The mouth, jaws, and facial tissues serve many unique functions. Deformities can result from trauma, as a consequence of tumor surgery, as a complication related to radiation therapy, certain infections, or birth defects. Frequently these problems have a serious impact on a person’s ability to speak, swallow, chew food, or affect their appearance. Many various reconstructive procedures are available to return a person to an improved functional level and cosmetic appearance. Select a topic from the menu to learn more about specific procedures Dr. Engroff offers to restore these tissues to a functional level.

Reconstruction of soft tissues

A loss of soft tissue frequently accompanies the removal of a benign or malignant tumor. It can also be a problem in severe trauma of the facial region. Correction of this tissue loss may be simple or complex depending on the type and amount of tissue lost.

When the amount of tissue that is lost is minimal, correction of the problem may be as simple as suture repair of the area. As the involved area becomes larger and the tissues involved more specialized, the techniques to replace those tissues become for complex as well. A flap is a surgical technique where tissue is moved from one area to another while maintaining that tissues blood supply. There are several categories of flaps.

Local flaps are used to move tissue from a nearby area to the area that requires reconstruction. They have the advantage of using similar tissue to replace the missing tissue but have the disadvantage of frequently being able to move only small amounts of tissue and may not be appropriate for larger deformities.

Regional flaps are used when larger areas need to be reconstructed. These flaps move tissue (frequently skin and muscle) from a further distance away, into the area involved. They maintain their blood supply by rotating vessels from one are to another. An example of such a flap is the pectoralis major flap where skin and muscle are rotated from the chest wall into areas on the neck or in the mouth.

Free flaps can be taken from distant areas of the body. They have the advantage of being suitable for a large variety of defects. They can be designed to match as close as possible the type of tissue that needs to be reconstructed. An artery and vein that supplies the flap at the distant site are brought with the flap to the head and neck, and are connected to suitable vessels in the neck. This way, the tissue maintains its blood supply and ability to heal. Examples include the forearm which relies on vessels from the arm to keep skin alive which is particularly well suited to reconstruct areas such as the tongue. A flap from the abdomen containing the rectus muscle and skin is suitable for larger areas.

Reconstruction of the bony structure of the face

In instances where bone needs to be replaced, there are two basic procedures available to replace it; bone grafting or the use of a bone containing flap. The bone grafting technique uses particles of bone and bone marrow taken from one area (frequently the hip) and placed into the area where bone is missing. This is a reliable technique that has the advantage of being able to mold the graft into the shape and size of the missing bone. Its disadvantage is that it does not have a blood supply initially, and relies on in-growth of vessels from the surrounding tissues. This makes it vulnerable to infection in the early stages of healing. It is generally only placed in a sterile field. In the case of surgery to remove a tumor that involves the mouth, the field is not sterile, and because of this, bone grafts are frequently done at a second surgery, when they can be placed in a sterile field.

Bone containing flaps have the advantage of maintaining a blood supply. This makes them more resistant to infection. They can be considered to reconstruct certain areas of the jaw at the same time a tumor is removed, thereby preventing the need for a second surgery in some cases. Common sites used for these flaps are the fibula in the lower leg, and the anterior iliac crest. Both of these areas have suitable vessels to support these flaps as free flaps.

Replacement of teeth

The final step in returning a patient to full function often involves replacing teeth that were lost as a consequence of tumor surgery, trauma, or teeth that never properly formed. Both bone grafts and bone flaps provide an excellent base to support replacement teeth.

Implant replacement of missing teeth is frequently used to restore a patients ability to chew food normally. Titanium implants similar in shape to the roots of the missing teeth are placed into the bone and allowed to “integrate”. The integration process occurs as the bone heals directly to the surface of the implant, effectively locking it into the bone. This process generally takes about six months. At that point, a dental prosthesis can be made that is supported by the implants and restores the missing teeth.