You are in: eMedicine Specialties > Plastic Surgery > HEAD AND NECK Head and Neck Cancer: ReconstructionArticle Last Updated: Jun 7, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Perry J Johnson, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Nebraska Medical Center Perry J Johnson is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Nebraska Medical Association Coauthor(s): Jason B Sigmon, MD, ENT Physicians of Oklahoma Editors: Lawrence Ketch, MD, FAAP, FACS, Head, Program Director, Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Colorado Health Sciences Center; Chief, Pediatric Plastic, The Children's Hospital of Denver; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Author and Editor Disclosure Synonyms and related keywords: head cancer, neck cancer, head reconstruction, neck reconstruction, head and neck cancer reconstruction, squamous cell, minor salivary gland tumor, squamous cell tumor, Mohs technique, abbe cross-lip flap, Estlander flap, Karapandizic flap, Bernard-Burow flap, squamous cell carcinoma, fibula flap, iliac crest flap, scapular flap INTRODUCTIONSection 2 of 9
  History Current treatment in head and neck cancer is based primarily on combined therapy, which includes radiation therapy, surgery, and chemotherapy. Orthovoltage radiation therapy was the mainstay of head and neck cancer treatment until the 1940s. Advances in the field of anesthesia and new, safer techniques in surgery led to the current combination of therapy offered to patients with cancer of the head and neck. The defects created with these advanced techniques at the time of surgery for head and neck cancer have led to advances in reconstruction. A brief history of these developments is provided below.
Frequency According to American Cancer Society statistics for the year 2000, new cases of cancer of the head and neck are estimated at 30,200 for cancer of the oral cavity and pharynx and at 10,100 for cancer of the larynx. Deaths from cancer of the oral cavity and pharynx are estimated at 7800; deaths from cancer of the larynx are estimated at 3900. GENERAL CONCEPTS OF RECONSTRUCTIONSection 3 of 9
Successful reconstruction requires careful preoperative patient assessment and development of an individualized treatment plan. Important considerations include tumor stage and prognosis, patient age, sex, body habitus and functional status, available reconstructive donor sites, and the psychosocial make-up of the patient. No reconstructive procedure should preempt adequate tumor resection. The first priority of head and neck cancer reconstruction is safety. The following reconstructive ladder is useful as a guide in planning reconstructive efforts:
As a general rule, when planning an individual patient's reconstruction, attempt the least complex and safest option from the reconstructive ladder first while maintaining form and function. The following sections describe reconstructive options in the head and neck based upon the anatomic site involved. RECONSTRUCTION OF LIP DEFECTSSection 4 of 9
HistoryCancers of the lip are associated with sun exposure and occur most frequently on the lower lip. Lip tumors occur most frequently on the exposed vermilion border along the midline of the lip. Less than 1% originate at the oral commissure. Most neoplasms of the lip are squamous cell type with minor salivary gland tumors occurring less frequently. Squamous cell tumors of the lip typically present as superficial exophytic lesions that are prone to ulceration with growth larger than 1 cm. Recurrent bleeding and crusting lesions of the lower lip that persist after conservative local care are hallmarks of tumor presentation. AnatomyThe average lip is 5-6 cm in length. The orbicularis muscle is circular and provides integrity to the upper and lower lips. During speech it is responsible for fine movements of the lips' margins. In addition, it provides an attachment point for the muscles of animation in the mid face. The orbicularis is arranged circularly and acts as a sphincter. This muscle is of particular importance in surgical resection and reconstruction, as muscle reapproximation is necessary to maintain lip tone and oral competency. The paired labial arteries originate from the facial artery branch of the external carotid artery and include a superior and inferior division to supply both upper and lower lip. The arteries run submucosal on the intraoral side of lips, meeting in the midline. Motor supply to the lip muscles is derived from the 7th cranial nerve, primarily its buccal and marginal mandibular branches. Sensation is provided by branches of the trigeminal nerve, specifically the mental nerve (V3) and infraorbital nerve (V2). The mucocutaneous junction of the lip includes the thin "white line" where the pale, dry epithelium of skin meets the red, moist gland containing vermilion of the lip. Alignment of this zone is the initial step in the closure of the lip skin. Reconstruction of Lower LipThe classically described decision tree for reconstruction of lower lip defects involves the classification of defects based upon 3 defect size groups: less than 1/2, 1/2-2/3, and 2/3 to complete lip. After an adequate surgical margin is obtained, either with frozen section or Mohs technique, defects less than half the size of the total lower lip length can usually be managed with primary closure. Smaller lesions can be removed with a wedge excision and primary closure, while larger lesions may incorporate a "W" to avoid crossing the mentolabial groove onto the chin. If the lesion involves nearly one half of the lip, then a rectangular excision with advancement flaps may be considered. Primary closure of defects larger then half the lower lip is limited due to excessive wound tension and deformity. As the defect size increases, the resulting loss of total lip circumference results in more noticeable microstomia and subsequent loss of function. Strategies for closure involve "borrowing" tissue from the opposing lip or cheek. This is most commonly recognized in the technique described by Abbe. Abbe cross-lip flap
Estlander flap The Estlander flap is another technique for management of 1/2-2/3 lip defects. The Estlander flap involves rotating the upper lip tissue around the lateral edge of the mouth to correct defects involving the oral commissure.
Karapandizic flap Finally, the Karapandzic flap is described for lower lip defects. This flap does not include borrowing of upper lip tissue as in the Abbe and Estlander flaps. A complete lip is formed by rotating the upper lip and perioral tissue by bilateral advancement flaps. Incisions are made in the melolabial creases bilaterally down through the skin and muscle but not through mucosa. The incision is carried inferior into the mental crease at the midline. Advancement results in closure of the lip defect. The disadvantage of this technique is frequent loss of sensory and motor innervation, and severe microstomia with large defects. Potential complications include microstomia, difficulty of introducing full dentures, inversion of the vermilion and flattened mentolabial junction, and dysesthesia/anesthesia of the lip. Defects greater than 2/3 of the total lip are best reconstructed using adjacent cheek tissue. Attempts are made to align the defect along the midline where the Webster modification of the Bernard-Burow repair can be utilized for reconstruction. Bernard-Burow flap
Reconstruction of Upper LipFor lesions up to 50% of the upper lip size, primary closure as described for the lower lip is performed. For defects involving 1/2-2/3 of the upper lip, the Abbe and Estlander flaps are preferred. A modified Burow technique, which utilizes perialar crescentic excisions and laterally based advancement flaps, works well for defects involving 2/3 or more of the upper lip area. In addition, a reverse Karapandzic flap can be performed. RECONSTRUCTION: TUMORS OF THE FLOOR OF MOUTH AND ALVEOLAR RIDGESection 5 of 9
HistoryCancers of the floor of mouth (FOM) predominate in men in their fifth and sixth decades of life. Multifocal carcinomas are more common in patients with tumors of the floor of the mouth. Most tumors are composed of squamous cell histologic type. The most common gross morphology is a superficial exophytic tumor of well or moderately well differentiated grade. Ulceration follows continued tumor growth with subsequent extension into adjacent soft tissue structures such as the oral tongue, submandibular space, and alveolar ridge. Bony involvement is heralded by tumor fixation, and restricted tongue mobility signifies invasion of intrinsic tongue musculature. Squamous cell carcinoma originating in the alveolar ridge is less common when compared to other sites in the oral cavity. Women are more commonly affected than men, and it occurs during the sixth decade of life. Of gingival cancers, 70% occur on the lower gum in the posterior third of the molar area. Most of these tumors spread to adjacent areas of the oral cavity and frequently are associated with bone destruction due to the tight mucosal adherence of the gingiva to the mandibular periosteum. Anatomy The floor of the mouth consists of the semilunar space of the mylohyoid and hyoglossus muscles extending from the inner aspect of the lower alveolar ridge to the undersurface of the tongue. This region extends to the anterior tonsillar pillar posteriorly. The ductal openings of the paired sublingual and submandibular glands are situated in the mucosal floor separated by the midline frenulum of the tongue. The lower alveolar ridge consists of the alveolar process of the mandible and its lining mucosa. The area extends from the line of insertion of the mucosa in the buccal gutter to the line of the free edge of the FOM mucosa. The posterior extent is defined by the ascending ramus of the mandible. The upper alveolar ridge extends from the upper gingival buccal gutter to the junction of the hard palate. It includes the alveolar ridge of the maxilla and its lingual mucosa. The posterior extent is defined by the superior end of the pterygopalatine arch. Reconstruction of Small, Localized DefectsEarly-stage cancers of the FOM respond equally well to primary surgical or external beam irradiation therapy. Reconstruction of defects after surgical resection of stage I and II lesions is accomplished with primary closure. Early lesions are typically superficial and exophytic with limited functional loss to the patient. Thus, primary closure or split-thickness skin grafting (STSG) is a safe and reliable option for repair with few resulting functional limitations. Reconstruction of Large, Advanced-Stage DefectsLate-stage cancers of the FOM include tumors that invade the mandible, intrinsic musculature of the tongue, and anterior tonsillar fossa. Management of these advanced tumors requires wide local resection that may include cortical or segmental mandibulectomy, en bloc FOM musculature resection, and partial or hemiglossectomy. Tumors with extensive anterior growth from the FOM may invade the lip or skin of the lower face. Reconstruction of these defects requires functional considerations not required of earlier stage FOM defects. Total or partial loss of the mandible incurs serious functional, aesthetic, and psychological morbidity for patients. Prior to the development of advanced reconstruction options for mandibular defects, patients were left with terrible cosmetic deformities and poor function, as observed in the "Andy Gump" deformity with anterior mandibular arch defects. While en bloc resection of advanced oral cavity tumors can be reconstructed with regional tissue transfer, such as the pectoralis major musculocutaneous flap, bony defects are best managed with an osteocutaneous free flap or in combination with regional tissue transfer. The limitations of the regional flap for reconstruction of more complex soft tissue deformities combined with the advancements in microvascular free tissue transfer over the last 2 decades has led to the broad application of free tissue transfer in head and neck reconstruction. Advances in anesthetic management and monitoring during microvascular free tissue transfer allow these procedures to be performed safely with reproducible results. Microvascular tissue transfers enable more complex soft tissue and bony tumor resection with the benefit of single-stage reconstruction. The variety of tissue sites distant from the head and neck available for tissue transfer has led to more aesthetic and functional reconstruction. Fibula flap The endosteal and periosteal branches of the peroneal artery supply the osteocutaneous free flap, consisting of the fibula bone and associated soft tissue paddle. As much as 25 cm of fibula bone can be harvested in the adult, and the fibula's extensive periosteal vascular support allows the creation of multiple osteotomies for aesthetic and functional reconstruction of the mandible. Angle-to-angle defects of the mandible can be reconstructed using the fibula flap. The bicortical bone of the fibula accepts plates and screws for fixation and osseointegrated dental implants. The fibula free flap provides potential sensory reinnervation via the lateral sural nerve. The location of the donor site allows simultaneous flap harvest and single-stage reconstruction with a two-team approach. Studies examining donor site morbidity after fibula free flap highlight the following short-term and long-term results after free tissue transfer:
Another disadvantage of the fibula free flap is the limitations of the soft tissue component of the flap. The skin islands' poor arc of rotation relative to the bone and its unpredictable vascularity are factors in this limitation. Patients with severe peripheral vascular disease may not be candidates for flap harvest if the lower limb vasculature is involved. Iliac crest flap The iliac crest osteocutaneous free flap is a source of large bone volume for mandible reconstruction after obliterative head and neck surgery. The principal vascular supply is the deep circumflex iliac artery. Advantages to the iliac crest as a free flap in head and neck reconstruction include the following:
A total of 14-16 cm of iliac crest can be harvested and osteotomies can be made that conform to most mandible defects. Unfortunately, harvest of an adequate skin island requires a large surface area to incorporate sufficient musculocutaneous perforators. The internal oblique muscle may be incorporated into the flap with dissection of the ascending branch of the deep circumflex iliac artery, which supplies this muscle. This allows an additional thin, pliable tissue for oral cavity and pharyngeal mucosal defects. The major disadvantage of the iliac crest flap is the bulk of the skin island and subcutaneous tissue, especially in obese individuals. These reasons limit the ability to reconstruct the contour of oral cavity defects. Other disadvantages to the iliac crest flap include donor site pain, retroperitoneal hematoma, and abdominal wall herniation. However, the iliac crest is well tolerated and reliable as a free flap, especially to reconstruct composite defects in the mandible and FOM where the iliac crest flap is limited in its soft-tissue resources. Scapular flap Free tissue transfer flaps based on the subscapular artery offer the advantage of bone from the scapula and 2 thin skin paddles based on the scapular and parascapular flaps, respectively. Harvesting the tissue at the level of the circumflex scapular artery supports both skin paddles and the bone. This permits reconstruction of modest mandibular resections in combination and provides intra-oral lining and soft tissue coverage for the cheek and neck. The major disadvantage of using this flap is the need to reposition the patient intraoperatively. If resection is performed before the harvest, the patient must be moved to the lateral decubitus or prone position to harvest the flap and then repositioned to insert the flap. If the harvest is performed prior to resection, care must be taken to ensure that the time of resection does not exceed ischemia time. In either event, coordination between the resection team and the reconstruction team is essential. Soft Tissue Reconstruction - Oral CavityWhile the osteocutaneous free flap reestablishes mandibular contour and function, replacement of large volume soft tissue loss in the oral cavity is limited in bone flaps. Both regional and free flaps have been used for reconstruction of defects resulting from tumor extirpation from the oral cavity. Regional flaps are based on a pedicled axial pattern vascular supply. Pedicle location and length define the limits of regional transfer in head and neck reconstruction. Primarily, branches of the subclavian or axillary arteries supply the regional flaps used in reconstruction of the head and neck. The subclavian artery arises from the innominate artery on the right or directly from the aortic arch on the left. The subclavian artery crosses the lateral border of the first rib to become the axillary artery. The axillary artery has 3 divisions: the supreme thoracic artery, thoracoacromial trunk, and subscapular trunk. The two primary divisions of the subclavian artery include the thyrocervical and costocervical trunks. Regional flaps can be classified as fasciocutaneous (eg, deltopectoral flap) or as myocutaneous (eg, pectoralis major, latissimus dorsi, trapezius flaps). Selection of a certain regional flap depends on the size and location of the defect and the limitations of the regional flap choices. The pectoralis myocutaneous flap is described below as the most commonly used regional flap for anterior oral cavity defects of large volume. Pectoralis major flap Baek and Aryian first described the pectoralis major flap for use in head and neck reconstruction in 1979. The pectoralis major flap is used widely in reconstruction of head and neck defects because of its reliable blood supply and ease of harvest. The pectoralis major muscle is fan-shaped and originates from the head of the clavicle superiorly, the sternocostal junction medially, and the lower ribs inferiorly. The primary blood supply to the flap is the pectoral branches of the thoracoacromial artery. The internal mammary and long thoracic arteries also provide blood supply to the pectoralis major flap. The incidence of total flap necrosis is reported to be 1-3%. One disadvantage of the pectoralis major flap is the loss of pectoralis muscle function in arm adduction and/or rotation. In overweight individuals, the pectoralis major flap may be bulky with abundant subcutaneous fat and poor musculocutaneous blood supply. This bulk can lead to postoperative contour deformities because of the effect of gravity. These limitations of the pectoralis flap led to the use of soft tissue free flaps for anterior oral cavity defects in which less tissue volume replacement is desired. Radial forearm free flap The radial forearm free (RFF) flap has numerous applications in the reconstruction of soft tissue defects. It provides a thin, pliable source of soft tissue for reconstruction of the FOM and tongue after tumor resection. Previous reconstruction options in FOM included STSG and the pectoralis myocutaneous flap. The STSG results in inadequate soft tissue volume and is prone to contracture and tethering of the remaining tongue, resulting in poor postoperative deglutition and speech. For reconstruction after partial glossectomy and FOM resections, the pectoralis major flap has a less reliable cutaneous paddle and is bulky. The RFF can be harvested to fit almost any shape of deformity in the tongue and FOM with less postoperative contracture and bulk, allowing for earlier return of speech and swallowing function after surgery. The RFF flap is a fasciocutaneous flap based on the radial artery harvested from the volar aspect of the forearm. A large surface area of thin and pliable skin with the potential for sensory reinnervation via the lateral antebrachial cutaneous nerves is available with the RFF flap. The radial forearm free flap has numerous advantages that account for its wide use in reconstruction of defects in the head and neck. Flap dissection can be performed simultaneously with tumor extirpation with placement in a single stage. The long vascular pedicle (up to 20 cm) and large caliber vessels add to flap versatility in conforming to a large variety of defects. Hair-bearing skin can be incorporated in the flap when desired. Bone from the radius of 10-12 cm in length can be incorporated into the flap for mandibular reconstruction. Subcutaneous fat may be incorporated into the flap for better augmentation of contour deformities and dead space that remain after tumor resection. Studies examining donor site morbidity after RFF flap highlight the following short-term and long-term results with their accompanying rates of frequency:
Vascular compromise of the hand is the most devastating complication related to harvest of the RFF flap. This occurs when insufficient collateral circulation via the ulnar artery exists. Use of the preoperative Allen test, in which the distal perfusion of the hand is ensured while occlusion of the radial artery is performed, eliminates the risk for postoperative vascular insufficiency. RECONSTRUCTION: TUMORS OF THE OROPHARYNXSection 6 of 9
History Most of the malignant lesions of the oropharynx are squamous cell carcinomas arising in the oral mucosa. Other rare malignancies include salivary gland tumors of minor salivary gland origins. Lymphoma may arise from the lymphatic tissue of the palatine and lingual tonsils. Like the oral cavity, evidence links most tumors of the oropharynx to smoking and alcohol use. Heavy alcohol abuse coupled with tobacco may synergistically increase the risk of cancer 15 times. In India, the custom of chewing betel nuts is responsible for an elevated risk of oropharyngeal carcinoma. Other etiologic factors possibly linked to the development of oropharyngeal carcinoma include nutritional deficiency, syphilis, trauma, dental irritation, viruses, and poor oral hygiene. Exposure to certain environmental substances such as isopropyl oils, sulfuric acid, and nickel are thought to be risk factors for oropharyngeal cancers. Anatomy The oropharynx is bounded by the oral cavity anteriorly, the hypopharynx inferiorly, and the nasopharynx superiorly. The superior extent is defined by a horizontal plane at the soft palate and the inferior border by a plane at the level of the hyoid bone. The anterior tonsillar pillar consisting of the palatoglossus makes up the anterior limit of the oropharynx, along with the soft palate and circumvallate papillae at the tongue base. The posterior pharyngeal wall makes up the posterior border of the oropharynx. Anatomic subsites within the oropharynx include the soft palate, uvula, tonsillar pillars and palatine tonsils, posterior pharyngeal walls, and base of tongue. Anatomic drainage within the oropharynx is diffuse with predilection for bilateral involvement and eventual drainage to the jugulodigastric node of the upper jugular lymphatic chain. Tumors of the soft palate, base of tongue, and oropharyngeal wall may drain primarily to the retropharyngeal and parapharyngeal lymph nodes. Reconstruction of soft palate defects Defects after surgical resection of the soft plate result in a variable loss in velopharyngeal competency dependent upon the extent of soft tissue loss. Primary closure of the smallest of soft palate lesions can result in inability to seal the oropharyngeal and nasopharyngeal cavities in speech and deglutition. This creates a noticeable change in voice resonance due to air escape behind an incompetent velum. Swallowing problems are most noticeable after ingesting liquids, with a resulting nasal regurgitation. Reconstruction can be obtained with free tissue transfer from the radial forearm or lateral arm with good results. These free flaps are especially valuable because they are thin and compliant. The radial forearm is most useful for defects including the lateral soft palate and tonsillar fossa after resection of primary tumors arising in the tonsil, tonsillar pillar, and lateral pharyngeal wall. The long vascular pedicle in the RFF flap is adequate to reach defects in these areas. Over time, the flaps remodel to the normal contour of the oropharynx, allowing reconstitution of normal swallowing. The use of additional obturators for return of normal speech is available for larger defects that include the midline of the soft palate. Primary closure augmented by small STSG for smaller defects of the lateral soft palate and tonsillar fossa is effective. It is limited by greater contraction and scarring over time. The temporalis fascia flap has been used to reconstruct defects of the oropharynx via tunneling beneath the zygoma into the lateral pharyngeal wall and tonsil region. Reconstruction of base of tongue The base of tongue defect poses the greatest difficulty in terms of preservation of normal speech and swallowing. Most primary tumors of the base of tongue are treated initially with combined chemotherapy and radiation therapy protocols for this very reason. Recurrent tumors require surgical resection, and the resulting defects often preclude the return of normal swallowing function after reconstruction. Large lesions precluding the use of wedge resection often result in large volume soft tissue defects requiring regional or free flaps. The pectoralis major flap as described in previous sections is useful for replacing the large tissue loss after composite resection. With intensive speech and swallowing rehabilitation, some patients can regain independent swallowing function, eliminating the need for long-term G-tube dependence. Reconstruction of posterior pharyngeal wall Tumors originating primarily in the posterior pharynx are less common. In many studies, inferior extending tumors of the posterior wall are classified as tumors of the hypopharynx. Large posterior pharyngeal wall tumors may encroach upon the skull base, making resection impossible. Small defects of the posterior pharynx can be closed primarily or augmented with STSG. Larger defects usually require free flap reconstruction. Thin, fasciocutaneous flaps such as the radial forearm or lateral arm have better long-term sensory recovery than thicker flaps. Essentials - Radial forearm and lateral arm flap Defects of the tonsillar fossa, soft palate, and pharyngeal walls are well suited to reconstruction with the RFF flap. The vascular pedicle provides ample length to reach the oropharynx. The RFF flap provides adequate soft tissue without the associated problems seen with bulkier flaps in deglutition and breathing. Fasciocutaneous vessels are transmitted to the skin paddle via the lateral intermuscular (brachioradialis-flexor carpi radialis) septum. The lateral and medial antebrachial cutaneous nerves provide sensate capabilities. Complications include the following:
First described by Song and associates in 1982, the lateral arm free flap is a source of fasciocutaneous tissue and muscle supplied by the posterior radial collateral artery. Like the RFF flap, the lateral arm flap provides a thin, pliable alternative for tissue reconstruction for a variety of defects in the oral cavity, oropharynx, larynx, and hypopharynx. In harvesting the lateral arm flap, the width of skin available that can be closed primarily is approximately 6 x 8 cm. A larger skin surface area can be harvested but requires STSG closure at the donor site. Harvest two sensory nerves, the posterior cutaneous nerves of the forearm and arm, with the lateral arm flap. The primary advantage of the lateral arm flap over other fasciocutaneous free flaps is the absence of risk of distal limb ischemia. Disadvantages of the lateral arm flap include the linear scar and anesthesia of the forearm after section of the posterior cutaneous sensory nerves. CONCLUSIONSection 7 of 9
Tumors of the head and neck, congenital deformity, and trauma are a few of the potential etiologies of soft-tissue defects in the head and neck. Caring for patients with these conditions requires an individualized approach that includes the goals of both preserved function and cosmesis. Consider the safest and most reliable methods of reconstruction before embarking on more complex and time-consuming options. The reconstructive ladder, incorporating the concepts of primary wound closure through microvascular free flaps, provides a blueprint for planning reconstruction of all soft tissue deformities. In addition, negative pressure dressings are being used more frequently to stimulate wound healing in head and neck reconstruction. Local and regional flaps are safe and reliable resources for reconstructing small-to-moderately sized defects in the head and neck. Local advancement and rotation flaps routinely are used in the closure of soft-tissue defects after removal of malignant skin tumors. The breadth of this method for reconstruction is illustrated best in the local flaps employed for the reconstruction of soft-tissue defects in the lip. The pectoralis major myocutaneous flap is a time-proven method for reconstructing almost all defects of the oral cavity, oropharynx, and hypopharynx. While surpassed by microvascular free flaps because of their versatility in reconstruction, the pectoralis flap still has many applications in patients with head and neck deformity. The microvascular free flap has revolutionized the field of head and neck reconstruction in terms of preserved function and cosmesis. Reconstruction of oromandibular defects using osteocutaneous free flaps gives patients new hope in the face of historically devastating defects. The free flap offers the creation of a naturally contoured mandible and the potential for dental restoration with osseointegrated implants. The reconstruction of soft tissue defects with thin, pliable, free flaps, as in the radial forearm free flap, offers improves chances for speech and deglutition after resection of oral cavity and oropharynx tumors. The techniques for reconstruction of cutaneous and bony defects in the head and neck have evolved greatly over the last 2 decades. The future should yield many new and exciting developments in the field of reconstructive surgery. RECONSTRUCTION: PHARYNGOESOPHAGEAL DEFECTSSection 8 of 9
HistoryCancer of the hypopharynx accounts for only 8-10% of all head and neck primary tumors. It presents most commonly in those aged 50-80 years, with males at greater risk than females. Heavy smoking and alcohol abuse are the usual etiologic factors; however, the association between iron-deficiency anemia and postcricoid cancers are well documented (Plummer-Vinson syndrome). By far the most common pathology of hypopharyngeal tumors is squamous cell carcinoma. In general, these cancers are associated with a poor prognosis due to a combination of late diagnosis, aggressive behavior with tendency for submucosal spread, skip lesions, and spread into the surrounding structures of the neck. AnatomyThe hypopharynx extends from the level of the hyoid bone superiorly to the lower border of the cricoid inferiorly. It is a cone-shaped structure in continuity with the oropharynx above and the cervical esophagus above. The hypopharynx is divided into the following regions: paired pyriform sinuses, postcricoid, and posterior pharyngeal wall. Pyriform sinus cancer is most common. The sinuses extend from the pharyngoepiglottic folds superiorly to an apex inferiorly lying at the level of the glottis. Laterally it is bound by the overlying thyroid cartilage and thyrohyoid membrane. Medially it is closely related to the laryngeal structures. The posterior pharyngeal wall is separated from the vertebral bodies posteriorly by the prevertebral fascia and the retropharyngeal space. Tumors arising de novo here are rare. Postcricoid cancer tends to spread superficially, extending into the cervical esophagus and pyriform sinuses. The postcricoid area extends inferiorly from the posterior surfaces of the arytenoids and the intervening mucosal fold to the inferior margin of the cricoid cartilage. The upper cervical esophagus originates at the lower border of the cricoid. Reconstruction - Pharyngoesophageal defectsReconstruction of the pharynx and cervical esophagus after resection for tumor involvement is most commonly attained with the use of free tissue transfer. The two most common donor sites are the radial forearm fasciocutaneous free flap and the jejunal free tissue transfer. RFF flap As described in previous sections, the RFF flap is a thin and compliant source of tissue for reconstruction of defects throughout the upper aerodigestive tract. The RFF may be used for reconstructing subtotal and total defects of the pharynx and cervical esophagus after tumor ablative surgery. Subtotal defects can be closed upon a remaining remnant of pharyngeal mucosa in both small and large defects in which primary closure is impossible due to high risk for postoperative stricture formation. Based upon the radial artery, the RFF pedicle easily reaches the pharynx and can be used to close defects including the posterior pharyngeal wall and base of tongue soft tissue. Complete circumferential defects can be reconstructed by tubing the pliable RFF flap. This requires an additional suture line of closure within the tubed flap as well as the superior and inferior suture lines for closure. Long-term studies show good long-term patency and functional swallowing for both subtotal and total defects closed with the RFF flap. In both cases, the RFF flap is closed over a standard nasogastric tube to facilitate enteral nutrition during the immediate postoperative period. Time to beginning of oral feeding varies among institutions, with a range of 7-21 days. Most centers await the passage of normal salivary flow, which coincides with diminished postoperative flap edema and adequate lumen patency to tolerate early small bolus feeding. Modified Gastrografin swallowing studies also are commonly used to anticipate the beginning of oral feeding. Long-term maintenance of lumen patency may require occasional upper pharyngeal dilation. Resumption of postoperative oral intake may be complicated by flap loss, fistula formation, or infection in some patients. Jejunal free flap The jejunum free flap (JFF) has been used for larger circumferential defects of the pharynx and upper cervical esophagus with excellent results. A 20-25 cm of jejunum can be harvested from the abdomen via an upper midline laparotomy. Once the operating head and neck surgeon has determined the extent of the pharyngoesophageal defect, the JFF can be harvested simultaneously by a second team. The JFF is based upon a branch of the superior mesenteric artery. Upon removal of the selected jejunal segment, the proximal and distal ends of the donor of jejunum are reanastomosed, and feeding gastrostomy and jejunostomy tubes are placed for bowel decompression and long-term enteral feeding. The jejunal graft is anastomosed in an isoperistaltic orientation to the defect within the neck. A distal segment of jejunum is separated from the free flap along its antimesenteric border and brought out through a small defect in the skin for postoperative monitoring. As with the RFF, a nasogastric tube is passed though the lumen of the graft for postoperative stenting. Within 5-7 days, the jejunal monitor is divided. Specific complications of the JFF include vascular compromise of nearby small bowel segments in the abdomen, ileus, and dysphagia secondary to jejunal peristalsis within the neck. Long-term swallowing function can be compromised by graft stricture, flap loss, and fistula formation. REFERENCESSection 9 of 9
Head and Neck Cancer: Reconstruction excerpt Article Last Updated: Jun 7, 2006 |
