Head and Neck Flashcards
The facial skeleton (viscerocranium) form from what type of ossification
Intramembraneous - perisoteal blood supply.
Antia-Buch max defect size?
2.5cm defect
Helical rim defects >3cm
Converse tunnel. Cartilage strut under post auricular skin. 3 weeks strut lifted on anteriorly based flap and inset.
Options for conceal bowl
Secondary
SG
Excise bare cartilage and SG
Max size of Tanzer
2cm
Options for middle 1/3 ear
Rim: Antia-Buch
Wedge <2cm
Cart graft - Dieffenbach (cart sutured to defect covered by flap) or converse
Contralateral chondrocutaneous composite flap.
Rim Recon Options
Small:
contralat composite, AB, Condrocut rotation.
Large:
-Cart graft and local flap (Converse 2 stage tunnel and lift)
-Tubed-pedicle (3 stage tub, inferior, superior)
Superior Third
Small:
-Tanzer excision
Large:
-C/l cart graft and flap (preaur banner)
- condrocut flap (Davis root +sg, OC helix based)
-Valise handle (3stage+sg) defect attached and elevated
- CC graft +TF flap
Middle third
Small: Tanzer
Large:
-Chonchal - flip flap (inc down to fascia)
-C/l composite graft/ Converse/ Dieff (2 stage st 1 sutured to defect)
Ear Recon:
Auto
Auto/ Allo
Pros
Coverage TE or free or ped TPF flap+SG.
C/l 6-8 costal synchondrosis.
Benign Ear Diff
granuloma pyogenicum,
beryllium granuloma,
verruca contagiosa,
verruca senilis,
cylindroma,
nevus,
papilloma,
lipoma,
lymphangioma,
leiomyoma, and
chondroma,
Upper eyelid recon
FULL THICKNESS
<25:
- direct closure
25-50:
- DC+ lat canthotomy
- Tenzel semicircular MC + comp
- Sliding Tarsoconj + FTSG or MC flap
> 50:
- Composite graft + MC flap (frick, FH)
- Cutler-Beard bridge (LL inf based rectangle composite) w=w
- central: (Mustarde lower lid switch) based on inf. arcade.
Lower Lid
Partial thickness
<50%
-Local cutaneous/MC flaps
>50%
-FTSG
-Tripier flap
-Fricke flap
-Mustarde Cheek rotation flap
Lower Lid
Full thickness
25-50%
- DC + lat cantotomy or inf C’lysis
- Deep: Tenzel SC +lysis
Tenzel–> McGregor–> Mustarde
- Unilat Tripier MC+ Composite
- Shallow: Hughes Tarsoconj adv + FTSG or MC
>50%
Shallow: Hughs TC Adv+ FTSG or MC
(bio Trip, Must, Frick, FH)
Deep: Septal CondMuc graft + mustarde
-McGregor temp z-plasty flap
Lower Lid
Full thickness
25-50%
- DC + lat cantotomy or inf C’lysis
- Deep: Tenzel SC +lysis
Tenzel–> McGregor–> Mustarde
- Unilat Tripier MC+ Composite
- Shallow: Hughes Tarsoconj adv + FTSG or MC
>50%
- Shallow: Hughs TC Adv+ FTSG or MC
(bio Trip, Must, Frick, FH)
- Deep: Septal CondMuc graft + mustarde
-McGregor temp z-plasty flap
-Composite + MC
What are the degrees of levator function?
Excursion of lid margin from full down to full up.
Excellent >10mm
Good 8-10mm (Min - FS/ MM Conj resec’n)
Fair 5-7mm. (Mod - Lev adv)
Poor 1-4mm (brow/front suspension)
Asian lid
Epicanthal folds
Lack pretarsal show
Lower lid crease (4-6 vs 8-10)
Lower insertion of orbital septum relative to tarsus (lower periorbital fat)
Chemosis Tx
Ointment/Lube/patching
Topical steroid drops, tarsorraphy
Conjunctiectomy
Retrobulbar Hematoma
Symptoms
Tx
Compression of Central Retinal Artery, Optic nerve.
Sudden onset:
Pain
Proptosis
Decreased visual acuity
Tx:
Admit, Ortho consult
Release sutures, canthotomy,
IV corticosteroids, acetazolimide
OR exploration
lymph drainage lips
Upper and lateral lower = summand
central lower = submental
RF for reoccurrence
Size, location
Depth, Grade, Perineural Inv., Marjolin
LN
Clinical RF
Vermillion Recon Options?
- Verm Adv or switch
- Mucosal Adv. VY, Biped
- Goldstein MC flap?
- Tongue, FAMM (Incas Bucc for vermillion recon only), Buccal
Commissure
Rhomboid mucosal
Double Skin flap and mucosal rhomb/ tongue
Zisser
Lower Lip Recon Options?
<1/3: Wedge, 1o
1/4-1/2: Johansson Adv (w=1/2defect) h=8-10mm, Reverse Abbe only lateral (1/2w) start at mid point, Eslander
1/2-2/3: Karapanzic preserves facian nerve for functional recon (Central),
Uni Gilles fan,
DAO
2/3 to total: Bilat Gilles fan,
Web-Bernard Burow, Fujimoro gate, recional/free
General Kara or BB if no lip.
Upper Lip Recon Options?
By unit
Philtrum: 1o, SG, Abbe, Peri alar
White lip: NL
Phil and lateral <1/4:
b/l perialar cres+abbe,
Rev Kara
Phil and lateral >2/3:
b/l NL + Abbe
Rev Kara + Abbe
WBB
Reg, free
Lateral:
1o,
A-T, Peri Alar Cres Adv,
NL, Abbe, Rev Est
Abbe or slander if comm, large do BB + Cres excision
Karapanzic
U incise skin in mental crease parallel to free margin and continue into melolabial crease,
- ID NVB release Ris to advance,
- back cut mucosa, or burow at commissure
Preserves sensation/orb function.
Dis: micro, asym, under proj.
Uni Gillies
Full thickness
No preservation of OO innervation, lacks sensory
WBB
Incise in labiodental and NL crease
Burows skin and sc only to preserve OO.
Narrow as possible to prevent puckering
(NEEDS Verm flap)
Adv: SS, local, complete LL
Dis: no function, insensate, Microstom. income.
Lip recon regional:
Indications for free:
Pec Mj, DP, Tubed neck, FC scalp
Large, Rads, composite, failed
Chin
Boardering on verm: A-T
Adv flap with burow triangle in parental crease
Modified limberg with scar in vertical midline (not crossing inf boarder of mind)
Lip Development
Upper: two medial nasal prom fuse with maxillary prom
Lower Mandibular pro
Lip Subunits
Lateral:
Phil col
Nasal sił
Alar base
NL fold
Med: Phil
Lip: Sensory Innervation
Fifth CN:
Upper: Infraorbital - Max Nerve, (Sidewall/ala, col, med cheek)
Lower: Mental (Mandibular)
Mental foramen landmark
Second mand bicusp
Most common lip cancer
Excision Recommendation
90% SCC 95% LL, lip is 1/4 of oral ca.
Diff:
Sebacious ca
Adenoid cystic
Acinic cell
Merkel Cell
“Full thickness 3-5mm hard for 90% with 2-3% RR at 5 year”
Eslander
Gillies
Kara
WB
Triangular based on superior lab artery
Gillies: rat advancement flap, upper cheek to close large centra LL >50% Flap l= Defect w, w=h
-Kara: composite flap with innervated OO. Midline Upper and lower defects. uni = 50%, bi for total/
WB- >80% Medial advancement of cheek (need ver recon - mucosal adv).
75% UL Defect
B/l Kara (innervated lip )+Abbe
Lateral lower lip defect + comm
Estlander
Mentalis function
Elevates central lower lip.
Tongue Recon Options
<25 = 1o, STSG, FAMM
20-60% = ALT, RFFF, Lateral Arm, Dorsalis Pedis (ALT MC for larger defect)
>70% ALT, TRAM, LD, Grac
Floor of mouth
Stage 1 <2cm local flap or STSG
Stage 2: 2-4cm local or free flap
Anterior:
Local: NL, Temp, FAMM, Tongue
Distant: PM, DP, Lat
Free: Rad/Ulnar FA, ALT, Fib if bone
Posterior:
Local: NL, FAMM
Distant: PM, DP
Free: RFFF, ALT, LA, DP, Fib
Buccal
Local: plat, FAMM, TPF +SG, Tongue
Distant: Pm (Bulky), DP
Free: RFFF, Ulnar, ALT thin
Cordeiro Classification
1- limited (1 or 2 walls) - FC
2- Subtotoal Orbit preserved
a) <50% transverse palate - FC/ obturator
b) >50% - OC required
3- Total - all 6 incl floor
a) orb contents preserved
Double (Fib+ RA + NVBG/ allo for Orbital floor), Temporalis for poor candidate.
b) resected - RA 3 paddle + fib for dental
4- Orbitomaxillectomy - RA
Test
Blood & Nerve Supply of Nose
Ext Carotid
Facial A –> Angular–> lateral nasal
–> Superior Lab –> columellar
Internal Max –> Infraorb
Internal Carotid
Opthalmic –> Anterior ethmoidal A –> External Nasal Br
Opthalmic –> Dorsal nasal (anast to lateral nasal)
Nerve:
External: Infratroch (radix), IO (sidewalls), Ant Ethmoid -External Br. (tip, alae)
Internal: Ant Ethmoid - Internal Br, Nasopalatine, Lesser Palatine
Nasal Recon Max Local flap?
Bilobe Design.
NL design and blood supply
1.5cm
Bilobe: lower third laterally based for tip, and vv.
NL: Medial edge in NL crease. Options: superior or inferior, one stage island or 2 stage pedicled.
Blood supply = perforators Inferior = facial artery ( Nasal ala, dorsum and sidewall) 1.5-2.5cm
Superior based = angular (random pattern) for lipa and oral.
Blood supply of Fronto nasal advancement, Rieger, dorsal nasal or miter
Defect?
Glabellar?
Angular artery.
Middline lower or middle third.
Glabellar–> medial canthi
Anatomy of Paramed FH flap
Ways to lengthen?
Supratroch travels on PO becoming SC at hairline.
Nasal Lining:
SG
Infold flap
Vestibular lining.
Septal Muco Pericondrial
Facial artery musculo mucosal
Free
Describe Submental Artery Flap
Indications/ CI
MC Platysma Flap (laterally based).
Submental br of facial artery parallel to ant belly of diagastic.
Indications:
Extra oral (lower and midface), Oral (up to palate posterior tongue)
Combined, hair bearing.
CI: Ips neck dissection.
Juri cervicofacial flap
Continue lateral from defect alon Zygomatic arch, preauriclar fold, retro auricular hairline.
Ped: Facial and submental artery.
Safe zone of frontal branch of facial Nerve.
>3.5 cm anterior to external auditory canal.
Cervicopectoral flap
MC based on Anterior thoracic perforators off the internal mammery artery.
Defect: lower lateral cheek (line from trag to commissure)
Steps: Extend defect posteriorly inferior to ear , retroauricular hairline, parallel to anterior border of trapezius crosses clav at DP groove then extended inferior PRN. SubCut in face , sub platy in neck deep to anteriro pectoral fascia on chest.
Deltopectoral Flap
Blood supply: IMA, and TA (axial flap)
Temporalis Flap:
Blood Supply:
Internal Max Artery –> Deep temportal branches (anterior and posterior)
STA - Middle temporal Artery
Indications: Turnover - posteriro oral, nasopharyns, orit, ear,
Lenthening: disinsert from corinoid, remove arch.
Trapezius
Blood Supply:
Upper: Occipital
Middle: Transverse Cerv–> Superficial Cerv
Lower: Deep br or TCA (dorsal scap) + IC
Frontal Br of facial nerve
Galea continuation
Scalp PO continuation
RUNS IN Superficial temporal fascia
STF laterally, smas in face, frontalis, occipitalis
Deep temporal fascia (at fusion line seprate and envelope ST fat pad)
Extending Scalp flap
Score PERPENDICULAR to axis
Facial Nerve Landmarks?
- Tragal pointer 0.5-1cm deep and inferior
- Deep to dephalad boarder of Posterior belly of diagastic
- Tampanomastoid suture 6-8mm deep to inferior end of suture line.
- Retrograde dissection
Salivary Tumors: When Rads?
Close or microscopically positive margins.
Proximity to facial nerve
Perineural/Lymphovascular invasion
Cervical Mets
Gustatory Sweating? Tx
Cross innervation post surgery disruction AT nerve. Cholenergic parasympathetic fibers ( GP CN9 via otic ganglion) innervate sympathetic skin sweat gland.
Observaation if mild, botox, alloderm or fascia graft.
Most common salivary tumors?
Benign (1, 2nd)
Malig?
Mets?
Benign: Plemorpic adenoma 80% of benign tumors, Warthins (papillary cystadenoma)
Children: hemangioma
Mucoepidermoid (in parodid), Adenoid cystic in other glands
Mets: Melanoma, SCC (heme spread of Breast, lung prost, kid, GI)
History of Salivary Gland tumor
First Branch Arch
Nerve: Trigem
Art: Maxillary
Cart: Mandible, Malleus & incus
Muscles: Temporalis, mass, Pter, TTym/VP, MH ABD.
Second Branch Arch
Facial nerve
Stapedial artery
Reicherts Cart: Mall (man), incus (proces), stapes, styloid process, styloid hyoid lig.
Muscles of facial expression, plat, stylohyoid, hyoid
Third Arch
GP nerve
Internal carotid
Hyoid (body, cornu)
Stylopharyngeus
4th Arch
(5th Arch = Nothing)
Sup Laryngeal nerve
Left: Aortic arch, Right: SC artery
Thyroid, cuneform
Pharyngeal construction, cricopharyngeal. Cricothyroid
6th Arch
Recurrent laryngeal
Pulmonary artery
Cricoid, arytenoids, corniculate
Intrinsic larynx muscles
Midface Embryo
Maxillary,
Med (tip, phil, UL) & lat Nasal (ala),
Frontonasal (dorsem)
Prominances fuse to form nose and upper lip.
(1st branchial arch)
Congen ML Mass Diff?
Dermoid
Gliomas - firm, nonpulse from lateral nasal wall
Encepaloceles - blue, pulsatile, compressibl emass or intrasasal mass at crib plate.
Furstenberg test (compression of Int jug)
Primary Palate?
Secondary Palate?
MNP
Shelves of max prominences.
Tongue Embryo
1st pharngeal arch (lingual nerve = branch of trigeminal , nerve to 1st.)
Posterior (GP nerve to 3rd)
Thyroglossal Duct Cyst
Asym Midline mass at hyoid - elevate with swallow.
Mgmt: Sustronk- excision and central hyoid
Frontal Sinus
Appears at 5-6 adult size by 12-20.
PHACE
Post Fossa
Hemangioma
Arterial lesions
Cardiac mal/ Corarctation
Eye
