prepared with cophenylcaine spray and lignocaine with adrenaline infi ltration. Bilateral tarsorrhaphies are done. A columella clamp is used to retract the columella. A total transfi xation incision is marked out on each side at the junction between the stratifi ed squamous and respiratory colum-nar epithelium

Fig. 1.6 The transfi xation incision is extended from the tip of the nose onto the nasal fl oor

Fig. 1.7 A sublabial incision is made from the fi rst molar of the ipsi-lateral side to fi rst molar of the contralateral side. The incision is deep-ened 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 pyri-form margin and the nasal fl oor

1.2 Midfacial Degloving

4

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

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

Fig. 1.11 Dissection is continued through the intercartilagenous inci-sion 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 con-tinued laterally to the nasomaxillary suture line and superiorly to the glabella. Soft tissue over the anterior maxilla is elevated with a perios-teal elevator in the subperiosteal plane to the zygoma and the infraor-bital rim. The neurovascular bundle in the infraorbital foramen ( arrow ) is carefully preserved


5

1.3 Lateral Rhinotomy with Medial Maxillotomy

Fig. 1.12 Moure’s incision begins below the medial aspect of the eye-brow 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. 1.13 The incision is carried to the bone. The angular vessels are coagulated

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 mar-gin is elevated. The lacrimal sac can be divided. The frontoethmoidal suture is identifi ed

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


6

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 mar-gin is elevated. The frontoethmoidal suture is identifi ed 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. 1.17 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

Fig. 1.18 The tumor is removed accordingly


7

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

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


8

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 fl oor is elevated from the pyriform aperture to the poste-rior 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 fl oor where a malleable copper retractor is placed. This is done to prevent injury to the nasal fl oor mucoperiosteum during subsequent osteotomy of the hard palate

1.4 Transpalatal Approach by Palatal Osteomucoperiosteal Flap

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 fi rst premolar tooth. It is made where the palatal mucoperi-osteum meet the tooth. The palatal mucoperiosteum is elevated just medial to the greater palatine canal posteriorly and posterior to the inci-sive 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 sum-mit 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 fl oor


9

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

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 ( arrow ) 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. 1.26 The nasal fl oor mucoperiosteum is cut open to expose the tumor

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

1.4 Transpalatal Approach by Palatal Osteomucoperiosteal Flap

10

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

Fig. 1.29 The POMP fl ap is placed back. Three to four sutures are placed between the elevated palatal mucoperiosteum with mucoperios-teum 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


11

Fig. 1.30 After orotracheal intubation, the patient is placed in the head–extended position. The mouth is opened and the palatal muco-periosteum ( arrow head ) on the involved side is refl ected 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 refl ected together with the hard palatal mucoperiosteum exposing the oropharyngeal extension of the tumor

1.5 Total Maxillary Swing (For Advanced Nasopharyngeal Angiofi broma)

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


12

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 refl ected medially and anchored with sutures. This exposes the nasal extension of the tumor. The periosteum over the orbital fl oor is elevated to the level to the infra-orbital foramen exposing the site for osteotomy

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

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


13

Fig. 1.36 The orbital fl oor is elevated and the infraorbital nerve is sectioned as it enters the infraorbital foramen on the orbita fl oor. The perios-teum of the orbital fl oor 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 maxilloeth-moidal 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 refl ected outwards as in the opening of a swing door exposing the entire surgical fi eld and the tumor


15

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 fi xed with miniplate and screws at the maxillozygo-matic suture, the frontal process of the maxilla, and the intermax-illary suture at the inferior margin of the pyriform aperture. In patients less than 18 years of age, absorbable miniplates and screws are used


16

Fig. 1.42 The tumor is removed with all its extensions

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


17

Fig. 1.44 The patient is placed in the supine position and the orotra-cheal intubation is done and the tube is taped to the corner of the mouth opposite the side of the tumor. After the fi eld 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

1.6 Total Maxillectomy

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

Fig. 1.46 The sublabial part of the incision is extended from the mid-line to the third molar teeth and went round it. The incision begins in the upper lip. The cheek fl ap is raised by grasping the upper lip between the thumb and the index fi nger of the surgeon and the assistant puts the incision under tension and compress the superior labial artery. The gin-gival mucosa of the upper alveolus from the central incisor to the last molar of the involved side is refl ected and elevated together with the cheek fl ap


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 refl ected 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 ante-rior nasal spine ( arrowhead )

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 pos-terior direction, thus opening the palatal halves in the midline separat-ing the maxilla

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


19

Fig. 1.50 The whole maxilla with the nasal bone, ethmoid sinus and pterygoid plates are removed with the specimen

Fig. 1.51 After removal of the specimen, the full-length of the tempo-ralis 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. 1.52 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. 1.53 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

Figs. 1.54 and 1.55 The removed specimen containing the tumor consists of the alveolar of the upper jaw with tooth, fl oor 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 tem-poral depression is minimal


21

1.7 Total Maxillectomy with Orbital Exenteration

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

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

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

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

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


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 obliter-ate 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 muco-periosteum 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 fl ap is placed back and the Weber – Dieffenbach incision is closed


24

Fig. 1.66 The facial incision heals with minimal scaring


25

Fig. 1.67 In cases where the cheek skin is to be removed, the lip split is avoided. The cheek skin instead of refl ecting is removed with the specimen

1.8 Extended Total Maxillectomy with Cheek Skin Excision

Fig. 1.68 The postoperative specimen consists of the eye and cheek skin with the maxilla

Fig. 1.69 The defect consisted of a open maxillary cavity

Fig. 1.70 The cavity is obliterated with temporalis muscle

1.8 Extended Total Maxillectomy with Cheek Skin Excision

26

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


http://dx.doi.org/10.1007/978-3-319-15645-3_6

27

1.9 Craniofacial Resection

Fig. 1.72 A bicoronal incision is made and a scalp fl ap is raised anteriorly

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

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. 1.75 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

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

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 cribri-form plate is drilled and removed with the maxilla and orbit inferiorly

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

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


29

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



2.1 Arytenoidectomy and Lateralization of Vocal Cord (Modifi ed Woodman’s Technique)

Larynx and Trachea 2

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

32

a 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 ster-nocleiodomasoid muscle laterally

Fig. 2.4 The strap muscles are identifi ed and undermined in a supero-inferior direction and retracted laterally

2 Larynx and Trachea

33

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

Fig. 2.6 The inferior horn of the thyroid cartilage and the cricothyroid articulation are identifi ed. The cricothyroid joint is disarticulated

Fig. 2.7 From this step, the operating microscope and the microsurgi-cal instruments facilitate the subsequent steps. The arytenoid cartilage is identifi ed by following the upper border of the cricoid cartilage posteromedially

Fig. 2.8 The muscular attachments are removed and the laryngeal mucosa is refl ected from the arytenoid cartilage with fi ner 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

2.1 Arytenoidectomy and Lateralization of Vocal Cord (Modifi ed Woodman’s Technique)

34

Fig. 2.9 A gentle lateral traction on the arytenoid cartilage 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 fi xed through a separate holes made at the posteroinferior aspect of the thyroid cartilage. At this stage the thyroid cartilage is returned to the neutral position and the assistant passes a fi breoptic nasolaryngoscope to see the intercordal distance which, after tightening the sutures, should be between 4 and 5 mm. Endoscopic examination also confi rm the extramucosal nature of the procedure

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

a b

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


35

2.2 Frontolateral Vertical Partial Laryngectomy

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

Fig. 2.13 The skin fl ap 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

Fig. 2.14 The membrane and the perichondrium attached on the supe-rior and the inferior border of the exposed thyroid cartilage is incised by a scarpal. With the help of a fi ne elevator, the inner perichondrium of the thyroid cartilage is elevated and the laryngeal soft tissues are sepa-rated 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 pro-tection 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 carti-lage is left attached to the underlying laryngeal soft tissues


36

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 visual-ized through the aperture created

Fig. 2.17 Depending on the extent of the tumor, the inner perichon-drium 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. 2.18 The rest of the attachments of the tumor is cut with a strong curved scissors and the specimen ( inset ) is removed

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


37

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 retrac-tion, the true and the false cords of the normal right side are pulled forward and sutured to the anterior border of the ipsilateral thyroid car-tilage with fi ne sutures; these sutures are anchoreed to holes made on the thyroid cartilage with a fi ne 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

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 tracheos-tomy tube is removed


38

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 fl ap is elevated at least 1 cm above the level of the hyoid bone. A functional neck dissection is per-formed at this stage

2.3 Supracricoid Laryngectomy with Cricohyoidoepiglottopexy

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 con-strictor muscles are cut along the posterior borders of the thyroid carti-lage. Using a perichondrium elevator, the pyriform sinus mucosa is released. The superior laryngeal vessels are identifi ed 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 over-lying the cricoid cartilage is elevated on the side of the tumor. This step is necessary to achieve wider resection on the diseased side


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

Fig. 2.30 The periosteum of the hyoid bone ( arrow ) is incised anteri-orly and laterally using a periosteum elevator and the preepiglottic space is separated from the posterior surface of the hyoid bone

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

Fig. 2.32 The larynx is grasped with a Allis forceps and pulled in an anteroinferior direction to have maximum visualization. The endol-aryngeal resection is performed under direct vision. On the contralat-eral 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 pro-ceed anteriorly in the cricothyroid membrane and joined with the cut from the contralateral side. The specimen is removed and hemostasis is achieved


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 mid-line 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 fl exed 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 fi nal refi nement of the tracheotomy is made. The previously sectioned sternohyoid muscles are sutured, drain inserted and the skin closed in two layers


42

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

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

2.4 Supraglottic Horizontal Partial Laryngectomy


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

Fig. 2.40 After removal of the hyoid bone, the thyrohyoid membrane and the thyroid cartilage are exposed by refl ecting the thyrohyoid, sterno-hyoid 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


45

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

exposed by refl ecting the thyrohyoid, sternohyoid and, omohyoid mus-cles inferiorly

Fig. 2.43 A plane of cleavage is established between the thyroid carti-lage 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

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 inferi-orly. 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 pyri-form sinus to the margins of the resected false cords with 3-0 chromic catgut


47

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

cartilage perichondrium, the thyroid cartilage and the external thyroid cartilage perichondrium. The neck is fl exed 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

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

Fig. 2.50 The fl ap 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 Laryngectomy


49

Fig. 2.51 The medial borders of the sternomastoid muscles are identi-fi ed and dissected in its medial plane. The carotid sheath is identifi ed 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 thy-roid 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

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


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 mem-brane 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 carti-lage 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

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


53

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

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

Fig. 2.63 The pharynx is closed by carefully apposing mucosal edges with the help of mucosal or extramucosal sutures from above down-wards or vice versa. During this fi rst 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

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


55

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

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 fi stula formation

Fig. 2.65 At this stage, the patient head is made slightly fl exed from extended position to lessen the tension on the suture lines. Using a heavy and fi ne sutures the peritracheal fascia is stitched to the subcuta-neous 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 fl aps 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 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


57

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

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 anasto-mosed 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

2.6 Total Laryngopharyngoesophagectomy with Gastric Pull Up

58

2.7 Upper Tracheal Resection and Anastomosis for Trachea Stricture

Fig. 2.71 Post intubation tracheal stricture at the fi rst 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


59

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


60

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 fl ap is raised and the strap muscles exposed


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 stric-ture (between fi rst 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

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

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


63

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 surface of the trachea and preceded anteriorly


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



3.1 Sistrunk Procedure for Thyroglossal Cyst

Thyroid 3

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

66

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 Thyroid

67

3.2 Hemithyroidectomy

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

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

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


68

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

Fig. 3.10 The left inferior thyroid artery is ligated

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

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

3 Thyroid

69

a

b

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


70

3.3 Total Thyroidectomy

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

Fig. 3.15 The recurrent laryngeal nerve on each side are identifi ed 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 Thyroid

71

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

3.3 Total Thyroidectomy


4.1 Submandibular Sialoadenectomy

Salivary Glands 4

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

74

Fig. 4.2 Skin incision is carried below the platysma and subplatysmal fl ap raised exposing the submandibular gland with tumor. At the angle of the mandible, the facial artery and vein are identifi ed, ligated and refl ected 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 Salivary Glands

75

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

4.1 Submandibular Sialoadenectomy

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 Salivary Glands

77

4.2 Superfi cial Parotidectomy

Fig. 4.6 Modifi ed 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 fi ngerbreaths 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 identifi ed and preserved. The anterior fl ap is raised superfi cial to the greater auricular nerve and the parotid fascia. Elevation of the posterior and inferior fl ap exposed the tail of the parotid. The fl aps 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


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 identifi cation

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

4 Salivary Glands

79

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


80

4.3 Superfi cial 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 fl aps are raised as described in Fig. 4.7 . The greater auricular nerve is identifi ed and preserved. The facial nerve trunk is identifi ed as described in Fig. 4.8

4 Salivary Glands

81

Fig. 4.13 The parotid gland superfi cial 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 fl ap is returned and wound closed in layers

4.3 Superfi cial Parotidectomy with Deep Lobe Resection

82

4.4 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 Salivary Glands

83

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

4.4 Total Parotidectomy with Facial Nerve Graft with Sural Nerve

84

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

4 Salivary Glands

85

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


86

Fig. 4.23 The TPFF is separated from the underlying areolar tissue and fascia covering the temporalis muscle. The branches of the superfi cial temporal artery are cut and ligated at the margin of the fl ap

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 Salivary Glands

87

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

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


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 fl ap is placed over the fat graft. A drain is inserted and the incision closed in layers

4 Salivary Glands


5.1 Repair of Alar Defect with Full Thickness Skin Graft

Repair of External Nose Defects 5

Fig. 5.1 Incision site is marked out for nasal basal cell carcinoma excision

Fig. 5.2 The defect after excision

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

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

5 Repair of External Nose Defects

91

5.2 Superior Based Nasolabial Flap for Reconstruction of Alar Defect

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

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

5.2 Superior Based Nasolabial Flap for Reconstruction of Alar Defect

92

Fig. 5.8 The nasal dorsum turnover fl ap is refl ected down

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

Fig. 5.10 The donor area of the nasolabial fl ap is sutured; the nasal dorsum turnover fl ap forms the roof of the vestibule

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


93

5.3 Modifi ed Reiger Glabellar Rotation Flap

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

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 rota-tion fl ap for inner lining

5.3 Modifi ed Reiger Glabellar Rotation Flap

94

Fig. 5.14 The fl ap is transported to cover the defect

Fig. 5.15 Appearance of the patient 3 months after operation


95

5.4 Island Forehead Flap for Reconstruction of External Nose Defect

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

Fig. 5.17 The fl ap is raised in the subgaleal plane

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


96

Fig. 5.20 Between 2 and 2.5 cm above the supraorbital margin the periosteum is incised and the fl ap is dissected in the subperiosteal plane to include and protect the supratrochlear vessels. The fl ap 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


97

Fig. 5.22 The fl ap is mobilized to the nasal defect

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


98

5.5 Schmid-Meyer Frontotemporal Flap

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

Fig. 5.25 The fl ap is done in stages. First stage. This fl ap 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 fl aps are raised from its bed and the non- epithialised surface covered with split-thickness skin graft. The fl ap is wider in deeper plane than superfi cial giving it a trapezoidal shape in cross sec-tion. The skin edges of the donor area of the fl ap are approximated. A 1 cm/2 cm piece of cartilage is implanted subcutaneously 1.5–2 cm lat-eral to the lateral end of the fl ap ( arrow ); these measurements depends on the size of the defect


99

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

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

Fig. 5.28 Third stage: After 2–3 weeks of the second stage, the fl ap is strangulated at the tip in preparation for defi nitive transfer. This delay is continued until the blanching response of the fl ap tissue to fi nger pressure disappear within 3 seconds

5.5 Schmid-Meyer Frontotemporal Flap

100

Fig. 5.31 The patient appearance 6 months after operation

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

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


101

5.6 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

5.6 Oblique Forehead Flap for Basal Cell Carcinoma of Nasal Dorsum

102

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


103

5.7 Anterior Scalping Flap for Nose Reconstruction

Fig. 5.35 The anterior scalping fl ap 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. 5.37 The anterior scalp fl ap is completely elevated

Fig. 5.38 The contralateral forehead is undermined to provide ade-quate 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


105

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

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

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


106

Fig. 5.44 The fl ap is divided and returned to the forehead

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



6.1 Facial Artery Musculomucosal (FAMM) Flap

Axial and Free Flaps 6

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 orifi ce of the parotid duct marks the posterior limit of the fl ap

Fig. 6.2 When incising the anterior border of the fl ap, the superior labial artery is identifi ed. It is ligated and by following its proximal course, the facial artery is identifi ed

108

Fig. 6.3 The fl ap 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 identifi ed and ligated

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

6 Axial and Free Flaps

109

Fig. 6.5 The fl ap 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 fl ap with its vas-cular pedicle is passed under the nerve to the neck


110

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

Fig. 6.8 The fl ap is mobilized to the oral cavity


111

Fig. 6.9 The defect is closed with interrupted sutures

Fig. 6.10 The fl ap 6 weeks after operation


112

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

6.2 Palatal Flap

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


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 fl ap becomes rotatable

Fig. 6.14 The fl ap 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 fl oor of mouth

6.2 Palatal Flap

114

6.3 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 fl ap 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 fl ap is outlined by an index fi nger-thumb pinch test to assess primary closure


115

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

deep to the platysma and overlying the facial artery is identifi ed 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 fl ap


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 fl ap is ready to be mobilized to the defect


118

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 fl ap with its pedicle is passed below the bridge of skin

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


119

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

Fig. 6.25 A distally based fl ap based on reverse fl ow is created by ligating the facial artery and vein proximal to the origin of the submen-tal artery to cover the cranially located defect. The position of the man-dibular branch of the facial nerve, which is the pivotal point for fl ap rotation restricts the distal dissection of the pedicle. The nerve is care-fully dissected out and the fl ap is passed under it

Fig. 6.26 A distally based reverse fl ow submental fl ap is able to reach defects in the hard palate following maxillectomy


120

Fig. 6.27 Inferiorly based nasolabial fl ap is mobilized

6.4 Nasolabial Flap

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

Fig. 6.29 The donor site is closed

Fig. 6.30 Gingivolabial defect closed with nasolabial fl ap


121

Fig. 6.31 The fl ap site marked out

6.5 Trapezius Flap

Fig. 6.32 The feeding transverse cervical artery and vein are identifi ed

6.5 Trapezius Flap

122

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

Fig. 6.34 The fl ap used to close oral cavity defect


123

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

6.6 Lattismus Dorsi Flap

Fig. 6.36 The lattismus dorsi fl ap is marked out

6.6 Lattismus Dorsi Flap

124

Fig. 6.37 The feeding vessels of lattismus dorsi fl ap are identifi ed

Fig. 6.38 The lattismus dorsi fl ap is mobilized with feeding vessels

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


125

Fig. 6.40 The clavicle and the approximate course of the vascular pedicle are marked out. The fl ap 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 identifi ed

6.7 Pectoralis Major Myocutaneous Flap


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


127

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

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


128

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

Fig. 6.47 The pectoralis major myocutaneous fl ap is transferred to the neck superfi cial to the clavicle to be used to reconstruct defects as required


129

Fig. 6.48 The radial forearm fl ap 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

6.8 Radial Forearm Free Flap


130

Fig. 6.50 The dissection is done from the lateral to medial. The skin fl ap 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 fl exor carpi radialis overlap


131

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

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



7.1 Mandibulotomy for Access

Mandible 7

Fig. 7.1 The incision for midline mandibulotomy is marked out run-ning 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 is done in the midline. The soft tissue attach-ments to the fl oor of mouth to the mandible are excised and the mandi-ble is refl ected laterally pivoting at the temporomandibular joint

134

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 Mandible

135

7.2 Segmental Mandibulectomy and Reconstruction with Stabilizing Plate and Screw

Fig. 7.4 Through an incision two fi nger breaths below the angle of mandible, the mandibular tumor is exposed and marked out for segmen-tal mandibulectomy

Fig. 7.5 The proximal and distal ends of the mandible are exposed after mandibulectomy and freed of any tissue attachments in prepara-tion for plating

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. 7.7 The excised specimen with mandible is sent for further examination

7.2 Segmental Mandibulectomy and Reconstruction with Stabilizing Plate and Screw

136

7.3 Segmental Mandibulectomy and Reconstruction with Rib Graft

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 peri-osteum refl ected

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. 7.11 The required length of the rib is measured and cut with a rib cutter

7 Mandible

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

7.3 Segmental Mandibulectomy and Reconstruction with Rib Graft

138

7.4 Bilateral Hemi Mandibulectomy and Reconstruction with Fibular Graft Microvascular Anastomosis

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

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

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

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

7 Mandible

139

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. 7.19 The excised tumor specimen is examined and sent for histo-pathological examination

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

7.4 Bilateral Hemi Mandibulectomy and Reconstruction with Fibular Graft Microvascular Anastomosis

140

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

7 Mandible


8.1 Repair of Lip Defect with Abbe- Estlander Flap

Lips and Face 8

Fig. 8.1 The axial fl ap 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 fl ap 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

142

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

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

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

8 Lips and Face

143

8.2 Repair of Full Thickness Lip Defect

Fig. 8.6 Full length mucosal lesion of the lower lip with cutaneous infi ltration 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

8.2 Repair of Full Thickness Lip Defect

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

145

8.3 Repair of Near Total Lop Defect by Karapandzic Flap

Fig. 8.12 Full thickness of the lower lip involved by exophytic squa-mous 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

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

8.3 Repair of Near Total Lop Defect by Karapandzic Flap

146

8.4 Repair of Medial Canthal Defect with Split Forehead Flap

Fig. 8.15 The excision margin around squamous cell carcinoma of the medial canthal region and the fl ap 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 fl ap is elevated and is splitted in the middle. The split fl ap is rotated to cover the defect. The donor area is also closed in layers

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

8 Lips and Face

147

8.5 Deep-Plane Cervicofacial Rotation- Advancement Flap

Fig. 8.18 The incision marking for excision of neurofi broma involv-ing the midface and adjoining external nose

Fig. 8.19 Th neurofi broma 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 fl ap is raised with incision along the right nasolabial crease; the plane of dissection is made superfi cial 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 fl ap covers most of the raw area except in the medial canthus and adjoining nasal dorsum

8.5 Deep-Plane Cervicofacial Rotation-Advancement Flap

148

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

8 Lips and Face

149

8.6 Temporalis Muscle Flap Transposition Technique for Paralysed Face

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

Fig. 8.24 Reanimation of the mouth. The incision for the temporalis muscle fl ap 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

Fig. 8.25 The middle third of the muscle (roughly 4 cm or two fi ngers 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 commis-sure. 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’


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 para-lyzed angle of the mouth with fi ngers. The incision is deepened down to the muscle. The temporalis muscle is exposed. A subcutaneous tunnel is created by blunt dissection with forceps and fi ngers. In the temporal fossa the tunnel lies superfi cial to the superfi cial musculoaponeurotic system (SMAS). In the face, it lies between the fat and facial muscles layer. The middle and index fi ngers are passed through the tunnel to create adequate diameter

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 inci-sions helped in this process of adjustment. The lower ends of both the parts were stitched together at the lateral canthus. The temporalis mus-cle strips are stitched to the orbicularis oris and tarsal plates through the upper and lower lid incisions with the help of the fi ne absorbable sutures. Likewise, the tip of the muscle strip is attached to the medial canthal ligament

8 Lips and Face

151

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


152

8.7 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 fl ap is raised above the superfi cial temporal artery ( arrow head ). The posterior branch of the superfi cial temporal artery is identifi ed ( 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 fi ne drill burr, ad holes are made at the proximal edge of the cut. With the help of sutures the periosteum is fi xed with bone fl ap. The outer table of the calvarial bone is next cut using a curved osteotome till the cancellanous layer is reached

8 Lips and Face

153

Fig. 8.32 A tunnel is created between the periosteum and the bone fl ap 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 fl ap with the covering periosteum are elevated with using a curve osteotome. The elevated bone fl ap covered by periosteum and pedicled on the posterior branch of superfi cial temporal artery is free to be mobilized

Fig. 8.33 The bone fl ap 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 fl ap

Fig. 8.34 The defect heals satisfactorily 3 months after operation

8.7 Pedicled Calvarial Bone Graft


9.1 Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy

Temporal Bone Malignancy 9

Fig. 9.1 Postauricular incision used for elevation of anterior musculo-periosteal fl ap and identifi cation 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 tempo-ralis muscle mobilization if needed after the procedure

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

156

Fig. 9.3 Neck dissection is done and the facial nerve identifi ed. 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 identifi ed. Cranial nerves XI and XII are also identi-fi ed. 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 seg-ment 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 Temporal Bone Malignancy

157

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 styloid process and lateral tympanic bone covering the

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

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

9.1 Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy

158

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

9.2 Subtotal Petrosectomy with Excision of Pinna

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

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

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

9 Temporal Bone Malignancy


10.1 Excision of Lipoma Over Parotid Region

Head and Neck 10

Fig. 10.1 Parotid lipoma before excision

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

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

161

10.2 Excision of Sebaceous Cyst

Fig. 10.5 Submandibular sebaceous cyst before excision

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

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

Fig. 10.8 The cyst opened exposing the sebaceous contents

10.2 Excision of Sebaceous Cyst

162

10.3 Excision of Parapharyngeal Neurofi brosarcoma

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

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

Fig. 10.12 Dissection at the lateral border of the tumor shows involve-ment of the accessory nerve

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

10 Head and Neck

http://dx.doi.org/10.1007/978-3-319-15645-3_7

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

10.3 Excision of Parapharyngeal Neurofi brosarcoma

164

10.4 Excision of Neck and Mediastinal Neurofi broma

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

Fig. 10.16 Orotracheal intubation is done; an inverted ‘L’ shaped inci-sion given whose horizontal limb is on the upper part of the tumor and the vertical limb on the 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 Head and Neck

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 fi eld after excision of tumor exposing the neurovascular structures preserved

10.4 Excision of Neck and Mediastinal Neurofi broma

166

10.5 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 fl ap 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 Head and Neck

167

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

Fig. 10.23 The accessory nerve is identifi ed


168

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 Head and Neck

169

Fig. 10.26 Investing layer of the deep fascia over the scalenus muscle is refl ected 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

171

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


172

10.6 Modifi ed 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 fl aps are raised

10 Head and Neck

173

Fig. 10.33 Accessory nerve supplying trapezius muscle is identifi ed 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 identifi ed; dissection continued to lateral border of sternocleidomastoid muscle


174

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 Head and Neck

175

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


177S.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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References

179S.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

Index

A Abbe-Estlander fl ap

lower lip reconstruction , 141 upper lip reconstruction , 141

Advancement fl ap cheek reconstruction , 18, 24, 93, 121, 124, 125

Ala reconstruction Reiger glabellar rotation fl ap , 93

Anterior scalping fl ap 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 superfi cial temporal , 85, 86, 152, 153 superior thyroid , 49 transverse facial , 122

Arytenoidectomy with lateralization of vocal cord , 31–34

B Bilateral hemimandibulectomy

reconstruction with fi bular graft , 138–140 Blind sac closure , 82–84

C Calvarial bone graft , 152–153 Converse's forehead scalping fl ap

reconstruction of nasal defect , 95–97 Cricopharyngeal myotomy

with total laryngectomy , 54

D Deltopectoral fl ap , 128

F Facial nerve

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

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 fl ap

lower lip reconstruction , 141, 143, 145

L Lacrimal sac and nasolacrimal duct , 5, 6, 13 Laryngectomy

frontolateral partial of Leroux-Robert , 35–37 subtotal supracricoid , 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 fl ap

Abbe-Estlander , 141 Gillies, Karapandzic , 145

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

180

Muscle digastric anterior and posterior bellies , 60, 116, 117 inferior constrictor , 33, 38, 47, 52 scalenus anterior , 169 scalenus middle , 169 scalenus posterior , 169 sternocleiodomastoid , 32 temporalis , 20, 24, 26, 27, 83, 86, 149–151, 155 trapezius , 173, 174

Myotomy cricopharyngeal , 54

N Neck dissection

anterior , 167, 168 elective, functional , 38 modifi ed radical , 172–175 radical , 172–175 supraomohyoid , 166–171

Nerve accessory , 162, 163, 167, 168, 172–175 ansa cervicalis, facial , 74, 78, 80–84, 88, 109, 116, 120, 155, 156 glossopharyngeal, hypoglossal , 156, 163 infraorbital , 14 lingual , 74, 75, 163 marginal mandibular , 116 maxillary, phrenic , 169, 173 recurrent laryngeal , 39, 68, 70 sural , 82–84 vagus , 49, 156, 162, 163, 170

O Orbital apex , 14, 16 Orbital exenteration , 22–25 Orbital fi ssure

inferior , 5, 6 superior , 22

P Parotidectomy

superfi cial , 77–81 total , 82–84, 156, 158

Parotid or Stenson's duct , 107

Pharyngectomy partial with total laryngectomy , 35–37

Pharyngotomy with total laryngectomy , 38–41

S Skin graft

full thickness , 89–90 partial thickness,

Sternocleidomastoid muscle , 38, 67, 70, 77, 133, 156, 166, 167, 173, 174

Sternotomy , 164 Subglottic stenosis , 38 Submandibular or Wharton's duct , 73–76, 116, 118, 170, 174 Submandibular salivary gland

excision , 161 Superfi cial musculoaponeurotic system (SMAS) , 85, 150

T Temporalis muscle transfer , 149–151 Thoracic duct

injury , 175 ligation , 175

Thoracic esophagus digital or endoscopic mobilization,

Thyroidectomy hemi , 67–69, 71 total , 70–71

Total maxillary swing , 12–17, 19 Tracheal sleeve resection

with laryngotracheal anastomosis , 52 Tracheostomy , 34, 35, 37, 53, 61 Transpalatal approach

palatal mucoperiosteum , 9–11

V Veins

anterior facial , 49, 74 common facial , 49, 156 internal jugular , 49, 83, 156, 157, 163, 170, 174 middle thyroid , 49

W Weber-Fergusson incision , 12, 18

Z

Z-plasty,

Index

Zg13h.color.atlas.of.head.and.neck.surgery.a.stepby step.guide

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