An Overview of this Challenging Component of Care for Patients with Neoplastic Disease Processes or Traumatic Injuries
Reconstructions of the head and neck region are a challenging, rewarding and necessary component of the care patients that present with neoplastic disease processes or traumatic injuries receive. There is evidence of different forms of head and neck reconstruction being performed as early as ancient Egyptian periods, and these surgical procedures continue to be an evolving and growing area.1 While it would be impossible to cover the entirety of this topic in one article, here’s a brief overview to initiate discussion and further reading.
Patient Characteristics
Any discussion of reconstructive options should begin with a review of the patient being treated. Patient’s health, planned adjuvant therapy and previous surgery and therapies must be a factor in the reconstruction planning. Unfortunately, many patients with head and neck defects associated with extirpative surgery will either need multiple procedures and or have had or are planned for adjuvant therapy.
Age alone should not be considered a contraindication to reconstructive procedure. Significant comorbidities, which correlate to worse preoperative evaluation scale scores, are a concern for reconstructive surgeons. These factors can determine if the patient is a candidate for reconstruction, what setting the reconstruction can be done, procedural room versus operative room, what other testing is needed, should the procedures be done as an outpatient procedure or involve an observational period and what type of reconstruction can be done.2,3,4
Wound Characteristics
The anatomy of the head and neck is intricate. In fact, it would be more appropriate to list the area as the aerodigestive, vision, vocal and non-vocal communication, social interaction, head and neck area. Reconstruction in this area affects many processes necessary for life and for social interaction. Understanding and systematically describing the wounds of the head and neck is of extreme importance.
Analysis of the wound should include evaluation of the extent and tissue involved, whether it is mucosal, skin, full or partial in thickness, muscular or bone. Precise evaluation of the location is also important.
There are multiple classification systems that assist with this, for example the aesthetic sub-units of the face.5 Precise evaluation of the wound location is necessary because of the effect that reconstruction can have on surrounding tissue. For example, consider periorbrital wound reconstruction and eyelid functional changes.
Reconstructive Goal
After understanding the particulars of the wound, the next important step is to understand the primary objective of the reconstruction, whether it be to reestablish continuity or integrity of the aerodigestive system, to maximize function or if the aesthetic results are the primary concern. It is rare that all three, continuity or integrity, function and the aesthetic results, can be maximized with one option or with one procedure.
Reconstruction Options
Following the evaluation of the patients’ health issues, as well as the wound characteristic and needs, the next area of focus is on what reconstruction options are available. There are a variety of ways to approach this vast area. One helpful way to categorize these options is to use what the reconstruction option is composed of, where it comes from and how and when it is transitioned or moved into the defect or wound.
Composition
Composition is more straightforward and includes skin full or partial thickness, mucosal, fascial, muscle, bone, cartilage, intestinal, or combination of the different tissue types.
Timing
Immediate reconstructions are performed at the time the wound is created. Delayed reconstruction involves some temporizing procedure or dressing first, followed by definitive procedure later. This is sometimes done to allow for confirmation of marginal control of cancer, to improve chance of viable tissue transfer or to allow the patient to recover to a point that would allow for a larger procedure.
Transfer
Method of transfer could include grafting, local tissue rearrangement, regional pedicled rotation or free tissue transfer.
Grafts
Grafting describes the procedure in which the transferred tissue is transferred without its own blood supply and is dependent on the recipient wound to form a vascular supply. Grafts can include an autograft from the patient, an allograft from other persons or a xenograft from other animals.
Flaps
A flap describes procedures where the transferred tissue is transferred with its own blood supply.
Local flaps or local tissue rearrangement is a very important technique, particularly for facial wound reconstruction. There are a variety of options that are classified based on whether their blood supply is axial or random, their configuration and their movement in relation to the wound. An example of these techniques would be the paramedical forehead flap for nasal reconstruction.6
Regional flaps can have different tissue types, are axial in their blood supply and do not share an immediate proximity to the wound. An example of this would be the use of the pectoralis myocutaneous flap for facial, oral or pharyngeal reconstruction. The key principle for regional flaps is that they are transferred to the wound based on their native artery and vein. Although supercharging or preforming additional vascular anastomosis is preferred, this is supplemental to the intact native vascular system.
Free tissue transfer offers the most diverse tissue compensation and most donor sites. They are axial in their blood supply. An example of this is the fibular osteomyocutaneous flap for facial, oral, mandibular reconstruction. The key principles for free tissue transfer is the need for microsurgical training and technique to anastomose the transferred tissue artery and vein to recipient vessel at the wound defect.7
Synthetic Material
Synthetic or alloplastic materials such as titanium are occasionally used in head and neck reconstruction for structural support.
Tissue Engineering
It is hopeful that advances in tissue engineering will allow for reconstruction options without corresponding morbidity of harvesting tissue from patients.
Choosing an Option
After understanding the patient, wound characteristics and the options, the next step is making a plan. Early teachings approach this using a stepwise process from least complex in surgical technique to most complex. This is summarized in the reconstructive ladder.
It should be noted that the use of primary closure and secondary intention can be used on very select wounds, however in some situations a less complex reconstruction can fall short of achieving the form and aesthetic results of more complex reconstruction options.
Reconstructive Ladder
The reconstructive ladder options begin with healing by secondary intention followed by primary closure, skin grafting (split or full thickness), composite grafts, local flaps and regional pedicled flaps and ends with free tissue transfer.
Reconstructive Triangle
A more integrated approach is to consider possible procedural options as being contained in a reconstructive triangle or circle, where it is possible to consider and use all available options regardless of complexity in the goal of safely maximizing results.
Surgical and traumatic wounds of the head and neck region can present multiple obstacles to the reconstructive surgeon. These wounds have a wide range of effects on a patient in the areas of altered appearance and function. The results of these wounds also have a psychological and social affect on the patient, often decreasing a patient’s quality of life.
Our goal as reconstructive surgeons is to use all available techniques and work with the oncological and rehabilitation teams to restore as much form and function as possible for patients affected by these defects.
References
1. Yadav P. (2014). Recent advances in head and neck cancer reconstruction. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 47(2), 185–190. doi:10.4103/0970-0358.138939
2. Reiter, M., Baumeister, P., & Jacobi, C. (2017). Head and neck reconstruction in the elderly patient: a safe procedure? European Archives of Oto-Rhino-Laryngology, 274(8), 3169-3174.
3. Bridger, A. G., O’Brien, C. J., & Lee, K. K. (1994). Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. The American journal of surgery, 168(5), 425-428.
4.. Malata, C. M., Cooter, R. D., Batchelor, A. G., Simpson, K. H., Browning, F. S., & Kay, S. P. (1996). Microvascular free-tissue transfers in elderly patients: the Leeds experience. Plastic and reconstructive surgery, 98(7), 1234-1241.
5. Menick, F. J. (1987). Artistry in aesthetic surgery. Aesthetic perception and the subunit principle. Clinics in plastic surgery, 14(4), 723-735.
6. Prohaska, J., & Cook, C. (2018). Flaps, Rotation. In StatPearls [Internet]. StatPearls Publishing.
7. Hurvitz, K. A., Kobayashi, M., & Evans, G. R. (2006). Current options in head and neck reconstruction. Plastic and Reconstructive Surgery, 118(5), 122e-133e
