Colour Atlas Head Neck Surgery 2015

Siba P.
Dubey
Charles P. Molumi
Color Atlas of
Head and Neck Surgery
A Step-by-Step Guide
123
Color Atlas of Head and Neck Surgery
Siba P. Dubey • Charles P. Molumi
Color Atlas of Head

and Neck Surgery
A Step-by-Step Guide
Siba P. Dubey Charles P. Molumi
University of Papua New Guinea and Port Moresby General Hospital
Port Moresby General Hospital Boroko, National Capital District,
Boroko, National Capital District, Papua New Guinea
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
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Everyday, we learn from our patients; this book is dedicated to them.
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 qualifications. 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 fine 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, FRACS

Melbourne, Australia
vii
Foreword II
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 qualified 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 figure 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)
ix
Preface
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 flaps. The surgery of the skull base deserves special mention as it
is performed within the confines 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 benefitted 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
xi
Contents
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 Angiofibroma) . . . . . . 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
(Modified 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 Superficial Parotidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.3 Superficial 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 Modified 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
xiii
xiv Contents
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 Neurofibrosarcoma . . . . . . . . . . . . . . . . . . . . . . . 162
10.4 Excision of Neck and Mediastinal Neurofibroma . . . . . . . . . . . . . . . . . . . . . . 164
10.5 Supra Omohyoid Neck Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
10.6 Modified Radical Neck Dissection. Accessory Nerve Preserved . . . . . . . . . . 172
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Nose and Paranasal Sinus
1
1.1 Sublabial Approach for Maxillary Cyst
Fig. 1.2 The incision begins 0.5 cm above the junction of the gingivo-
Fig. 1.1 Right nasolabial swelling due to cyst in the maxillary sinus
labial sulcus mucosa. It extends from the canine to the first molar tooth.
The incision is made bone deep. The superior mucosal flap is raised
preserving the neurovascular bundle in the infraorbital foramen
S.P. Dubey, C.P. Molumi, Color Atlas of Head and Neck Surgery: A Step-by-Step Guide, 1
DOI 10.1007/978-3-319-15645-3_1, © Springer International Publishing Switzerland 2015
2 1 Nose and Paranasal Sinus
Fig. 1.3 A small gouge is placed at the canine fossa and hammered till Kerrison rongeurs till adequate exposure is attained. In cases where the
the maxillary sinus antrum is entered taking care not to damage the root bone is thinned out by the tumor, this might not be necessary
of the tooth. The opening is enlarged by nibbling the bone edges with a
Fig. 1.4 The tumor is removed and the cavity is packed with an acroflavin 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
1.2 Midfacial Degloving 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 Fig. 1.7 A sublabial incision is made from the first molar of the ipsi-
with cophenylcaine spray and lignocaine with adrenaline infiltration. lateral side to first molar of the contralateral side. The incision is deep-
Bilateral tarsorrhaphies are done. A columella clamp is used to retract ened to the periosteum of the canine fossa
the columella. A total transfixation incision is marked out on each side
at the junction between the stratified squamous and respiratory colum-
nar epithelium
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 floor
Fig. 1.6 The transfixation incision is extended from the tip of the nose
onto the nasal floor
Fig. 1.9 Through the sublabial incision, the upper lip and the colu- Fig. 1.11 Dissection is continued through the intercartilagenous inci-
mella are elevated exposing the anterior end of the septal cartilage and sion exposing the dorsum of the upper lateral cartilage and then to the
marking over the lower lateral cartilage at the junction between the nasal bones. The periosteum is incised with a curved Joseph knife, and
stratified squamous and columnar epithelium for the intercartilagenous the soft tissue is separated from the nasal bones. The elevation is con-
incision 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
Fig. 1.10 An intercartilagenous incision is made to join the superior

end of the transfixation incision medially (joining to the septal incision)
(arrow) and the nasal floor laterally (arrow head)
1.3 Lateral Rhinotomy with Medial Maxillotomy 5
1.3 Lateral Rhinotomy with Medial Maxillotomy
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 identified
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. 1.15 The nasal alar is mobilized by carrying the Moure’s incision
through the entire thickness along the pyriform aperture
Fig. 1.13 The incision is carried to the bone. The angular vessels are
coagulated
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 identified 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. 1.18 The tumor is removed accordingly
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
1.3 Lateral Rhinotomy with Medial Maxillotomy 7
Fig. 1.19 After hemostasis the nasal cavity is packed with gauze and the bone placed back and fixed with miniplate and screws
Fig. 1.20 The nasal alar is returned and the skin closed with interrupted sutures
1.4 Transpalatal Approach by Palatal Osteomucoperiosteal Flap
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 floor 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
Fig. 1.23 On the side of the lesion a inverted ‘J’ shaped cut is made on
heavy scissor, the junction of the maxillary crest and septum is cut all
the bony hard palate. The side arms of the inverted ‘J’ is placed at the
the way from its anterior end to the posterior end. A space is created
junction of the horizontal and vertical part of the hard palate. The sum-
between the bony and soft tissues of the nasal floor where a malleable
mit of the inverted ‘J’ is located almost 2 cm posterior to the base of the
copper retractor is placed. This is done to prevent injury to the nasal
central incisor tooth. By this way, the very thick palatal bone is avoided.
floor mucoperiosteum during subsequent osteotomy of the hard palate
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 floor
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 first 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
1.4 Transpalatal Approach by Palatal Osteomucoperiosteal Flap 9
Fig. 1.24 The contralateral palatal cut is made through the midline Fig. 1.26 The nasal floor mucoperiosteum is cut open to expose the
sublabial incision. A through and through osteotomy is done without tumor
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. 1.25 Pressure with a periosteal elevator from the nasal side
towards the oral side opens up the palatal osteomucoperiosteal flap,
(POMP flap) in the oral cavity like the lid of a box. The flap is pedicled
on the mucoperiosteum of the normal side from the opposite premolar Fig. 1.27 The tumor is removed accordingly either in whole or in
to the last molar tooth. This exposes the nasal floor mucoperiosteum on piece meal
both sides. The POMP flap (arrow) is retracted with a retractor or
sutured and anchored with a weight at the non pathological side
Fig. 1.28 After the tumor is completely removed, the nasal floor mucosperiostum is sutured together to closed off the nasopharynx
Fig. 1.29 The POMP flap is placed back. Three to four sutures are sublabial incision is closed in two layers. A light nasal packing is done
placed between the elevated palatal mucoperiosteum with mucoperios- and kept for 3–4 days
teum of the gingivolabial sulcus across spaces between the teeth. The
1.5 Total Maxillary Swing (For Advanced Nasopharyngeal Angiofibroma) 11
1.5 Total Maxillary Swing (For Advanced Nasopharyngeal Angiofibroma)
Fig. 1.31 The anterior and posterior faucial pillars are incised and the
soft palate reflected together with the hard palatal mucoperiosteum
exposing the oropharyngeal extension of the tumor
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 reflected 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. 1.32 The operation is continued to the face. The Weber-Fergusson

incision (without the gingivolabial component) is marked out on the face
Fig. 1.34 The anterior lacrimal crest is drilled out to expose the lacri-
mal sac
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 reflected medially and
anchored with sutures. This exposes the nasal extension of the tumor.
The periosteum over the orbital floor is elevated to the level to the infra-
orbital foramen exposing the site for osteotomy
Fig. 1.35 The lacrimal sac is transsected and anchored with sutures
Fig. 1.36 The orbital floor is elevated and the infraorbital nerve is sectioned as it enters the infraorbital foramen on the orbita floor. The perios-
teum of the orbital floor is elevated as far as the orbital apex
Fig. 1.37 Osteotomies are made at the frontal process of maxilla and notch located on the anterior nasal spine in the midline at the inferior
maxillozygomatic suture with an oscillating saw and the maxilloeth- margin of the pyriform aperture. It is gently hammered in both anterior
moidal junction is separated with a small thin straight osteotome. A and posterior directions, which opens up the palatal halves in the line of
straight osteotome is placed between the arms of the small V- shaped fusion
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 reflected outwards as in
the opening of a swing door
exposing the entire surgical field
and the tumor
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 fixed 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
Fig. 1.42 The tumor is removed with all its extensions
Fig. 1.43 The facial and palatal wound heals up without scaring
1.6 Total Maxillectomy 17
1.6 Total Maxillectomy
Fig. 1.44 The patient is placed in the supine position and the orotra- Fig. 1.46 The sublabial part of the incision is extended from the mid-
cheal intubation is done and the tube is taped to the corner of the mouth line to the third molar teeth and went round it. The incision begins in the
opposite the side of the tumor. After the field is draped and prepared the upper lip. The cheek flap is raised by grasping the upper lip between the
eyelids are sewn together with a 6-0-nylon suture. The Weber-Fergusson thumb and the index finger of the surgeon and the assistant puts the
incision is marked out and injected with 1:100,000 lignocaine with incision under tension and compress the superior labial artery. The gin-
adrenaline gival mucosa of the upper alveolus from the central incisor to the last
molar of the involved side is reflected and elevated together with the
cheek flap
Fig. 1.45 The incision is made 1–2 mm from the eyelashes along the
edge of the lid. The subciliary flap 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. 1.48 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-
Fig. 1.47 The palatal mucoperiosteum of the involved side (when hard terior direction, thus opening the palatal halves in the midline separat-
palate is free of tumor) is elevated as described in total maxillary swing. ing the maxilla
The elevated gingivolabial mucosa is made continuous with the
reflected 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. 1.49 A curved osteotome is

placed in the pterygomaxillary
fissure behind the last molar with
the concavity of the blade facing
upwards and hammered to free
the pterygomaxillary suture
1.6 Total Maxillectomy 19
Fig. 1.50 The whole maxilla with the nasal bone, ethmoid sinus and
pterygoid plates are removed with the specimen
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. 1.51 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. 1.53 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
Figs. 1.54 and 1.55 The removed specimen containing the tumor consists of the alveolar of the upper jaw with tooth, floor 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
1.7 Total Maxillectomy with Orbital Exenteration 21
1.7 Total Maxillectomy with Orbital Exenteration
Fig. 1.59 The upperlid incision is deepened to the periorbita of the

Fig. 1.58 When orbital exenteration is considered a Dieffenbach superior orbital rim
extension alone the superior palpebral is added
Fig. 1.60 From there the orbital contents are dissected and retracted the orbital contents inferiorly to the oral cavity exposing the ophthalmic
down from the roof of the orbit to the floor. Osteotomies are done as artery and optic nerve. The ophthalmic artery and nerve are cut and
described in total maxillectomy. The maxilla is mobilized together with ligated and removed together with the maxilla
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
1.7 Total Maxillectomy with Orbital Exenteration 23
Fig. 1.63 The exposure also allows for tumor extensions to the base of skull to be removed
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
Fig. 1.64 The full length of the temporalis muscle is raised to obliter- the nasal cavity. The cheek flap is placed back and the Weber –
ate the cavity and achieve oronasal separation Dieffenbach incision is closed
Fig. 1.66 The facial incision heals with minimal scaring

1.8 Extended Total Maxillectomy with Cheek Skin Excision 25
1.8 Extended Total Maxillectomy with Cheek Skin Excision
Fig. 1.67 In cases where the cheek skin is to be removed, the lip split Fig. 1.69 The defect consisted of a open maxillary cavity
is avoided. The cheek skin instead of reflecting is removed with the
specimen
Fig. 1.70 The cavity is obliterated with temporalis muscle

Fig. 1.68 The postoperative specimen consists of the eye and cheek
skin with the maxilla
Fig. 1.71 A appropriate flap with skin (as described in Chap. 6) is placed over the temporalis muscle to replace cheek skin
1.9 Craniofacial Resection 27
1.9 Craniofacial Resection
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. 1.72 A bicoronal incision is made and a scalp flap is raised

anteriorly
Fig. 1.73 A separate pericranial flap is raised for later use on cranial Fig. 1.75 Burr holes are made on each side just above the frontal sinus
base border. A craniotomy is done using a giggly saw or stricker saw
Fig. 1.76 The bone flap is removed and kept in saline for later use
Fig. 1.78 The excised intracranial component of the tumor is removed

through the extra cranial defect
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- Fig. 1.79 After tumor removal the pericranial flap is draped over the
form plate is drilled and removed with the maxilla and orbit inferiorly defect in the skull base
1.9 Craniofacial Resection 29
Fig. 1.80 The bone flap is placed back and held in place with plate and screws
Larynx and Trachea
2
2.1 Arytenoidectomy and Lateralization of Vocal Cord (Modified Woodman’s Technique)
Fig. 2.1 A tracheoyomy is usually already performed at the beginning as most of the patients suffer from bilateral abductor palsy
32 2 Larynx and Trachea
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- Fig. 2.4 The strap muscles are identified and undermined in a supero-
nocleiodomasoid muscle laterally inferior direction and retracted laterally
2.1 Arytenoidectomy and Lateralization of Vocal Cord (Modified Woodman’s Technique) 33
Fig. 2.7 From this step, the operating microscope and the microsurgi-
Fig. 2.5 The thyroid cartilage is rotated with the help of a sharp double
cal instruments facilitate the subsequent steps. The arytenoid cartilage
pronged hook to expose the entire posterior border of the thyroid alar.
is identified by following the upper border of the cricoid cartilage
The inferior constrictor muscle is incised along the entire length of the
posteromedially
thyroid alar
Fig. 2.6 The inferior horn of the thyroid cartilage and the cricothyroid
articulation are identified. The cricothyroid joint is disarticulated
Fig. 2.8 The muscular attachments are removed and the laryngeal
mucosa is reflected from the arytenoid cartilage with finer 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
Fig. 2.10 A small knot is placed and the wound is closed in layers
after placing a drain
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 fixed 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
fibreoptic nasolaryngoscope to see the intercordal distance which, after
tightening the sutures, should be between 4 and 5 mm. Endoscopic
examination also confirm the extramucosal nature of the procedure
a b
Fig. 2.11 After healing when there adequate airway (a) on expiration and (b) on inspiration during fiberoptic nasolaryngoscopy, the tracheostomy
tube is decannulated
2.2 Frontolateral Vertical Partial Laryngectomy 35
2.2 Frontolateral Vertical Partial Laryngectomy
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 fine elevator, the inner perichondrium of
the thyroid cartilage is elevated and the laryngeal soft tissues are sepa-
Fig. 2.12 The incision could be a small or a big apron-flap; it depends rated from each thyroid alar. This step is continued till a paramedian
on the necessity of neck dissection. The tracheostomy could be per- tunnel is created between the upper and lower border of the thyroid
formed at the beginning or at the end of the procedure 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
Fig. 2.13 The skin flap 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. 2.18 The rest of the attachments of the tumor is cut with a strong
curved scissors and the specimen (inset) is removed
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 Fig. 2.19 The small raw area is expected to heal by granulation and
the arytenoid cartilage epithelization
2.2 Frontolateral Vertical Partial Laryngectomy 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 fine sutures; these sutures are anchoreed to holes made on
the thyroid cartilage with a fine diamond burr as the thyroid cartilage is Fig. 2.22 The strap muscles are reapproxmated and overlapped in the
friable midline in a closed water-tight way over a suction drain. The rest of the
incision is closed in two layers
Fig. 2.21 The two halves of the thyroid cartilage are sutured together
Fig. 2.23 After 4 weeks the raw area is epithelized and the tracheos-
by a slowly absorbing thick suture material
tomy tube is removed
2.3 Supracricoid Laryngectomy with Cricohyoidoepiglottopexy
Fig. 2.26 The external thyroid perichondrium and the inferior con-
strictor muscles are cut along the posterior borders of the thyroid carti-
Fig. 2.24 A ‘U’ type incision is given. It is passed along the anterior lage. Using a perichondrium elevator, the pyriform sinus mucosa is
border of the sternocleidomastoid muscles, down to the level of the released. The superior laryngeal vessels are identified and ligated, and
cricoid cartilage. A subplatysmal skin flap is elevated at least 1 cm the internal laryngeal nerves preserved
above the level of the hyoid bone. A functional neck dissection is per-
formed at this stage
Fig. 2.27 The sternothyroid muscles are dissected downwards beyond

the cricoid cartilage thereby exposing the cricothyroid muscles. The
Fig. 2.25 The sternohyoid and thyrohyoid muscles are cut along the muscles are carefully transected to expose the cricothyroid membrane.
upper border of the thyroid cartilage. The former muscles are dissected With the help of the perichondrial elevator, the subglottic mucosa over-
downwards to expose the sternothyroid muscles. The muscles along the lying the cricoid cartilage is elevated on the side of the tumor. This step
oblique line of the thyroid cartilage (labelled C in the picture) are cut is necessary to achieve wider resection on the diseased side
and the larynx is rotated by a hook
2.3 Supracricoid Laryngectomy with Cricohyoidoepiglottopexy 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. 2.30 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. 2.29 The inferior horn on the ipsilateral side is disarticulated to

allow the paraglottic space to be removed completely 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
Fig. 2.32 The larynx is grasped with a Allis forceps and pulled in an entire paraglottic space is anterior to the cut while the pyriform sinus is
anteroinferior direction to have maximum visualization. The endol- behind it, and both are spared. The vertical prearytenoid incision and
aryngeal resection is performed under direct vision. On the contralat- the medial transverse cricothyroidotomy are connected. This allows the
eral side, a vertical prearytenoid incision is made from the aryepiglottic lateral cricoarytenoid muscle to be spared on the contralateral side; so it
fold to the superior border of the cricoid cartilage with a scissors. The 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 interarytenoid muscle. Subsequently, the cut on the tumor bearing side pro-
wider. The cuts are made over the arytenoid, conserving the posterior ceed anteriorly in the cricothyroid membrane and joined with the cut from
mucosa, then continued vertically in the posterior subglottis through the the contralateral side. The specimen is removed and hemostasis is achieved
2.3 Supracricoid Laryngectomy with Cricohyoidoepiglottopexy 41
Fig. 2.34 Before closure, it is made sure that the ventricular mucosa is cricoid cartilage on the side of arytenoid resection. The remaining
removed entirely and there is no perforation of the pyriform sinus arytenoid cartilage is pulled forward to the posterolateral aspect of the
mucosa. The mucosa of the arytenoid cartilage is sutured covering the cricoid cartilage to avoid the posterior sliding of the former
cartilage. The remaining arytenoid mucosa is sewn over the denuded
Fig. 2.35 Three thick sutures (‘0’ vicryl) are placed, one in the mid- the hyoid bone. The tension is less in the suture line as the previously
line and one on either side 1 cm away from midline. They are passed to released cervicomediastinal trachea moves upward. At this stage the
encircle the cricoid cartilage, cross the epiglottis and the base of the final refinement of the tracheotomy is made. The previously sectioned
tongue and lastly, encircle the hyoid bone. The neck is flexed and the sternohyoid muscles are sutured, drain inserted and the skin closed in
sutures are tied tightly leaving no gap between the cricoid cartilage and two layers
2.4 Supraglottic Horizontal Partial Laryngectomy
Fig. 2.36 Following a ‘U’ incision, the flap is raised in the subplatysmal plane, exposing the underlying strap muscles and hyoid bone
Fig. 2.37 The internal laryngeal nerve is identified and preserved as it runs along with the superior laryngeal artery
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
Fig. 2.40 After removal of the hyoid bone, the thyrohyoid membrane and the thyroid cartilage are exposed by reflecting 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
Fig. 2.42 The perichondrium is elevated from the anterolateral surface exposed by reflecting the thyrohyoid, sternohyoid and, omohyoid mus-
of the thyroid cartilage and reflected inferiorly. After removal of the cles inferiorly
hyoid bone, the thyrohyoid membrane and the thyroid cartilage are
Fig. 2.43 A plane of cleavage is established between the thyroid carti- between the notch and the inferior border. The thyroid cartilage incision
lage to be resected and the underlying perichondrium. With a Stryker is continued superiorly at each side along the lines corresponding to the
saw, horizontal incisions are made across the thyroid cartilage midway perichondrial incisions
Fig. 2.44 The thyroid cartilage above the horizontal incision is resected exposing the underlying perichondrium
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
Fig. 2.45 The pharynx is entered as described in laryngectomy. After catgut
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. 2.47 Laterally the base of the tongue is sutured to the inferior cartilage perichondrium, the thyroid cartilage and the external thyroid
constrictor musculature with chronic catgut 3-0. Anteriorly, interrupted cartilage perichondrium. The neck is flexed and the laryngeal mucosa
sutures are placed through the base of the tongue, the internal thyroid 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
2.5 Total Laryngectomy
Fig. 2.49 A ‘U’ flap incision is marked out; extension could be made for neck dissection
Fig. 2.50 The flap 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- (arrow). The dissection is continued to the level of the clavicle below
fied and dissected in its medial plane. The carotid sheath is identified and hyoid above on both sides. The branches of anterior jugular vein
and the common carotid artery, internal jugular vein and vagus nerve are transsected and tied
are retracted laterally. The superior belly of omohyoid muscle is incised
Fig. 2.52 On the side of the tumor, appropriate neck dissection is done Fig. 2.53 On the contralateral side of the tumor, the superior
depending on the neck node metastasis. The superior and inferior thy- and inferior thyroid artery and vein are preserved
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. 2.54 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
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- cut with scissors laterally on each side of the epiglottis and then the cut
brane to enter the pharyngeal lumen in the area of the vallecula between follows inferiorly along the aryepiglottic folds on each side and turns
the base of the tongue and the epiglottis. The surgeon with headlight medially just below the level of the superior border of the cricoid carti-
moves to the head end of the table. Through the pharyngotomy, the lage to join the incision from the opposite side
epiglottis is grasped with Allis forceps and the pharyngeal mucosa is
Fig. 2.58 The larynx is released by dividing the extramucosal tissues cricoarytenoid articulation (A) thereby keeping away from probable
and any residual tissue of the inferior constrictor muscles along the malignant spread to the latter
same line of the mucosal cut. Both cuts are joined posteroinferior to the
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
Fig. 2.60 The larynx with attached one thyroid lobe is removed. A through the tracheostoma. The shape of the tracheal cut is made so it
new tracheostoma is made through the skin below the tip of the incision extended backward and obliquely upward making the membranous part
in patients who did not have any prior tracheostomy. The anesthetist 5 mm higher than cartilaginous one
gradually remove the orotracheal tube and the surgeon insert a new tube
Fig. 2.61 After removal of the specimen the nasogastric tube is directed into the stomach
Fig. 2.62 A cricopharyngeal pharyngeal myotomy is made using a sharp knife till the mucosa is seen transparent
Fig. 2.63 The pharynx is closed by carefully apposing mucosal edges should be carefully inverted so that outer surface is apposed to outer
with the help of mucosal or extramucosal sutures from above down- surface when approximated. Usual pharyngeal closure line look like a
wards or vice versa. During this first layer of closure the mucosal edges straight line or ‘T’ shaped
Fig. 2.64 In the second layer of pharyngeal closure are done by inter- The third layer of the pharyngeal closure are made using pharyngeal
rupted sutures so as to bury the first one; the pharyngeal wall is picked constrictors and the preserved strap muscles of the neck. Particular
up with a fine, atraumatic round needle just lateral to the crease of the attention is given to the suprastomal area; the commonest site of fistula
first suture line without penetrating the mucosa, and the knots are tied. formation
Fig. 2.65 At this stage, the patient head is made slightly flexed from
extended position to lessen the tension on the suture lines. Using a
heavy and fine 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 flaps 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
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
2.6 Total Laryngopharyngoesophagectomy with Gastric Pull Up 57
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
Fig. 2.69 Anchor sutures are placed through the muscular wall of the
stomach and anchored to the paravertebral fascia
2.7 Upper Tracheal Resection and Anastomosis for Trachea Stricture
Fig. 2.71 Post intubation tracheal stricture at the first 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
2.7 Upper Tracheal Resection and Anastomosis for Trachea Stricture 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
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 flap is raised and the strap muscles exposed
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 first 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
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
Fig. 2.79 The stenosed circumference of the trachea is resected.

A endotracheal tube is passed guided by the “leader” catheter
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
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
Thyroid
3
3.1 Sistrunk Procedure for Thyroglossal Cyst
Fig. 3.1 A 5–6 cm transverse incision is made over the cyst; in case of Fig. 3.2 The sinus opening with the attached skin or the cyst is grasped
a sinus the central part of the incision should encircle the opening of the and retracted superiorly taking care to preserve the integrity of the tract;
sinus. The platysma muscle is cut and the dissection proceed cranially dissection is continued till hyoid bone is reached
in the subplatysmal plane
66 3 Thyroid
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
3.2 Hemithyroidectomy 67
3.2 Hemithyroidectomy
Fig. 3.5 Collar incision is marked out along the skin crease from ante- Fig. 3.7 The facia over the strap muscles are incised and the muscles
rior border of sternocleidomastoid muscle from one side to the other on each side are separated in the midline
Fig. 3.8 The thyroid tumor is exposed and the strap muscles are
retracted laterally
Fig. 3.6 Subplatysmal flap is raised superiorly to the level of the hyoid
bone and inferiorly to the suprasternal region
68 3 Thyroid
Fig. 3.9 The left recurrent laryngeal nerve running below the inferior Fig. 3.11 The parathyroid gland is identified and separated from the
thyroid artery in this case is identified thyroid gland with its vascular supply intact
Fig. 3.10 The left inferior thyroid artery is ligated Fig. 3.12 The superior thyroid pedicle (arrow) is ligated close to the
gland and the tumor is removed in total
3.2 Hemithyroidectomy 69
Fig. 3.13 (a, b) The entire thyroid tumor is examined by sectioning and sent for histopathological examination
70 3 Thyroid
3.3 Total Thyroidectomy
Fig. 3.14 A collar incision is marked out along the skin crease extend- Fig. 3.16 The tumor is removed and hemostasis is achieved. The right
ing between the lateral borders of sternocleidomastoid muscles for neck common carotid artery is exposed
dissection as well
Fig. 3.15 The recurrent laryngeal nerve on each side are identified and
preserved. The tumor with neck dissection specimen is removed in one
piece
3.3 Total Thyroidectomy 71
Fig. 3.17 The intact specimen is sent for histopathological examination. The incision is closed as in hemithyroidectomy
Salivary Glands
4
4.1 Submandibular Sialoadenectomy
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 4 Salivary Glands
Fig. 4.2 Skin incision is carried

below the platysma and
subplatysmal flap raised exposing
the submandibular gland with
tumor. At the angle of the
mandible, the facial artery and
vein are identified, ligated and
reflected 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
4.1 Submandibular Sialoadenectomy 75
Fig. 4.4 The lingual nerve is

dissected away from the gland
and the submandibular duct is cut
and ligated
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
4.2 Superficial Parotidectomy 77
4.2 Superficial Parotidectomy
Fig. 4.6 Modified 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 fingerbreaths
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
identified and preserved. The
anterior flap is raised superficial
to the greater auricular nerve and
the parotid fascia. Elevation of
the posterior and inferior flap
exposed the tail of the parotid.
The flaps 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
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 identification
Fig. 4.9 The parotid gland

superficial to the facial nerve is
divided and removed with the
tumor
4.2 Superficial Parotidectomy 79

with the tumor is removed and a
radivac drain inserted and the
wound is closed in layers
4.3 Superficial 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 flaps are raised as
described in Fig. 4.7. The greater
auricular nerve is identified and
preserved. The facial nerve trunk
is identified as described in
Fig. 4.8
4.3 Superficial Parotidectomy with Deep Lobe Resection 81

superficial 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 flap is returned and
wound closed in layers
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
4.4 Total Parotidectomy with Facial Nerve Graft with Sural Nerve 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
Fig. 4.20 Blind sac closure of

external auditory canal is done
and the wound is closed in layers
4.5 Temporoparietal Facial Flap (TPFF) and Abdominal Fat Graft for Prevention of Frey’s Syndrome Following Parotidectomy 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 flap is raised

in the subfollicular plane
superficial to the superficial
musculoaponeurotic system
(SMAS). At this stage, injury to
the hair follicles above and to the
branches of the superficial
temporal artery below is avoided.
The elevation of the skin flap is
carried out till the superior
temporal line is reached and in
both anterior and posterior
direction till an adequate
dimension of the flap to cover the
raw area created by
parotidectomy is reached
Fig. 4.23 The TPFF is separated

from the underlying areolar
tissue and fascia covering the
temporalis muscle. The branches
of the superficial temporal artery
are cut and ligated at the margin
of the flap
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
4.5 Temporoparietal Facial Flap (TPFF) and Abdominal Fat Graft for Prevention of Frey’s Syndrome Following Parotidectomy 87
Fig. 4.25 The abdominal fat is

harvested superficial to the rectus
abdominis muscle
Fig. 4.26 The harvested

abdominal fat is trimmed to
required size
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

flap is placed over the fat graft. A
drain is inserted and the incision
closed in layers
Repair of External Nose Defects
5
5.1 Repair of Alar Defect with Full Thickness Skin Graft
Fig. 5.1 Incision site is marked out for nasal basal cell carcinoma
excision
Fig. 5.2 The defect after excision
90 5 Repair of External Nose Defects
Fig. 5.3 Full thickness skin graft is harvested from the postauricular Fig. 5.5 Wound heals without scaring, 10 weeks after operation
region
Fig. 5.4 Full thickness post auricular skin graft is used to close the
nasal defect
5.2 Superior Based Nasolabial Flap for Reconstruction of Alar Defect 91
5.2 Superior Based Nasolabial Flap for Reconstruction of Alar Defect
Fig. 5.6 The flap is marked out for reconstruct of alar defect using a superior based nasolabial flap
Fig. 5.7 A nasal dorsum turnover flap (arrow head) and a superior based nasolabial flap (arrow) are raised
Fig. 5.10 The donor area of the nasolabial flap is sutured; the nasal
dorsum turnover flap forms the roof of the vestibule
Fig. 5.8 The nasal dorsum turnover flap is reflected down
Fig. 5.11 The nasolabial flap is sutured with the nasal dorsum and
with the turnover flap
Fig. 5.9 The nasal dorsum turnover flap is stabilized by suturing its
lateral and basal sides with the respective parts of the vestibular skin
5.3 Modified Reiger Glabellar Rotation Flap 93
5.3 Modified Reiger Glabellar Rotation Flap
Fig. 5.12 The incision is marked out for reconstruction of the alar defect using a Reiger glabellar rotation flap
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 flap for inner lining
Fig. 5.14 The flap is transported to cover the defect
Fig. 5.15 Appearance of the patient 3 months after operation

5.4 Island Forehead Flap for Reconstruction of External Nose Defect 95
5.4 Island Forehead Flap for Reconstruction of External Nose Defect
Fig. 5.16 A skin island forehead flap is marked out to be used for nasal
defect
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. 5.17 The flap is raised in the subgaleal plane
Fig. 5.19 A 2 cm cuff of subcutaneous tissue at the frontogaleal layer

is raised along with the island of skin
Fig. 5.20 Between 2 and 2.5 cm above the supraorbital margin the periosteum is incised and the flap is dissected in the subperiosteal plane to
include and protect the supratrochlear vessels. The flap 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
5.4 Island Forehead Flap for Reconstruction of External Nose Defect 97
Fig. 5.22 The flap is mobilized

to the nasal defect
Fig. 5.23 The defect is closed and donor site closed with interrupted
sutures
5.5 Schmid-Meyer Frontotemporal Flap
Fig. 5.24 Defect on nasal tip and adjoining alar of both sides Fig. 5.26 The two flaps are raised from its bed and the non-epithialised
surface covered with split-thickness skin graft. The flap is wider in
deeper plane than superficial giving it a trapezoidal shape in cross sec-
tion. The skin edges of the donor area of the flap 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 flap (arrow); these measurements depends
on the size of the defect
Fig. 5.25 The flap is done in stages. First stage. This flap is based on
supraorbital and supratrochlear arteries and had 2 pedicles which are
label (A) and (B) in this picture
5.5 Schmid-Meyer Frontotemporal Flap 99
Fig. 5.27 Second stage: Begins 4 weeks after the first stage. A thin ply is occluded partially. The strangulation is gradually increased; sub-
rubber tube is looped around the bridge of the skin between the lateral sequently the bridge of the skin in the loop is cut and it produced a free
ends of the flap and medial to the cartilage implant thereby blood sup- bipedicled flap with implanted cartilage at the lateral end
Fig. 5.28 Third stage: After 2–3 weeks of the second stage, the flap is strangulated at the tip in preparation for definitive transfer. This delay is
continued until the blanching response of the flap tissue to finger pressure disappear within 3 seconds
Fig. 5.31 The patient appearance 6 months after operation
Fig. 5.29 The lateral end of the flap is cut and sutured to the defect at
the nasal tip
Fig. 5.30 Fourth stage: Four weeks later the flap healed satisfactorily
and its distal end is divided near the nasal tip. Pedicle of the flap is
returned to the forehead; reimplantation of the pedicle is necessary to
return a distorted brow line to its original position
5.6 Oblique Forehead Flap for Basal Cell Carcinoma of Nasal Dorsum 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

Fig. 5.34 The oblique forehead flap is elevated and the flap is rotated to cover the defect. The donor area covered with split thickness skin graft
5.7 Anterior Scalping Flap for Nose Reconstruction 103
5.7 Anterior Scalping Flap for Nose Reconstruction
Fig. 5.37 The anterior scalp flap is completely elevated
Fig. 5.35 The anterior scalping flap 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 Fig. 5.38 The contralateral forehead is undermined to provide ade-
reaching the upper limit of the frontalis the dissection is done at the quate mobility
supraperiosteal plane
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
5.7 Anterior Scalping Flap for Nose Reconstruction 105
Fig. 5.41 The nasal columella

created from the anterior scalping
flap is sutured to the remaining
columella on each side
Fig. 5.43 The flap 6 weeks later is ready to be divided
Fig. 5.42 The alar and rest of nasal defect is sutured to the flap and the
donor site is covered with split skin graft
Fig. 5.44 The flap is divided and returned to the forehead
Fig. 5.45 The flap heals with patent nostril and the donor site heals with minimal scaring over time
Axial and Free Flaps
6
6.1 Facial Artery Musculomucosal (FAMM) Flap
Fig. 6.2 When incising the anterior border of the flap, the superior
labial artery is identified. It is ligated and by following its proximal
course, the facial artery is identified
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
orifice of the parotid duct marks the posterior limit of the flap
108 6 Axial and Free Flaps
Fig. 6.3 The flap 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 identified and ligated
Fig. 6.4 Dissection is continued underneath the facial artery to the neck over the mandible. The flap is completely mobilized from the neck with
the facial artery and vein in view
6.1 Facial Artery Musculomucosal (FAMM) Flap 109
Fig. 6.5 The flap 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 flap with its vas-
cular pedicle is passed under the nerve to the neck
Fig. 6.7 With artery forceps, a tunnel is created communicating the floor of mouth and neck
Fig. 6.8 The flap is mobilized to the oral cavity

6.1 Facial Artery Musculomucosal (FAMM) Flap 111
Fig. 6.9 The defect is closed with interrupted sutures
Fig. 6.10 The flap 6 weeks after operation

6.2 Palatal Flap
Fig. 6.11 The patient is intubated with endotrachal tube in the midline and patient is placed in head extended position. The flap marked is out
with interrupted diathermy point
Fig. 6.12 The palatal mucoperiosteal flap is elevated from the bony hard palate in the anteroposterior direction by blunt and sharp dissection from
nonpedicle to the vascular pedicle side
6.2 Palatal Flap 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
flap becomes rotatable
Fig. 6.14 The flap 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 floor of mouth
6.3 Submental Artery Flap
Fig. 6.15 With the patient in supine position and head extended, the to a contralateral point across the midline. The inferior limit of the flap
face and head are prepared. The upper limit of the flap is marked along is outlined by an index finger-thumb pinch test to assess primary
the mandibular arch in the submental region from the ipsilateral angle closure
6.3 Submental Artery Flap 115
Fig. 6.16 The flap is elevated from the contralateral side of the pedicle deep to the platysma and overlying the facial artery is identified and
in the subplatysmal plane. When dissecting the upper margin of the preserved. The dissection is continued till the midline is reached
flap, the marginal mandibular branch of the facial nerve which lies just
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
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 flap
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 flap is ready to be mobilized to the defect

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 flap with its pedicle is passed below the bridge of skin
Fig. 6.23 The flap covers the retro auricular defects; drain inserted and donor area closed
Fig. 6.24 For closure of defects in the tongue after glossectomy; the flap is passed into the oral cavity deep to the mandible and mobilized into
the oral cavity
Fig. 6.26 A distally based reverse flow submental flap is able to reach
defects in the hard palate following maxillectomy
Fig. 6.25 A distally based flap based on reverse flow 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 flap
rotation restricts the distal dissection of the pedicle. The nerve is care-
fully dissected out and the flap is passed under it
6.4 Nasolabial Flap
Fig. 6.29 The donor site is closed
Fig. 6.27 Inferiorly based nasolabial flap is mobilized
Fig. 6.28 A tunnel is created in the cheek mucosa and flap directed Fig. 6.30 Gingivolabial defect closed with nasolabial flap
into the oral cavity
6.5 Trapezius Flap 121
6.5 Trapezius Flap
Fig. 6.31 The flap site marked out
Fig. 6.32 The feeding transverse cervical artery and vein are identified
Fig. 6.33 The flap with the feeding vessels attached is completely mobilized
Fig. 6.34 The flap used to close oral cavity defect

6.6 Lattismus Dorsi Flap 123
6.6 Lattismus Dorsi Flap
Fig. 6.35 The postoperative cheek defect to be closed with lattismus dorsi flap and an alternate flap
Fig. 6.36 The lattismus dorsi flap is marked out

Fig. 6.39 The outer cheek defect closed with lattismus dorsi flap.
Inner mucosa is closed with a alternate flap
Fig. 6.37 The feeding vessels of lattismus dorsi flap are identified
Fig. 6.38 The lattismus dorsi flap is mobilized with feeding vessels
6.7 Pectoralis Major Myocutaneous Flap 125
6.7 Pectoralis Major Myocutaneous Flap
Fig. 6.40 The clavicle and the approximate course of the vascular pedicle are marked out. The flap 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 identified
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
6.7 Pectoralis Major Myocutaneous Flap 127
Fig. 6.44 The pectoral branch of thoracoacromial artery (arrow) identified. Pectoral nerve (arrow head) exiting the pectoralis minor is identified
and transsected
Fig. 6.45 The muscular attachment to the humerus is transsected and the flap is completely mobilized
Fig. 6.46 A tunnel is created for the passage of the pectoralis major muscle flap to the neck
Fig. 6.47 The pectoralis major myocutaneous flap is transferred to the neck superficial to the clavicle to be used to reconstruct defects as required
6.8 Radial Forearm Free Flap 129
6.8 Radial Forearm Free Flap
Fig. 6.48 The radial forearm flap 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 radial artery and cephalic vein. The cephalic vein and radial artery are
forearm through the use of an elastic bandage and raising the tornique transsected and ligated
to 250 mmHg. The distal skin incision is made to gain exposure of the
Fig. 6.50 The dissection is done from the lateral to medial. The skin flap 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 flexor carpi radialis
overlap
6.8 Radial Forearm Free Flap 131
Fig. 6.52 The proximal radial artery and cephalic vein are exposed by separating the brachioradialis from the flexor carpi radialis muscles
Fig. 6.53 The radial forearm free flap is ready to be divided when the vessels of the donor site to be anastomosed are ready. The tornique is
released
Mandible
7
7.1 Mandibulotomy for Access
Fig. 7.2 Mandibulotomy is done in the midline. The soft tissue attach-
Fig. 7.1 The incision for midline mandibulotomy is marked out run- ments to the floor of mouth to the mandible are excised and the mandi-
ning in the midline of lower lip to the level of the hyoid and laterally to ble is reflected laterally pivoting at the temporomandibular joint
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
134 7 Mandible
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
7.2 Segmental Mandibulectomy and Reconstruction with Stabilizing Plate and Screw 135
7.2 Segmental Mandibulectomy and Reconstruction with Stabilizing Plate and Screw
Fig. 7.4 Through an incision two finger breaths below the angle of Fig. 7.6 Stabilization plate are placed and held in place with screws
mandible, the mandibular tumor is exposed and marked out for segmen- placed at the proximal and distal cut ends of the mandible
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. 7.7 The excised specimen with mandible is sent for further
examination
136 7 Mandible
7.3 Segmental Mandibulectomy and Reconstruction with Rib Graft
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. 7.8 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 reflected
Fig. 7.11 The required length of the rib is measured and cut with a rib
cutter
7.3 Segmental Mandibulectomy and Reconstruction with Rib Graft 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
138 7 Mandible
7.4 Bilateral Hemi Mandibulectomy and Reconstruction with Fibular Graft

Microvascular Anastomosis
Fig. 7.16 The end of the tumor on each side of the mandible is identi-
fied and the tissues over the tumor dissected off to expose the tumor
Fig. 7.14 Huge mandibular ameloblastoma involving both halves of

the mandible requires hemimandibulectomy
Fig. 7.17 After exposure of the tumor, the tumor free part of the
mandible on both sides is exposed to be cut
Fig. 7.15 The incision extends from the mastoid process of one side
and curves over the tumor to the other side
7.4 Bilateral Hemi Mandibulectomy and Reconstruction with Fibular Graft Microvascular Anastomosis 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 Fig. 7.19 The excised tumor specimen is examined and sent for histo-
ramus on each side is visible (arrows) pathological examination
Fig. 7.20 The left fibula is marked out for free fibular graft
140 7 Mandible
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
Lips and Face
8
8.1 Repair of Lip Defect with Abbe-Estlander Flap
Fig. 8.1 The axial flap 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 flap 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 8 Lips and Face
Fig. 8.4 The donor area is mobilized and closed in three layers. The lip
commissure is formed in the process of flap rotation. The cut ends of the
lip is sutured
Fig. 8.3 (a, b) Using a sharp cut, the tumor is excised. The medially
based flap is designed, mobilized and rotated into the defect, and
sutured in place in three layers, skin, muscle and mucosa
Fig. 8.5 After 4 weeks the wound heals with less scaring. The scar is
eventually indistinguishable
8.2 Repair of Full Thickness Lip Defect 143
8.2 Repair of Full Thickness Lip Defect
Fig. 8.6 Full length mucosal lesion of the lower lip with cutaneous
infiltration in the midline is marked out for excision Fig. 8.8 The defect of the lip after excision
Fig. 8.7 The mucosal lesion is excised with a ‘V’ shaped cutaneous Fig. 8.9 The closure of the surgical defect is begun by placing sutures
and mucosal incision in the midline through the vermillion edge of the skin of the ‘V’ shaped defect for
accurate approximation
144 8 Lips and Face
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
8.3 Repair of Near Total Lop Defect by Karapandzic Flap 145
8.3 Repair of Near Total Lop Defect by Karapandzic Flap
Fig. 8.14 The skin and mucosal margins are closed. The oral sphincter
function is maintained but significant microstoma resulted
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
146 8 Lips and Face
8.4 Repair of Medial Canthal Defect with Split Forehead Flap
Fig. 8.17 The flap and donor site heals well within 8 weeks
Fig. 8.15 The excision margin around squamous cell carcinoma of the
medial canthal region and the flap 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 flap
is elevated and is splitted in the
middle. The split flap is rotated
to cover the defect. The donor
area is also closed in layers
8.5 Deep-Plane Cervicofacial Rotation-Advancement Flap 147
8.5 Deep-Plane Cervicofacial Rotation-Advancement Flap
Fig. 8.18 The incision marking for excision of neurofibroma involv-

ing the midface and adjoining external nose Fig. 8.20 A posteriorly based deep-plane cervicofacial rotation and
advancement flap is raised with incision along the right nasolabial
crease; the plane of dissection is made superficial to the facial muscles.
Subsequently, the incision is extended to the upper part of the neck at a
plane deep to the platysma
Fig. 8.19 Th neurofibroma is excised leading to the formation of a

large defect in the midface, medial canthus and adjoining bridge of the
nose
Fig. 8.21 This flap covers most of the raw area except in the medial
canthus and adjoining nasal dorsum
148 8 Lips and Face
Fig. 8.22 On the right side, an appropriate size island flap (described in 5.4) is raised to cover the remaining defect in the medial canthus and
adjoining nasal dorsum
8.6 Temporalis Muscle Flap Transposition Technique for Paralysed 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;
Fig. 8.25 The middle third of the muscle (roughly 4 cm or two fingers
direct or indirect nerve reconstruction were not an option
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’
Fig. 8.24 Reanimation of the mouth. The incision for the temporalis
muscle flap 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
150 8 Lips and Face
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- Fig. 8.27 The anterior third of the muscle is brought out through the
lyzed angle of the mouth with fingers. The incision is deepened down to incision at the lateral canthus. The anterior third of the split muscle is
the muscle. The temporalis muscle is exposed. A subcutaneous tunnel is now negotiated through the tunnels in such a way that the posterior part
created by blunt dissection with forceps and fingers. In the temporal occupied the lower lid and the anterior one in the upper lid. The cranial
fossa the tunnel lies superficial to the superficial musculoaponeurotic part of the muscle lies at the medial canthus. The canthal and lid inci-
system (SMAS). In the face, it lies between the fat and facial muscles sions helped in this process of adjustment. The lower ends of both the
layer. The middle and index fingers are passed through the tunnel to parts were stitched together at the lateral canthus. The temporalis mus-
create adequate diameter cle strips are stitched to the orbicularis oris and tarsal plates through the
upper and lower lid incisions with the help of the fine absorbable
sutures. Likewise, the tip of the muscle strip is attached to the medial
canthal ligament
8.6 Temporalis Muscle Flap Transposition Technique for Paralysed Face 151
Fig. 8.28 All the incisions are closed and the suction drain inserted to the temporal wound
152 8 Lips and Face
8.7 Pedicled Calvarial Bone Graft
Fig. 8.29 Wide bony defect and soft tissue scaring resulted secondary
to extensive cholesteatoma with complications Fig. 8.31 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 fine drill burr, ad holes are made at the proximal edge of the cut.
With the help of sutures the periosteum is fixed with bone flap. The
outer table of the calvarial bone is next cut using a curved osteotome till
the cancellanous layer is reached
Fig. 8.30 The skin flap is raised above the superficial temporal artery
(arrow head). The posterior branch of the superficial temporal artery is
identified (arrow) and traced in the posterosuperior direction till the
part of the calverion overlying the posterior half of the parietal bone is
reached
8.7 Pedicled Calvarial Bone Graft 153
Fig. 8.32 A tunnel is created between the periosteum and the bone flap at
the inferior 20 % of the circumference. Using a mastoid drill and diamond Fig. 8.34 The defect heals satisfactorily 3 months after operation
burr this part of the bone is cut keeping the vascular pedicle intact and the
bone flap with the covering periosteum are elevated with using a curve
osteotome. The elevated bone flap covered by periosteum and pedicled on
the posterior branch of superficial temporal artery is free to be mobilized
Fig. 8.33 The bone flap 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 flap
Temporal Bone Malignancy
9
9.1 Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy
Fig. 9.2 Anteriorly based mastoid musculoperiosteal flap is raised and

left attached to the catalagenous canal to be used later for obliteration of
Fig. 9.1 Postauricular incision used for elevation of anterior musculo- the mastoid cavity
periosteal flap and identification 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
156 9 Temporal Bone Malignancy
Fig. 9.3 Neck dissection is done and the facial nerve identified. The and vagus nerve identified. Cranial nerves XI and XII are also identi-
facial nerve is dissected into the parotid gland postauricularly and up to fied. Total parotidectomy is done. The tympanic segment of the facial
the point of second division. The sternocleidomastoid muscle is nerve is removed as it is involved by the tumor. Radical mastoidectomy
retracted posteriorly and common carotid artery, internal jugular vein is done
Fig. 9.4 The tegmen, posterior fossa plate, sigmoid sinus from the to the stylomastoid formen which is drilled out to mobilize the nerve for
sinodural angle to the jugular bulb is skeletonized. The mastoid seg- ene-to-end facial hypoglossal anastomosis. The sternocleidomastoid
ment of the facial nerve is dissected off the fallopian canal all the way muscle is detached from the mastoid tip and tip removed
9.1 Subtotal Petrosectomy for Middle Ear Carcinoma with Facial Palsy 157
Fig. 9.5 The bony eustachian tube is drilled down to the isthmus. The carotid foramen are removed. The upper cervical internal carotid artery,
carotid artery is exposed medial to the eustachian tube (blue marker in cranial nerve IX and internal jugular vein are exposed. The tumor is
the picture). The styloid process and lateral tympanic bone covering the removed
Fig. 9.6 The incision is closed and suction drain inserted in the neck
158 9 Temporal Bone Malignancy
9.2 Subtotal Petrosectomy with Excision of Pinna
Fig. 9.9 The defect is closed with pectoralis major myocutaneous flap
with nipple
Fig. 9.7 Squamous cell carcinoma of the middle ear with pinna and
posterior auricular extension
Fig. 9.10 The nipple is transferred back to the donor site on the chest
after healing
Fig. 9.8 Defect after excision and subtotal petrosectomy, total paroti-
dectomy and ascending ramus mandibulectomy (arrow head)
Head and Neck
10
10.1 Excision of Lipoma Over Parotid Region
Fig. 10.1 Parotid lipoma before excision
Fig. 10.2 Raising the flap at the subcutaneous tissue level exposed the
lipoma. It is easily excised by staying very close to the tumor
160 10 Head and Neck
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

10.2 Excision of Sebaceous Cyst 161
10.2 Excision of Sebaceous Cyst
Fig. 10.7 The intact specimen with intact capsule is removed and
examined
Fig. 10.5 Submandibular sebaceous cyst before excision
Fig. 10.6 The skin flap is raised at the subcutaneous tissue plane
exposing the cyst. Tissue attachments around the capsule are excised
and the cyst removed Fig. 10.8 The cyst opened exposing the sebaceous contents
10.3 Excision of Parapharyngeal Neurofibrosarcoma
Fig. 10.9 Incision is marked out for mandibulotomy and inclusion of Fig. 10.11 The tumor is dissected away from the common carotid
previous surgical scar for excision with the tumor artery and followed to the angle of the mandible
Fig. 10.12 Dissection at the lateral border of the tumor shows involve-
ment of the accessory nerve
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
10.3 Excision of Parapharyngeal Neurofibrosarcoma 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

10.4 Excision of Neck and Mediastinal Neurofibroma
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. 10.15 The tumor occupied lower half of the neck and in the
superior 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
10.4 Excision of Neck and Mediastinal Neurofibroma 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 field after excision of tumor exposing the neurovascular structures preserved
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 flap 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
10.5 Supra Omohyoid Neck Dissection 167
Fig. 10.22 Superficial layer of deep fascia over the anterior border of sternocleidomastoid muscle is separated from the muscle
Fig. 10.23 The accessory nerve is identified

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
Fig. 10.26 Investing layer of the deep fascia over the scalenus muscle is reflected exposing the upper trunk of brachial plexus and phrenic nerve
Fig. 10.27 The carotid sheath is opened exposing the contents

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
Fig. 10.30 Hemostasis of the surgical field is done at the end of the procedure, suction drain is inserted and the wound closed in layers
10.6 Modified 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 flaps are raised

10.6 Modified Radical Neck Dissection. Accessory Nerve Preserved 173
Fig. 10.33 Accessory nerve supplying trapezius muscle is identified 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
identified; dissection continued to lateral border of sternocleidomastoid muscle
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 sected away as it passes through the sternocleidomastoid muscle and
process is divided, upper end of internal jugular vein (arrow head) is preserved. Submandibular gland and submental nodes are dissected and
ligated and divided, accessory nerve supplying trapezius muscle dis- specimen removed enbloc
10.6 Modified Radical Neck Dissection. Accessory Nerve Preserved 175
Fig. 10.37 On the left side, the thoracic duct if identified is ligated to prevent chyle leak
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Index
A Fat graft, 85–88

Abbe-Estlander flap Flap
lower lip reconstruction, 141 deltopectoral,
upper lip reconstruction, 141 facial artery musculomucosal (FAMM),
Advancement flap 107–111
cheek reconstruction, 18, 24, 93, 121, 124, 125 forehead
Ala reconstruction island, 95–97
Reiger glabellar rotation flap, 93 midline,
Anterior scalping flap oblique, 101–102
nasal reconstruction, 103–106 lattisimus dorsi musculocutaneous, 124, 125
Artery nasolabial, 91–92, 121
external carotid, 163 pectoralis major myocutaneous, 126–129, 158
facial, 74, 107–111, 116–118, 120, 140 radial forearm free, 130–132
greater palatine, 19 Schmid-Meyer, 98–100
internal carotid, 157, 163 submental artery, 115–120
lingual, 163
superficial temporal, 85, 86, 152, 153
superior thyroid, 49 G
transverse facial, 122 Gillies advancement flap
Arytenoidectomy lower lip reconstruction, 141, 143, 145
with lateralization of vocal cord, 31–34
L
B Lacrimal sac and nasolacrimal duct, 5, 6, 13
Bilateral hemimandibulectomy Laryngectomy
reconstruction with fibular graft, 138–140 frontolateral partial of Leroux-Robert, 35–37
Blind sac closure, 82–84 subtotal supracricoid, 38–41
supraglottic horizontal partial, 42–47
total, 48–56
C vertical partial, 35–37
Calvarial bone graft, 152–153 Laryngopharyngoesophagectomy
Converse's forehead scalping flap with gastric pull-up, 56–57
reconstruction of nasal defect, 95–97 Lateral rhinotomy, 5–8
Cricopharyngeal myotomy Lower lip
with total laryngectomy, 54 primary closure, 15
reconstruction with flap
Abbe-Estlander, 141
D Gillies,
Deltopectoral flap, 128 Karapandzic, 145
F M
Facial nerve Mandibulectomy, 135–140, 158
anastomosis with hypoglossal nerve, 156 Mandibulotomy, 133–134, 162
peripheral branches, Maxillectomy, 18–27, 120
reanimation by temporalis muscle transfer, 149 Midfacial degloving, 3–4
DOI 10.1007/978-3-319-15645-3, © Springer International Publishing Switzerland 2015
180 Index
Muscle Pharyngectomy
digastric anterior and posterior bellies, 60, 116, 117 partial with total laryngectomy, 35–37
inferior constrictor, 33, 38, 47, 52 Pharyngotomy
scalenus anterior, 169 with total laryngectomy, 38–41
scalenus middle, 169
scalenus posterior, 169
sternocleiodomastoid, 32 S
temporalis, 20, 24, 26, 27, 83, 86, 149–151, 155 Skin graft
trapezius, 173, 174 full thickness, 89–90
Myotomy partial thickness,
cricopharyngeal, 54 Sternocleidomastoid muscle, 38, 67, 70, 77, 133, 156, 166,
167, 173, 174
Sternotomy, 164
Subglottic stenosis, 38
N Submandibular or Wharton's duct, 73–76, 116, 118, 170, 174
Neck dissection Submandibular salivary gland
anterior, 167, 168 excision, 161
elective, Superficial musculoaponeurotic system (SMAS), 85, 150
functional, 38
modified radical, 172–175
radical, 172–175 T
supraomohyoid, 166–171 Temporalis muscle transfer, 149–151
Nerve Thoracic duct
accessory, 162, 163, 167, 168, 172–175 injury, 175
ansa cervicalis, ligation, 175
facial, 74, 78, 80–84, 88, 109, 116, 120, 155, 156 Thoracic esophagus
glossopharyngeal, digital or endoscopic mobilization,
hypoglossal, 156, 163 Thyroidectomy
infraorbital, 14 hemi, 67–69, 71
lingual, 74, 75, 163 total, 70–71
marginal mandibular, 116 Total maxillary swing, 12–17, 19
maxillary, Tracheal sleeve resection
phrenic, 169, 173 with laryngotracheal anastomosis, 52
recurrent laryngeal, 39, 68, 70 Tracheostomy, 34, 35, 37, 53, 61
sural, 82–84 Transpalatal approach
vagus, 49, 156, 162, 163, 170 palatal mucoperiosteum, 9–11
V
O
Veins
Orbital apex, 14, 16
anterior facial, 49, 74
Orbital exenteration, 22–25
common facial, 49, 156
Orbital fissure
internal jugular, 49, 83, 156, 157, 163, 170, 174
inferior, 5, 6
middle thyroid, 49
superior, 22
W
P Weber-Fergusson incision, 12, 18
Parotidectomy
superficial, 77–81
total, 82–84, 156, 158 Z
Parotid or Stenson's duct, 107 Z-plasty,

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December, 2014 Vincent C. Cousins, BMedSci, MBBS, FRACS

Boroko, National Capital District, Papua New Guinea Siba P. Dubey, MS

1 Nose and Paranasal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

6 Axial and Free Flaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

1.1 Sublabial Approach for Maxillary Cyst

1.2 Midfacial Degloving

Fig. 1.8 The nasal vestibule is released circumferentially by a through

Fig. 1.10 An intercartilagenous incision is made to join the superior

1.3 Lateral Rhinotomy with Medial Maxillotomy

Fig. 1.18 The tumor is removed accordingly

1.4 Transpalatal Approach by Palatal Osteomucoperiosteal Flap

Fig. 1.21 A 5 cm gingivolabial sulcus incision is made equally on

1.5 Total Maxillary Swing (For Advanced Nasopharyngeal Angioﬁbroma)

Fig. 1.32 The operation is continued to the face. The Weber-Fergusson

Fig. 1.38 A curved osteotome

Fig. 1.39 A curved osteotome

Fig. 1.40 Any bleeding vessels

Fig. 1.41 After satisfactory

Fig. 1.42 The tumor is removed with all its extensions

1.6 Total Maxillectomy

Fig. 1.48 Osteotomies are performed at the zygomaticomaxillary

Fig. 1.49 A curved osteotome is

1.7 Total Maxillectomy with Orbital Exenteration

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

Fig. 1.65 The temporalis muscle is sutured to the periosteium of the

Fig. 1.66 The facial incision heals with minimal scaring

1.8 Extended Total Maxillectomy with Cheek Skin Excision

Fig. 1.70 The cavity is obliterated with temporalis muscle

1.9 Craniofacial Resection

Fig. 1.72 A bicoronal incision is made and a scalp flap is raised

Fig. 1.78 The excised intracranial component of the tumor is removed

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

2.2 Frontolateral Vertical Partial Laryngectomy

Fig. 2.15 An elevator is placed in the subperichondrial plane for pro-

Fig. 2.20 Complete hemostasis is achieved and a tracheotomy is done

2.3 Supracricoid Laryngectomy with Cricohyoidoepiglottopexy

Fig. 2.27 The sternothyroid muscles are dissected downwards beyond

Fig. 2.29 The inferior horn on the ipsilateral side is disarticulated to

2.4 Supraglottic Horizontal Partial Laryngectomy

2.5 Total Laryngectomy

2.6 Total Laryngopharyngoesophagectomy with Gastric Pull Up

Fig. 2.67 Procedure is same as

Fig. 2.68 The esophagus is

Fig. 2.70 The esophagus is excised at the gastroesophageal junction

2.7 Upper Tracheal Resection and Anastomosis for Trachea Stricture

Fig. 2.79 The stenosed circumference of the trachea is resected.

Fig. 2.81 The endotracheal tube

Fig. 2.83 The tracheal ends are

Fig. 2.84 A sunction drain is inserted and the wound is closed in

3.1 Sistrunk Procedure for Thyroglossal Cyst

3.3 Total Thyroidectomy

4.1 Submandibular Sialoadenectomy