Trends in head and neck reconstruction: challenges in sub-Saharan Africa .

1. Trends in head and neck reconstruction: challenges in sub-Saharan Africa. Odunayo M. Oluwatosin, FMCS (Nig) Department of Plastic Surgery University College Hospital Ibadan

2. Indications for head and neck reconstruction • congenital (oro/cranio-facial clefts) • trauma (RTAs, human and animal bites) • tumour (ameloblastoma, basal and squamous cell carcinoma, osteogenic carcinoma, neurofibromas) • post-infective sequellae (cancrumoris) • arterio-venous malformations

4. Unoperated cleft lip: it is not uncommon to see an adult like this with cleft in the upper lip

7. History • Pre – Crile era • Advent of radiotherapy, general anaesthesia, blood transfusion, and antibiotics • Oro-pharyngeal reconstruction: Edgertonin 1951 • Pedicled flap reconstruction: McGregor, Bakamjian

8. History • Musculocutaneous flap pectoralismajor: Ariyan latissimus dorsi • Other musculocutaneous flaps: Sternocleidomastoid, Platysma, Trapezius Serratus Anterior

9. Disadvantages of musculocutaneous flaps History • Disfiguring donor defect • Excessive bulk • Bulging pedicle • Limited arc of flap rotation

10. Trends • Microvascular free tissue transfer • Pedicled perforator flap • Supraclavicular artery island flap • Occipito-cervico-dorsal fascio-cutaneous flap

11. Perforator flaps in head and neck reconstruction: Trends • Facial Artery Musculo-Mucosal • Submental artery • Internal mammary artery • Temporo-parietal artery

12. Facial Artery Musculo-Mucosal

13. Trends • Microvascular free tissue transfer • Pedicled perforator flap • Supraclavicular artery island flap • Occipito-cervico-dorsal fascio-cutaneous flap

14. Supraclavicular artery island flap

15. Trends Ideal flaps for facial resurfacing Distant tissues Colour mis-match Texture mis-match Demarcation with the neighbouring facial skin • Thin • Reliable • Good color match Immediate vicinity of the head and neck

16. Algorithm for treatment of scalp and skull defects No defect eglaceration Resuscitate patient Direct closure No periosteal covering (bone exposure) Defect Intact periosteum Surgically created wound small defect Skull fracture Large defect No skull fracture Undisplaced Full thickness skin graft Depressed skull fracture Split skin graft Elevate fracture Primary replacement with rib, iliac bone and serratus anterior musculoperiosteal free flap No dural defect FLAP TRANSFER Defect less than 36cm2 Defect less than 150cm2 Temporal fascia or fascia lata graft Possibility of distortion of hair line Defect up to 175cm2 Total scalp loss Scalp rotation flap with direct closure of donor defect Scalp Salvageable (not crushed) Scalp not salvageable Orticochea’s three or four flap scalp transposition Galealpericranial flap plus split skin graft Large scalp rotation flap with skin graft Free latissimus dorsi muscle flap with skin graft Replantation (microvascular anastomosis)

17. Ideal mandibular reconstruction restores: • the bony contour • mastication • deglutition • articulation • and maintains an adequate airway

18. Most common donor sites for mandible: • Fibula • Scapula • Iliac • Crest • Radius Alloplastic materials: bone plates and screws

19. Challenges of head and neck reconstruction in sub-Saharan Africa • Inadequate prevention, screening and early diagnosis • Inadequatepublic health education • Late stage presentation/referral of trauma and swellings • Management of cases by quacks. • Management of cases by less qualified personnel

20. Challenges of head and neck reconstruction in sub-Saharan Africa • Poverty and scarcity of treatment funds • Lack of interdisciplinary approach to cancer therapy • Inadequate provision/ maintenance of infrastructure and necessary equipment • Lack of continuing professional education of personnel

21. Tackling the challenges