Role of Reconstructive Surgery in Management of Cancer: Current State and Practice in Sub-Saharan Africa

Fig. 12.1

Algorithm for treatment of scalp and skull fracture

In head and neck cancer, a tumour excision that leaves a deformity after reconstruction produces a low quality of life. An appropriate nasal reconstruction therefore has to be performed after nasal extirpation in extensive squamous or basal cell carcinoma. Similarly, auricular reconstruction should be performed where the ear has had to be removed after excision of squamous cell carcinoma. A patient who developed an asymmetrical smile along with facial asymmetry from facial nerve palsy secondary to parotid or mastoid surgery will benefit from a cross facial nerve graft and a free tissue neurovascular muscle transfer for facial re-animation. We have reconstructed several pharyngeal and oesophageal defects with pectoralis major musculo-cutaneous flap and supraclavicular flaps after tumour excision.

Defects that approach half of the eyelid in size may be closed with a cheek rotation flap (Mustarde 1983). McGregor’s (1973) modification of this flap involves use of a Z- plasty to assist in closing the donor site in the region of the temple. When a full lower lid loss is to be reconstructed, the cheek flap may be extended down to the front of the ear. Because these flaps consist only of the skin layer, over the newly reconstructed eyelid, they have to be under laid by chondromucosal graft taken preferably from the nasal septum (Oluwatosin 2015).

Patients who have had an orbital exenteration sometimes pose a problem as far as skin cover is concerned. The reconstructive method should be tailored to the defect and the patient’s needs. When a prosthetic is planned, the goal should be to create an open cavity with a skin graft, regional flap, or thin free flap (Hanasono et al. 2009).

The reverse flow submental artery flap may be used in this regard (Karacal et al. 2005) and also for reconstruction of the lower and middle thirds of the face as well as oral cavity. Skin take over bone is usually poor for the reason that ordinary cortex does not supply the vascularity required for skin graft take. If the area is carefully decorticated, graft take may be enhanced. Bulky flaps are indicated when a closed cavity is preferred, such as when no prosthetic is planned or when the defect is extensive. To fill up the orbit, a temporalis (Oluwatosin et al. 2000), or distant latissimus dorsi flap may be used. These muscle flaps will readily accommodate skin grafts on top of them.

12.2.1 Nasal Reconstruction

The nose is about the most prominent part of the face and attention should be provided to its detailed reconstruction for the patient’s emotional well-being. For losses in the nasion, and upper part of bridge of the nose, a glabella transposition “finger”, or sliding flap, and for losses involving tip and supratip areas, bilobed flaps may be transferred.

The bilobed flap is particularly suited for the region of the nose. Here, when a transposition flap is transferred to cover a defect, a smaller flap may be raised at 90^° to it to cover the donor site. When there is a combined tip and ala loss surface, the seagull flap (Millard) may be utilised. For the lateral side of the ala, a nasolabial flap, either as a transposition or as a VY advancement flap will be useful.

In planning alar reconstruction, when one of the two epithelial surfaces is intact, support and cover can often be delivered reliably but if substantial amount of all three layer are lacking, the reconstruction becomes more complex. The nasolabial turnover flap/composite graft combines the advantage of producing the three layers of the nostril with transfer in a single stage. A superiorly based nasolabial flap, lined internally by auricular chondrocutaneous, nasal septal chondromucosal, or hard palatal mucosal graft is a possibility. Another alternative is the use of a superiorly based nasolabial flap whose distal tip may be folded in for lining. Most authors recommend a delay procedure for this method thus adding the disadvantage of a second stage.

Hunt’s concept of using posterior auricular skin as a flap based on the anastomosis of superficial temporal artery and postauricular artery was refined by Washio and others. It provides thin auricular skin and thicker mastoid skin combined with ear cartilage. It however carries the disadvantage of requiring a second stage of division of flaps.

12.2.1.1 Nasal Defect Classification

A system for scoring and classification of nasal defects has been proposed by Bayramicli (2006). Here, it is assumed that the soft tissue coverage of the nose is in continuity with the cheeks, glabella and upper lip while the osteocartilaginous infrastructure is in continuity with the two nasofrontal buttresses, the frontal bar and the palate. Division of soft tissues and skeletal framework into sub-units and grading these on a logo, based on their gravity in reconstructive strategies, any nasal defect is described by shading the involved sub-units on the logo. The sum of the points appended each sub-unit gives the total score of defect.

The severity of the tissue loss is assessed according to a “classification system” which is derived from this scoring system. Thus nasal defects are classified into one of four main types corresponding to their scores viz: