Reconstructive Methods

Tissue removal as part of cancer treatment, known as ablative surgery, necessitates reconstruction of the tissue that was removed. Reconstructive surgery may be performed either by the same surgeon who performed the ablative surgery or by a surgeon who specializes in head and neck reconstruction.

When considering the best reconstructive option, issues of safety (protecting vital structures), overcoming impaired wound healing related to prior radiation and/or chemotherapy, restoring or improving appearance, and function (optimizing breathing, chewing, speaking, and swallowing) are taken into account. The simplest reconstruction that achieves all of these goals is usually the best option. To that end, if a patient is undergoing ablative surgery for treatment of a head and neck cancer, it is important to understand some basic reconstructive methods.

Primary Closure

Primary closure occurs when a wound is closed by bringing the edges together with stitches, staples, tape, or skin glue. The end result is a thin scar located where the surgical incision was made.

Aftercare of a wound that is sealed by primary closure is quite simple. A surgeon might ask their patient to avoid getting it wet for one to three days to prevent infection. It is also recommended that it be kept out of the sun or covered with sunscreen when they go outside to prevent discoloration of the scar. This site should be monitored for up to six months following surgery in order to optimize the end result. In addition, over-the-counter scar creams can be used to help improve the appearance.

Cases for Primary Closure

• Incisions made to remove tumors deep in the neck or face that don’t require removal of the overlying skin.
• Excision of small areas of skin along with removal of deeper tissue in the face or neck.
• Removal of some small cancers of the oral cavity, such as on the tongue, inner aspect of the cheek, or floor of mouth.

Local Flaps

A local flap involves rotating or moving skin from an area nearby to a surgical defect to close the surgical wound. A local flap is not based on a defined artery and vein. Local flaps are typically used after skin cancer removal or removal of small surface-level tumors on the face or neck.

Advantages

The advantages of a local flap are that they are technically easier (but still require expertise and careful planning to get the best outcome), require shorter operative times, and generally match the skin color and thickness better than skin grafts, regional flaps, and free flaps.

Disadvantages

A disadvantage of using a local flap is that the size of the flap is limited to relatively small defects.

Regional Flaps

A regional flap uses tissue from a part of the body near the head and neck region while keeping it attached to its regional blood supply. The flap of skin and/or muscle is rotated into the surgical defect, with the blood supply still connected to the donor site via a vascular pedicle. Compared to free flap surgery, regional flap surgery is quicker and requires less post-operative care and monitoring. However, because a regional flap must remain attached to its blood supply, there is less flexibility in flap size, thickness, and ability to reach certain locations.

Pectoralis Major Muscle Flap

A regional flap commonly used in head and neck surgery is the pectoralis major muscle or musculocutaneous flap. The pectoralis major muscles are located on the front of the upper chest and extend from the humerus and clavicle (collarbone) to the mid-ribs. Depending on the type of reconstruction required, the pectoralis flap may or may not involve taking a small amount of skin from the chest in addition to the muscle.

Latissimus Dorsi Flap

Another regional flap regularly used for head and neck reconstructive surgery is taken from the latissimus dorsi, a large flat muscle that extends from the middle to lower back. It is located on the side of the chest on the flank region of both sides of the body. The latissimus dorsi muscle has the greatest surface area of any muscle in the body and can be used to cover larger surgical defects. It can be harvested as muscle alone or with a segment of the overlying skin of this region.

The following figure demonstrates a variety of commonly used regional flaps that each offer a unique set of advantages and are accompanied by certain disadvantages.

Free Flaps

Free flap surgery, also referred to as free tissue transfer or microvascular reconstruction, involves removing a segment of tissue and its blood supply from one part of the body and transplanting it to another part of the body. The types of tissue that can be transferred include skin, muscle, fascia, bone, bowel, and combinations of tissue that may be required for the specific defect that is being restored. The artery and vein of the flap are sewn to an artery and vein near the wound to provide the flap with a new blood supply. This procedure is performed under a microscope using very fine sutures.

Advantages of Free Flap Reconstruction

• The flap is new, healthy tissue that is distant from any previous surgery or radiation.
• Bone, muscle, skin, fascia, fat and nerves can all be transferred to the donor site to match the tissue that was removed as precisely as possible.
• The flap can cover wounds of various sizes and thicknesses.
• Unlike a skin graft, the skin of a free flap does not contract.

Free flaps do, however, require special technical expertise, extra surgical time, and close monitoring to identify and correct any blood supply problems that may occur during the postoperative period. If a clot forms in the artery or vein that serves the flap, the flap can fail. If this happens, the patient will require either an additional free flap or another type of reconstruction that may not be as desirable.

Tissue for a free flap can be taken from almost anywhere in the body, as long as it is well vascularized. Some of the more common types of free flaps and examples of their use in head and neck reconstruction are summarized in the following table:

Type	Description	Uses
Rectus Abdominis	Harvested from the front of the abdominal wall. Provides either thick skin with healthy muscle or healthy muscle alone.	Total tongue Skull base Scalp
Radial Forearm	Harvested from the solar surface of the forearm along with one of the 2 arteries that supplies the hand. Provides thin, pliable skin and fascia that can line large defects or be turned into a tube.	Oral cavity Partial tongue Skull base Partial or total pharynx (throat) Hard and soft palate Lip
Radial Forearm with Bone	Harvested from part of the circumference of the radius, and has limited strength. Provides thin, pliable skin combined with a thin piece of bone, known as the radius.	Maxilla (upper jaw) Orbital floor (base of eye)
Anterolateral Thigh	Harvested from the front of the thigh. Provides thicker skin, fascia, and sometimes muscle for slightly larger defects.	Total or subtotal tongue Partial or total pharynx (throat) Skull base Midface
Fibula	Harvested from the central portion of the bone on the side of the calf, while preserving the portion of that bone that makes up the ankle and the knee joints. Harvest is only possible when it is determined that the circulation to the foot is well preserved by the other 2 arteries that run through the calf. Provides reliable long bone, with or without skin.	Mandible (lower jaw) Maxilla (upper jaw) Most bone defects of the head and neck
Scapular System	Harvested from the shoulder blade on the upper back. Provides multiple mobile components including bone, skin, and muscle.	Large defects that require a large amount and variety of tissue types. Bone defects where a fibula cannot be safely used because of vascular disease in the legs.