The Division of Head and Neck Surgery boasts a robust reconstructive practice to match the high volume ablative oncology practice. Performing more than 150 pedicled and microvascular flaps per year, the nationally recognized UNC Head and Neck Reconstructive Team of Drs. Patel, Hackman, and Blumberg, provide state of the art reconstruction for traumatic and oncologic defects from the brain/skull base to the upper mediastinum for the residents of North Carolina.
This skilled team of reconstructive surgeons continues to be on the cutting edge of reconstruction, including utilizing image-guided 3D medical modeling for complex bony reconstruction and conducting prospective and quality improvement research in the field of reconstructive surgery. The scapular tip free tissue transfer has become a workhorse of bony reconstruction for this team, who have presented and published on its versatility and reliability as a first line bony reconstruction.
Areas of Reconstructive Expertise
Lateral Skull Base
Anterior and Mid skull base, including endoscopic free tissue skull base reconstruction
Bone Flaps – Fibula, Scapular Tip, Scapula, Radial Forearm
A pliable skin flap based on the submental branches of the facial artery and vein, the flap is typically designed in the submentum (area under the chin) after assessing redundancy with a pinch test. The skin is elevated with a small cuff of muscle and can be rotated to cover external facial and ear defects, oral cavity (tongue and floor of mouth) defects, oropharyngeal TORS defects and lower pharyngeal defects after laryngectomy. The donor site is closed primarily leading to long term excellent cosmesis. The flap paddle can be as large as 12 x 6 cm, provided that the patient has enough redundant neck skin. In some instances, a small bone segment may be included in the flap when necessary.
Another pliable skin flap, more remote in location than the submental flap, and therefore useful if their is concerning of malignant lymph nodes in the submentum or vessel compromise, which would hinder raising the submental flap. This flap is based on the supraclavicular artery of the transverse cervical system, which runs deep in the lower neck, and therefore may be compromised if the patient has had a prior neck surgery in this area. The skin paddle from this flap can be harvested to the tip of the deltoid on the upper arm and rotated to cover neck, floor of mouth and pharyngeal defects. Flaps wider than 6 cm require a secondary skin graft for closure of the donor site on the shoulder.
This mucosal flap is harvested from the internal cheek mucosa and based on the buccal artery branch of the facial artery. The flap dimensions are limited to a few centimeters in width, as more could cause cheek contracture that would limit mouth opening. The flap is best suited to reconstruct small floor of mouth, TORS tonsil resection sites and palate defects.
A robust muscle flap with broad dimensions and the ability for incorporate the overlying skin. The flap can be used to resurface many defects in the head and neck, but is limited in its ability to reach above the lower jaw (mandible). As it is a muscle flap, harvest of the flap results in longterm loss of chest press function (push-up motion) on the side of the harvest.
Another robust muscle flap, again with the potential for massive surface dimensions upwards of 10 x 20 cm. The flap may be elevated as muscle alone, with overlying skin or in chimeric fashion along with the scapula system flaps (hyperlink). The latissimus flap may be used as a large rotational pedicle flap, or as a free tissue transfer. Elevation of this flap requires an approximate 20 degree sidelying position during elevation. Again, as a muscle-based flap, patients longterm will have reduced pull-up strength on that side. This flap can be innvervated – the nerve supplying the latissimus muscle can be connected to a nerve in the head and neck in the hopes of future muscle activity). This is most useful when reconstructing a total tongue defect, as innervation of the flap may improve longterm swallowing recovery.
A thin and pliable skin flap raised off of the forearm and transplanted elsewhere for skin/mucosal reconstruction. The flap removes skin from the lower part of the forearm by the wrist, and this area is covered by a separate skin graft from the thigh or abdomen. Temporary hand stiffness after surgery is expected, but longterm weakness or numbness is not expected. The hand should be checked before surgery to make sure that removal of the flap and vessel will not compromise blood flow to the hand.
A slightly thicker skin flap than the forearm flap, which is raised off of the upper arm and transplanted elsewhere for skin/mucosal reconstruction. There is no need for a secondary skin graft, as this donor site can be closed primarily. Numbness of the elbow and outside of the forearm may be experience after surgery, but muscle function is not affected. This flap is useful for tongue and other oral caivty reconstruction. It is also excellent for reconstruction after removal of large parotid cancers with facial nerve sacrifice, as the flap contains a nerve segment to allow for facial nerve grafting.
A slightly even thicker skin flap than the lateral arm flap, which is raised off of the outside of the thigh and transplanted elsewhere for skin/mucosal reconstruction. There is no need for a secondary skin graft, as this donor site can typically be closed primarily. Numbness of the outside of the knee is likely. Typically the outside quad muscle (vastus lateralis) is weakened after this surgery, but this seems to have limited effect on physical activity. The flap is very versatile and can be used to reconstruct almost any skin or soft tissue defect.
A muscle based flap, based on the rectus abdominus muscles (6-pack), this flap may be raised as a muscle only flap , or include overlying skin and soft tissue. It is typically reserved for reconstructing large volume defects of the scalp or skull base. As the flap entails removal of half of the ab muscles, core strength is reduced and there is an increased risk of ventral hernias.
The worldwide workhorse bone flap for reconstruction, the fibula flap can provide 20+ cm of bone for reconstruction. Skin paddles and muscle may be harvested as well. The blood flow to the foot should be assessed before surgery, as the flap involves removal of the peroneal artery, which is one of 3 arteries supplying the foot. In patient’s with peripheral vascular disease (clogged arteries with poor blood flow), the peroneal vessel may not be open, or may be the sole supply to the foot. In theses instances, the flap cannot be used as either the flap itself, or the foot may die. The skin defect created can be closed with a skin graft from the thigh or abdomen. Due to the relative instability of losing the fibula bone, patients are put in a support boot after surgery and avoid weight bearing until 5-7 days after surgery. Physical therapy is required to recover gait and strength.
Another bone-based flap, that we prefer as the first line reconstruction option for bone defects of the head and neck. The flap involves removal of the lower tip of the scapula, preserving the shoulder joint region and superior scapula. The flap yields up to 10 cm of bone stock, which is suitable for most defects. Given the vascular system of the axilla, multiple chimeric combinations can be designed to bring in separate muscle and skin paddles, which allows for unparalleled versatility in reconstructing complex 3-dimensional defect involving bone, soft tissue and skin. The flap harvest requires patients be placed in a 20 degree side lying position, but the donor site can typically be closed primarily without the need for a secondary skin graft. Patients are ambulating after surgery, and do not display significant deficits in shoulder/arm strength or range of motion (current study being conducted at UNC to scientifically quantify the effects of the flap harvest on patient function).