Rekonstruktion von Defekten im Kopf-Hals-Bereich nach Tumorresektionen

Tumorresektionen im Kopf-Hals-Bereich resultieren aufgrund der engen anatomischen Lagebeziehungen häufig in Defekten, die eine komplexe Rekonstruktion erfordern. Um die funktionellen und ästhetischen Einschränkungen so gering wie möglich zu halten, ist eine gute präoperative Planung erforderlich. Dieser Beitrag soll die verschiedenen Möglichkeiten der Rekonstruktion erläutern und diese anhand von Beispielen anschaulich machen.

Abstract

Cancer surgery in the head and neck region often results in complex defects. The reconstructive ladder was developed to guide treatment decisions. In the head and neck region the most straightforward reconstructive technique is often not the most suitable, because it is comprised of many functional and aesthetic subregions that lie close together. If primary closure, secondary wound healing or negative wound pressure therapy are not an option, skin grafting is the next step. Larger or aesthetically and functionally challenging defects are often reconstructed with flap surgery. It is distinguished between local or regional flaps that are rotated or transposed into the defect and distant flaps. The blood supply of local/regional flaps is either random pattern or axial pattern, distant flaps are pedicled or free flaps. The vessels of free flaps are connected to the blood supply in the defect by microvascular anastomoses. The radial forearm flap, the pectoralis major flap and the anterolateral thigh flap are the most common distant flaps in the head and neck region. Preoperative planning is the most important step in reconstructive surgery. The method of reconstruction must be suited to the functional and aesthetic requirements of the defect but also to the morbidity and compliance of the patient and the surgical expertise of the clinic. Not only immediate postoperative complications such as insufficient anastomosis, infections or hematoma but also later, mostly functional complications such as dysphagia or dyspnea must be taken into consideration when planning the reconstruction of a defect in the head and neck region.

Kernaussagen

• Die rekonstruktive Leiter dient zur Orientierung bei der Planung einer Defektdeckung im Kopf-Hals-Bereich.

• Bei der Defektdeckung müssen funktionelle Aspekte wie Schluck-/Sprechfunktion und Atmung sowie ästhetische Aspekte wie Farbe, Form und Dicke des Transplantats beachtet werden.

• Die Methode der Rekonstruktion muss nicht nur an den Defekt, sondern auch an den Patienten und die operative Expertise angepasst werden.

• Die Kenntnis der anatomischen Grundlagen von Empfänger- und Spenderregion, insbesondere der Blutversorgung von Lappenplastik und zu deckendem Defekt, ist unerlässlich und beeinflusst die Wahl des geeigneten Transplantats.

• Die am häufigsten angewendeten Lappenplastiken im Kopf-Hals-Bereich sind der Pectoralis-major-Lappen, der Radialislappen und der anterolaterale Oberschenkellappen.

Schlüsselwörter

Rekonstruktion - Kopf-Hals-Region - Tumorchirurgie - Radialislappen - anterolateraler Oberschenkellappen - Pectoralis-Major-Lappen

Keywords

Reconstruction - head and neck - cancer surgery - radial forearm flap - ALT - pectoralis major flap

Publikationsverlauf

Artikel online veröffentlicht:
02. November 2023

• Literatur

• 1 Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg 2011; 127: 205s-212s DOI: 10.1097/PRS.0b013e318201271c. (PMID: 21200292)
• 2 Othman S, Shakir S, Azoury SC. et al. Utility of Dermal Wound Matrices Compared with Local-Tissue Rearrangement and Free Flap Reconstruction for Oncologic Scalp Wounds: A Multidisciplinary Dual Matched-Pair Analysis. Plast Reconstr Surg 2022; 149: 469-480 DOI: 10.1097/prs.0000000000008774.
• 3 Braza ME, Fahrenkopf MP. Split-Thickness Skin Grafts. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022
• 4 Baker S. Local Flaps in Facial Reconstruction. 4th ed. Mosby, US: Elsevier; 2021
• 5 Lang SH, Bootz F, Remmert S. Lappenplastiken und Transplantate im Kopf-Hals-Bereich. 1. Aufl.. Stuttgart: Thieme; 2018
• 6 Sommer K. The deltopectoral flap for reconstruction of the tracheostoma and of the ventral neck region. Laryngorhinootologie 2010; 89: 6-9 DOI: 10.1055/s-0030-1247175. (PMID: 20058213)
• 7 Sittitrai P, Srivanitchapoom C, Reunmakkaew D. et al. Submental island flap reconstruction in oral cavity cancer patients with level I lymph node metastasis. Br J Oral Maxillofac Surg 2017; 55: 251-255 DOI: 10.1016/j.bjoms.2016.10.022.
• 8 Bowe CM, Twigg J, Salker AM. et al. Outcomes of anastomotic venous flow couplers in head and neck free flap reconstruction – five-year experience in a single centre. Br J Oral Maxillofac Surg 2022; 60: 847-851 DOI: 10.1016/j.bjoms.2022.01.002. (PMID: 35183371)
• 9 Guo Z, Cui W, Hu M. et al. Comparison of hand-sewn versus modified coupled arterial anastomoses in head and neck reconstruction: a single operator’s experience. Int J Oral Maxillofac Surg 2020; 49: 1162-1168 DOI: 10.1016/j.ijom.2020.01.019. (PMID: 32035906)
• 10 Park HD, Min YS, Kwak HH. et al. Anatomical study concerning the origin and course of the pectoral branch of the thoracoacromial trunk for the pectoralis major flap. Surg Radiol Anat 2004; 26: 428-432 DOI: 10.1007/s00276-004-0273-8. (PMID: 15290107)
• 11 Remmert S. Pectoralis-major-Lappen. In: Funktionelle Wiederherstellung der oberen Luft- und Speisewege. 1. Aufl.. Stuttgart: Thieme; 2018
• 12 Jarvis MA, Jarvis CL, Jones PR. et al. Reliability of Allen’s test in selection of patients for radial artery harvest. Ann Thorac Surg 2000; 70: 1362-1365 DOI: 10.1016/s0003-4975(00)01551-4. (PMID: 11081899)
• 13 Chen CM, Lin GT, Fu YC. et al. Complications of free radial forearm flap transfers for head and neck reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: 671-676 DOI: 10.1016/j.tripleo.2004.10.010. (PMID: 15897852)
• 14 Archibald H, Stanek J, Hamlar D. Free Flap Donor-Site Complications and Management. Semin Plast Surg 2023; 37: 26-30 DOI: 10.1055/s-0042-1759795. (PMID: 36776806)
• 15 Peters BR, Richards HW, Berli JU. Optimizing Innervation in Radial Forearm Phalloplasty: Consider the Posterior Antebrachial Cutaneous Nerve. Plast Reconstr Surg 2023; 151: 202-206 DOI: 10.1097/prs.0000000000009771. (PMID: 36576827)
• 16 Kitamura Y, Oki M, Kurita M. et al. Combined Use of an Innervated Radial Forearm Flap and Labia Minora Peripheral Skin Graft for Total Upper Lip Reconstruction. J Craniofac Surg 2020; 31: 1678-1680 DOI: 10.1097/scs.0000000000006688. (PMID: 32649543)
• 17 Piotrowski S, Nałęcz D, Chmielecka J. et al. Free microvascular bone flaps used for cavity reconstruction in the head and neck area. Otolaryngol Pol 2023; 77: 1-5 DOI: 10.5604/01.3001.0016.2438. (PMID: 36806468)
• 18 Matsuda Y, Jayasinghe RD, Zhong H. et al. Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review. Healthcare (Basel) 2022; 10 DOI: 10.3390/healthcare10050960.
• 19 Engel H, Huang JJ, Lin CY. et al. A strategic approach for tongue reconstruction to achieve predictable and improved functional and aesthetic outcomes. Plast Reconstr Surg 2010; 126: 1967-1977 DOI: 10.1097/PRS.0b013e3181f44742. (PMID: 21124135)
• 20 Dilmaghani S, Behrangi E, Mazandarani M. et al. Needling, lasers, and Meso-Botox for hypertrophic and keloidal scars: A comprehensive review study on promising procedural treatments. J Family Med Prim Care 2022; 11: 4195-4204 DOI: 10.4103/jfmpc.jfmpc_1657_21. (PMID: 36352978)