Reconstruction after surgical treatment of head and neck cancers can be challenging. Goals for reconstruction include restoration of appearance as well as function when appropriate. Commonly encountered sites requiring reconstruction include the soft tissues of the face (including the critical areas of the eyes, ears, nose, and lips), scalp, tongue and oral cavity, maxilla, mandible, and pharynx. Advanced reconstructive techniques using microsurgery may be preferable to simpler techniques to obtain optimal outcomes. In this article, techniques for reconstruction in these areas as well as anticipated outcomes are discussed.
Key points
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Goals for head and neck reconstruction include optimal functional and aesthetic outcomes.
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Free flaps are often the first choice of reconstructive options in head and neck reconstruction.
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Appropriate flap selection optimizes functional outcomes.
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When possible, replace tissue with similar tissue.
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Early referral to physical therapy, occupational therapy, and speech and swallow therapy helps to optimize outcomes.
Patient evaluation overview
Evaluation of the patient needing reconstructive surgery is multifaceted but can be simplified based on the anatomic site of the cancer and the anticipated defect, evaluation of the potential donor sites for reconstruction, and whether adjuvant therapies are required. Attention to these domains during patient evaluation helps produce the best reconstructive result for each patient. Replacing like with like is an important principle in reconstructive surgery.
Patient evaluation overview
Evaluation of the patient needing reconstructive surgery is multifaceted but can be simplified based on the anatomic site of the cancer and the anticipated defect, evaluation of the potential donor sites for reconstruction, and whether adjuvant therapies are required. Attention to these domains during patient evaluation helps produce the best reconstructive result for each patient. Replacing like with like is an important principle in reconstructive surgery.
Soft tissue reconstruction
Soft tissue reconstruction of the head and neck stems largely from the extirpation of cutaneous malignancies, including basal cell carcinoma, squamous cell carcinoma, and melanoma. Based on the size of the residual defect after wide local excision of the malignancies with clear margins, reconstruction can pose a formidable challenge ( Table 1 ). This observation is especially true in sites where full-thickness defects involve components such as cartilage or mucosa in addition to the overlying skin. With the advent of Mohs micrographic surgery, the size of these defects can be decreased to facilitate closure and reconstruction. Healing by second intention, primary closure for small defects, or skin grafts for larger defects are the simplest options. They may produce inferior cosmetic outcomes. Here, the principal techniques for soft tissue reconstruction are presented by anatomic site.
| Type of Cancer | Recommended Margins of Resection |
|---|---|
| Basal cell carcinoma | 1–2 mm |
| Squamous cell carcinoma | 2–4 mm |
| Melanoma | |
| Melanoma in situ | 5 mm |
| <1 mm | 5 mm |
| 1–2 mm | 1 cm |
| >2 mm | 2 cm |
Eye
Reconstruction of the periorbital region can usually be achieved with skin grafts for partial-thickness defects or local tissue rearrangement for full-thickness defects. Large, full-thickness defects of the eyelids require lid switch procedures such as Fricke or Tripier flaps. If an orbital exenteration is necessary, reconstruction with cervicofacial flaps or free tissue transfer (such as a radial forearm flap) may be needed. If a prosthesis is planned, reconstruction with less bulky soft tissue is preferable. A bulkier flap is necessary to fill the cavity if prostheses are not used.
Ear
Because the ear is composed of cartilage as well as overlying soft tissue, reconstruction largely depends on whether a full-thickness or partial-thickness defect is created. If the perichondrium has been preserved, skin grafting or primary closure is the best option. However, if the defect encompasses the perichondrium or cartilage, conversion to a full-thickness wedge resection and primary closure or Antia-Buch helical advancement may be preferable. Another option is to use a cartilage graft from the contralateral ear or rib, which requires flap coverage with retroauricular skin or temporoparietal fascia. This approach requires a second stage to divide and inset the flap as well as additional skin grafting.
Mouth
The lips are composed of mucosa as well as the wet and dry vermilion overlying the orbicularis oris muscles. The upper lip has several distinct anatomic subunits, including the philtral columns, the Cupid bow, the white roll, and the tubercle. Lip reconstruction depends strongly on the amount of vermilion remaining. Partial-thickness defects may be reconstructed with vermilion switch procedures or vermilion and mucosal advancement flaps. Reconstruction of full-thickness defects also depends on the amount of residual lip tissue ( Table 2 ).
| Size of Defect | Reconstruction |
|---|---|
| <30% | Primary closure |
| Central lip defect 30%–50% | Abbé flap |
| 30%–50% | Schuchardt procedure |
| Subtotal lip defect 50%–80% | Karapandzic flap |
| Subtotal lip defect involving commissure | Estlander flap |
| Total lip defect | Radial forearm free flap |
Nose
The nose can be divided into 9 distinct cosmetic zones, including the nasal tip, dorsum, columella, and the paired nasal sidewalls, ala, and soft triangles. Primary closure is difficult because of absence of soft tissue laxity and skin grafts are prone to contour irregularities and pin-cushioning. Full-thickness defects can be particularly challenging because of the need to reconstruct the nasal mucosa. The primary options for nasal reconstruction include the bilobed flap, nasolabial flap, and paramedian forehead flap ( Table 3 ).
| Type of Flap | Size (cm) | Location |
|---|---|---|
| Bilobed flap | <1 | Ala, sidewall |
| Nasolabial flap | <1.5 | Ala |
| Paramedian forehead flap | >2 | All |
Cheek
The cheek is the largest surface of the face and can be divided in 3 anatomic zones: suborbital, preauricular, and buccomandibular. Primary closure of most cheek defects is recommended if possible. Local advancement, transposition, and rotation flaps are helpful for closure of smaller defects. For defects too large for local maneuvers, cervicofacial and cervicopectoral flaps are recommended.
Scalp
The scalp is composed of 5 distinct layers, including skin, subcutaneous fat, galea aponeurotica, loose areolar tissue, and pericranium. The blood supply is excellent. Although skin grafting can be performed whenever the pericranium is preserved, reconstruction of the scalp is determined largely by the size of the defect ( Table 4 ). If calvarial reconstruction is needed in addition to soft tissue coverage, concurrent cranioplasty with an implant can be performed without increased risk of complications ( Fig. 1 ).
| Size of Defect (cm) | Reconstruction |
|---|---|
| <3 | Primary closure with or without galeal scoring |
| 3–6 | Scalp rotation flap |
| 6–9 | Scalp rotation flap with skin grafting |
| >9 | Free tissue transfer |
Major Soft Tissue Defects of the Neck
In some instances, soft tissue reconstruction of the neck may be necessary when treating patients with head and neck cancers. These defects may be caused by primary extirpation of malignancies (large skin malignancies, combined laryngopharyngeal and skin defects) or secondary to complications attributable to previous surgery (pharyngocutaneous or orocutaneous fistulas, exposure of mandibular hardware, skin flap necrosis). The pectoralis or deltopectoral flaps may be useful in these scenarios. Once considered workhorse flaps for head and neck reconstruction for a multitude of defects (pharyngeal, mandibular, oral cavity), these 2 regional flaps are now more commonly used for soft tissue reconstruction of the oral cavity and neck in patients not deemed good candidates for free tissue transfer and for management of complications arising from previous resection and reconstruction. The pectoralis flap can transpose muscle alone or as a myocutaneous paddle. Based on the thoracoacromial blood supply, it provides ample muscle with a robust vascular supply to resurface neck defects, aid in healing orocutaneous or pharyngocutaneous fistulas (PCFs), or coverage of exposed mandible or mandibular hardware. The arc of rotation limits its scope and may place tension on the superior aspect of the suture line. In addition, fibrosis and contracture may result from rotation of the flap from the chest wall to the neck, limiting range of motion. Bulk may limit its usefulness for applications related to tracheostomal revisions. To avoid problems with neck and shoulder function, attention to rehabilitation is imperative after pectoralis flap reconstruction. The deltopectoral flap is an axial pattern skin flap based on perforators arising from the internal mammary vessels. It may be used in 1 stage, but transposed tissue survival is improved by delaying it before transfer. Skin grafting to the donor site may leave a prominent scar at the donor site. The pectoralis and deltopectoral flaps, although less important in the era of microsurgery, should remain in the armamentarium of the reconstructive head and neck surgeon.
Maxilla reconstruction
Although resection of palatomaxillary malignancies is uncommon, the resulting defect can cause substantial functional and cosmetic problems, because of the need to replace the mucosa, bony framework, and sometimes, the overlying soft tissue. Reconstruction of the three-dimensional framework of the midface must restore form as well as function. Reconstruction should enable the patient to speak and eat and should provide support for the orbital contents, maintaining separation of the oral and nasal cavities. In most centers, the most common approach is the placement of an obturator. However, they impose limitations in terms of maintenance, fitting, and comfort. Even when prosthetic rehabilitation is a reasonable option, free flap reconstruction of maxillary defects provides the patient with an excellent alternative.
To assess the extent of the maxillectomy defect and therefore select the appropriate reconstructive option, various classification systems have been proposed. The most common was proposed by Cordeiro and Santamaria in 2000 to address the anatomy of palatal and maxillary defects ( Table 5 ). A more elaborate classification system was proposed by Brown and colleagues, which defines the extent of the maxillary defect based on horizontal and vertical components.
| Type | Extent of Defect |
|---|---|
| I | Limited maxillectomy without palatal involvement |
| II | Subtotal maxillectomy with preservation of orbital floor |
| IIIA | Total maxillectomy with preservation of the orbit |
| IIIB | Total maxillectomy with orbital exenteration |
| IV | Orbitomaxillectomy with preservation of the palate |
The largest reported series of maxillectomy reconstructions included 246 patients over a 10-year period; the investigators proposed an algorithm based on the defect classification noted earlier. For partial maxillectomy defects that preserve both canine teeth, a prosthetic obturator is a reasonable option. However, if a large portion of the palate is resected, an obturator may not prove possible to retain. For suprastructure, premaxillary, and unilateral posterior defects, the investigators recommend a soft tissue flap to deliver adequate bulk and volume within the cheek as well as obliterate the maxillary sinus. Osteocutaneous flaps were reserved for unilateral and bilateral palatomaxillectomy defects to restore structure to the midface and provide the option for dental rehabilitation. Orbital floor reconstruction is certainly recommended and can be performed with a variety of materials, including titanium mesh, bone graft, or alloplastic materials. In the setting of orbital exenteration with palatomaxillectomy defects, large soft tissue flaps with multiple skin paddles are necessary to fill the orbital cavity, decrease the incidence of fistula, and to maintain the contour of the midface.
Tongue reconstruction
Reconstruction of the tongue after tumor resection is challenging, because of the highly specialized and important functions of the tongue. The tongue plays a major role in speech as well as the oral and pharyngeal phases of swallowing. The aim of reconstruction is to minimize the impact of resection on these crucial functions.
Classically, small defects of the tongue have been treated with primary closure, healing by second intention, or skin grafting. Although these approaches work well for defects isolated to the lateral tongue, larger glossectomies involving the oral tongue, anterior tongue, the base of tongue, or a combination of these (with or without involvement of the floor of mouth) often require more sophisticated microsurgical reconstructions.
The radial forearm free flap (RFFF) and the anterolateral thigh (ALT) free flap are the 2 most commonly used free flaps for tongue reconstruction, although others have been described. Use of vascularized flaps minimizes tethering of the tongue (thereby preserving mobility), provides bulk when needed, and allows for initiation of adjuvant radiation in a timely manner.
Selection of the appropriate flap requires nuanced judgment and should be made on an individual basis. For instance, hemiglossectomy defects isolated to the oral tongue are best suited for reconstruction with a thin, pliable flap such as an RFFF ( Fig. 2 ). In contrast, large defects involving the oral tongue and base of tongue or total glossectomy are best suited for reconstruction with more bulky tissue such as an ALT flap. There is no accepted classification in terms defining the nature of tongue defects, which significantly limits the ability to evaluate outcomes related to the type of flap used. Flap selection is important: the use of an overly bulky ALT flap for an oral tongue defect, or a thin RFFF flap for a large combined defect of the oral and base of tongue, would adversely affect the functional outcome.
Lam and Samman provide a systematic review of speech and swallowing function after glossectomy with free flap reconstruction. For defects involving the oral tongue or base of tongue (alone) reconstructed with free flaps, sentence intelligibility returned to normal or near normal in most patients within 6 months to a year. However, those patients with involvement of both oral and base of tongue (total or subtotal glossectomy) had significant impairment in speech rehabilitation. In this group, more than 60% had speech that was only occasionally understood, unintelligible, or could be understood only when the context was known to the listener. Factors influencing speech outcomes included tumor size, preservation of the tongue tip, and adjuvant radiation therapy. In addition, lateral defects with flap reconstruction had better outcomes in speech than anterior defects.
In the same review by Lam and Samman, swallowing function after glossectomy with flap reconstruction was evaluated. For oral tongue defects, although spillage and an increased number of attempts to clear liquid bolus may be seen in the short postoperative follow-up, these functions seem to return to normal or near normal at 1 year in most patients. For defects involving the base of tongue, bulk seems to be more important for swallowing to allow for contact with the pharyngeal wall (to enhance the pharyngeal phase of swallowing). For these defects, a more bulky flap such as an ALT flap should be considered. Problems include aspiration as well as pharyngeal residue for liquids and pudding consistencies. Most are able to resume pureed and solid food within a year. In the short-term, patients undergoing subtotal or total glossectomy as well as those with a combined oral and base of tongue resection have worse functional recovery despite free flap reconstruction than those undergoing resection of either oral tongue or base of tongue with a higher incidence of aspiration. However, these patients are also often able to return to a solid or soft diet within 2 years.
Postoperative radiation therapy has been shown to decrease functional recovery after free tissue transfer. This decrease is likely related to the fibrosis and decreased mobility of the reconstructed tongue. Aggressive speech and swallow therapy should be implemented to maximize function.
Attempts at sensory and motor reinnervation of flaps to restore sensation and motor function have been reported. Although various types of sensory recovery can be obtained (eg, 2-point discrimination, temperature), no functional improvement in terms of speech or swallowing has been demonstrated.
Mandible reconstruction
Defects involving the mandible may involve only an edge (marginal) or a complete segment (segmental). Small marginal mandibulectomy defects may be covered with local flaps or skin grafts if postoperative radiation therapy is not anticipated. However, for most larger marginal mandibulectomy defects, the RFFF is ideal given the thin, pliable nature of the tissue. If dental rehabilitation is planned, an osteocutaneous radial forearm flap or a free fibula osteocutaneous flap can be used to augment mandibular height.
Segmental defects of the mandible after ablative surgery are best reconstructed with microsurgical free flaps. Bone grafts in this setting (in which postoperative radiation is likely) lead to high rates of complications, including bone resorption, osteoradionecrosis, orocutaneous fistula, and infection. Reconstruction with a spanning titanium plate alone (without bony reconstruction) has also been described, but complication rates. including plate fracture, orocutaneous fistula, and need for plate removal. are high. Pedicled osteomyocutaneous flaps such as sternocleidomastoid with clavicle and pectoralis with rib have also been described, but the perfusion and quality of the bone stock in these flaps is low and does not allow for osteotomies for shaping. Free tissue transfer has supplanted these approaches.
Free osteocutaneous flaps provide optimal current outcomes for reconstruction of segmental defects of the mandible. The fibula, scapula, iliac crest, and radial forearm are the most commonly used; the free fibula flap is the workhorse for mandible reconstruction. These osteocutaneous flaps have characteristics that make them more or less suited to mandibular reconstruction, depending on the specific clinical situation ( Table 6 ). First described and popularized by Hidalgo in the 1980s, the free fibula flap can provide more than 20 cm of bicortical bone with excellent blood supply and good pedicle length to allow for reconstruction of most mandibular defects ( Fig. 3 ). Simultaneous elevation of the flap and extirpation of the cancer using a 2-team approach allow for shorter operative time (when compared with sequential tumor resection followed by flap harvesting and reconstruction). The investigators recommend preoperative computed tomography angiography for evaluation of vascular runoff to the foot as well as assessment of the quality of the pedicle (peroneal artery).
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