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Concepts and Defect-Oriented Approaches to Head and Neck Reconstruction

Marek Dobke, M.D., Ph.D.,1, 2  Ahmed Suliman, M.D.,1, 2 Fernando Herrera, M.D., 4  Christopher Reid, M.D.,2 Brittany Yee, M.S.,3 Brian Mailey, M.D.,1,2 Salim Saba, M.D. 1,2

Division of Plastic Surgery, 1 Department of Surgery,2 University of California San Diego, School of Medicine,3 San Diego, CA, USA and Medical University of South Carolina, Charlottsville, South Carolina4

 

Key words: Head and neck reconstruction, concepts, flaps

Acknowledgements: Presented at the First Interdisciplinary Congress of the Head and Neck Diseases. The Twenty First Century Medicine – Interdisciplinary Approach to Pathology of the Head and Neck. Moscow, May 27 – 29, 2013.

Disclosures: None

 

Address for correspondence:

Marek Dobke, M.D., Ph.D.

Professor of Surgery

Division of Plastic Surgery, University of California, San Diego

200 West Arbor Drive, San Diego, CA, USA 92103-8890

FAX: 619 543-3645; Phone: 619 543-6084; email: mdobke@ucsd.edu

 

ABSTRACT

Over the past thirty years the management of oncologic head and neck defects has evolved with the advent of microsurgical techniques. Extensive two- and three-dimensional cavities can be reliably reconstructed with good functional outcomes including preservation of respiration, phonation, mastication and deglutition.

Advancements in diagnostic imaging have been essential for achieving complete resection with negative oncologic margins, especially of difficult to access tumors. New imaging techniques have made three-dimensional virtual planning possible. These include, computer generated stereolithographic mandibular or midfacial skeletal models, which define skeletal defects and allow for precise prefabrication of orthognathic models, splints and customized modeling for free osseous (e.g., fibular) flaps based on individual defect anatomy. These advancements enable better dental rehabilitation and enhance overall aesthetic outcomes.

Furthermore, advancements in neoadjuvant radio- and chemotherapy have made previously unresectable tumors accessible to extirpation and ultimately reconstruction. Changing paradigms in radiotherapy with the ability to deliver radiation more accurately over smaller fields, and in more concentrated doses, have reduced collateral and biologically unnecessary damage to uninvolved peri-tumor tissue in order to allow for greater success with reconstructive flaps insets and healing.

The most recent addition to the armamentarium of oncologic and reconstructive surgeons has been the surgical robot. This technology appears to reduce resection related morbidity for selected types of tumors (e.g., oro-pharyngeal). This benefit also extends to harvesting of certain flaps for reconstruction, as compared to open-access approaches.

Reconstructive experiences, in the context of multiple specialty advancements for the management of the head and neck tumors range from post-Mohs’ surgery defects to extensive reconstructions. These often require composite tissue flaps for skeletal support, mucosal lining and soft tissue restoration with reconstitution of the natural barriers that exist between the gastrointestinal and respiratory tracts and skin coverage. Illustrative cases are presented.

 

INTRODUCTION

Technical innovations in head and neck reconstructive surgery evolved through the 1970s, 1980s and 1990s. Concomitantly, advances in diagnostic imaging, adjuvant and rehabilitative modalities (including dental rehabilitation) have improved cancer management outcomes. (Figure 1.). New approaches to reconstruction of extensive defects include prefabricated composite flaps, and are beginning to incorporate developments in the field of  regenerative medicine (e.g., stem cell induced tissue differentiation) and composite tissue allotransplantation (1,2). The objective of this review is to discuss surgical reconstructive principles and applications of new developments for the multidisciplinary management of head and neck tumors.

 

RECONSTRUCTION FOR SKIN AND EXTERNAL FACIAL SOFT TISSUE MALIGNANCIES

Improved understanding of head and neck axial blood flow allows many two-dimensional defects, requiring restoration of skin and mucosal lining, to be reconstructed with a combination of fasciocutaneous flaps, perforator flaps, tissue expansion, and skin- and composite grafts. , (3). These surgical strategies are confounded by new systemic chemotherapeutic modalities, such as those tested for the treatment of recurrent or advanced head and neck cancers. These agents may  alter the histology of recurrent lesions with infiltrative/morphoeic, micronodular, and metatypical growth patterns and also change patterns of facial wound healing. Examples of chemotherapeutic agents that may confound surgical assessment, and thus deserve a reconstructive surgeon’s attention, include Cetuximab, Hedgehog Inhibitors, an anti-cancer stem cell combination. (Figure 2.)(4,5).

 

WORKHORSE FLAPS IN HEAD AND NECK RECONSTRUCTION

The aim of head and neck reconstruction is to achieve acceptable functional and aesthetic results with minimal donor site morbidity. Increasingly radical surgery, both ablative and reconstructive may lead to better cancer outcomes with prolonged survival and cure rates, however, these gains may be offset by losses in quality of life due to deformity and disability. A rationale approache to reonstruction after two-dimensional, soft tissue defects was previously outlined by our group in 2012(3). However, the reconstruction of  “through-and-through” three-dimensional defects requires a more extensive, preoperative planning effort to achieve reasonable aesthetic outcomes, as a complement of osseocartilaginous, lining and external coverage  restoration is frequently needed for  the special functions of the face (e.g., different static and dynamic slings for support of the oral commissure). Local and regional flaps alone are often inadequate to restore bi-laminar lining or coverage and to obliterate three-dimensional defects. Thus, composite tissue transfers such as: folded, bi-paddled flaps, multiple flaps, combination of flaps and grafts and alloplastic implants have offered reconstructive solutions customized to a patient’s individualized anatomical and functional needs.

 

INFLUENCE OF RADIOTHERPAY ON HEAD AND NECK RECONSTRUCTION

Radiation therapy may be used for definitive curative therapy in select tumors (e.g., lymphoma and early stage nasopharyngeal squamous cell carcinoma), but more often used as a surgical adjunct or for palliation in advanced, incurable disease.  Radiation incurs an extensive amount of collateral soft tissue damage. Therefore, many reconstructive surgeons believe muscle-based flaps performed in previously irradiated areas have a substantially higher complication rate than those done in areas without antedecent radiation; this notion is refuted by others (7). Furthermore, advancements in radiotherapy and chemotherapy have made previously unresectable tumors amenable to total extirpation and subsequent reconstruction. Immediate intraoperative radiotherapy combined with reconstruction may be useful in recurrent, locally advanced tumors when conventional radiotherapy is not feasible (8). The ability to deliver radiation more accurately over smaller, targeted fields and in more concentrated doses allows for more effective tumor ablation and less collateral damage to uninvolved peri-tumor tissue. Ultimately, flap inset and healing has a higher likelihood of success, with better resultant aesthetics and quality of life (8,9).

 

CREATIVE, NOVEL AND SOMETIMES FORGOTTEN SOLUTIONS

Defects requiring reconstruction of the oral cavity lining and external skin coverage have been treated with flaps consisting of two skin paddles, two-flaps or a composite flap approach. Some advocated the rectus abdominis free flap, including posterior rectus fascia and peritoneum. Unlike fascial flaps, the peritoneal surface heals primarily and does not require weeks to mucosalize (10). Additionally, this flap is not overly bulky in the patient’s mouth. For similar reasons, prefabricated flaps using digestive tract autografts has been recently reported (11).

Efforts to improve aesthetic outcomes in free flap mandibular reconstruction paralleled developments in microvascular tissue transfers for primary reconstruction. Early recognition of the importance of the three dimensional reconstruction has lead to the use of templates to shape the osseous part of the flap (e.g., fibular, scapular, radial, iliac, etc.) based on preoperative lateral cephalograms and transverse plane computed tomography scans of the mandible. The surgical specimen also serving as an additional visual reference and source of measurements of the overall bone dimensions has evolved to modern computer generated stereolithographic models and markings for osteotomies (Figure 3,4) (1,12).  Other three-dimensional oro-manidbular reconstructions can be accomplished with the technique of the “double-barrel” fibula flap. This flap consists of stacking osteotomized fibular segments by removing  the central part of the bone allowing the flap to turn 180 degrees on itself. The osseous struts are essentially folded on top of each other to achieve a double-barrel.  The soft tissues of this flap, including the vascular pedicle, are folded, although continue to flow and remain intact. This technique doubles the vertical height of the osseous portion of the flap, allowing alignment to the vertical height of the mandibular stumps and are more reliable thana single barrel strut for placement of osseointegrated implants during dental rehabilitation (13).

Options for restoration of head and neck defects were expanded by the introduction of perforator flaps and into clinical practice (Table 2.). Patients benefit from less invasive donor site dissection, musculature preservation and relative ubiquity of flap donor choices (14). The supraclavicular artery island flap (SCAIF) is an example of such a flap, worthy to master as it provides an easy to contour thin fasciocutaneous substance, with acceptable color match to facial skin. The SCAIF provides ample tissue for resurfacing the lower face, neck and upper chest (Figure 5. and Figure 6). Additionally, the SCAIF can be tunneled for intraoral inset or folded for repair of circumferential pharyngoesophageal defects and tracheocutaneous fistulas. The mobility of the flap can be improved by the incorporation of the transverse cervical vessels, as they become the pivot point when the flap is rotated into its new position (15).

Relatively little is known about trends and approaches to the head and neck defects after tumor removal utilizing robotic surgery and less invasive access.  Preliminary data indicate that resultant defects are reconstructed with pedicled or free tissue transfer techniques just like defects after open access extirpation (16,17).

Lastly, as it becomes apparent that advanced head and neck cancer is becoming more prevalent with an aging population, reconstruction is obviated by patient comorbidities and general health condition. In cases where invasive and lengthy operating time is not feasible, simple (“damage control” type) solutions have to be sought.  The cervico-submental keystone island flap for facial region reconstruction is an example of a relatively versatile and highly mobile flap, which can be a workhorse suitable for a range of head and neck oncologic defects. This skin flap can be raised based on perforators of the external carotid artery and its branches. More importantly, flap reliability and a relatively short technical learning curve also make this flap advantageous (18).

 

 

 

 

 

 

 

REFERENCES

  1. Neligan PC. Head and neck reconstruction. Plast Reconstr Surg 2013;131:260e-269e.
  2. Thoma A. Microsurgical reconstruction of the head and neck. Clin Plast Surg 2005;32:XI-XII.
  3. Dobke M. Mohs’ surgery for facial soft tissue malignancies: successes and limitations – reconstructive surgeon perspective. Oncosurgery 2012;4:105-112.
  4. Hoff DD von, LoRusso PM, Rudin CM, Reddy JC, Yauch RL, Tibes R, Weiss GJ, Borad MJ, Hann CL, Brahmer JR, Mackey HM, Lum BL, Darbonne WC, Marsters JC, Sauvage FJ de, Low JA. Inhibition of the hedgehog pathway in advanced basal-cell catrcinoma. N Engl J Med 2010;361:1164-1172.
  5. Le H, Kleinerman R, Lerman OZ, Brown D, Galiano R, Gurtner GC, Warren SM, Levine JP, Saadeh PB. Hedgehog signaling is essential for normal wound healing. Wound Repair Regen 2008;16:768-773.
  6. Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg 2005;32:421-430
  7. Kiener JL, Hoffman WY, Mathes SJ. Influence of radiotherapy on microvascular reconstruction in the head and neck region. Am J Surg 1991;162:404-407.
  8. Chissov VJ, Chernichenko AV, Reshetov IV, Edemskaya OV, Polyakov AP. Intraoperative radiotherapy and reconstructive surgery in treatment of head and neck tumors. Oncosurgery 2010;2:52-61.
  9. Gluckman J. “Incurable” head and neck cancer. In: J. Gluckman, P. Gullane, J. Johnson (eds.): Practical Approaches to Head and Neck Tumors. Raven Press, New York, 1994:195-204.
  10. Mixter RC, Mayfield K, Dibbell DG, Rao VK. Intraoral reconstruction with a microvascular peritoneal flap. Plast Reconstr Surg 1991;88:452-457.
  11. Polyakov AP, Reshetov IV, Batukhtina E, Filushin M. Bioengineered reconstruction of upper digestive tract. Plast Reconstr Surg 2013;131,5S: 101.
  12. Hidalgo DA. Aesthetic improvements in free-flap mandible reconstruction. Plast Reconstr Surg 1991;88:574-587.
  13. Bahr W, Stoll P, Wachter R. Use of the “double-barrell” free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg 1998;56:38-44.
  14. Hofer SOP, Murea MAM. Pedicled perforator flaps in the head and neck. Clin Plast Surg 2010;37:627-640.
  15. Vinh VQ, Anh T van, Ogawa R. Anatomical and clinical studies of the supraclavicular flap: analysis  of 103 flaps used to reconstruct neck scar contracture. Plast Reconstr Surg 2009;123:1471-1480.
  16. Konofanos P, Hammond S, Halen JP ver, Samant S. Reconstructive techniques in transoral robotic surgery for head and neck cancer: A North American survey. Plast Reconstr Surg 2013;131:188e-197e.
  17. Park YM, Lee WJ, Youn IS, Lee DW, Lew DH, Lee JM, Ha JG, Kim WS, Koh YW, Choi EC. Free flap reconstruction after robot-assisted neck dissection via a modified face-lift or retroauricular approach. Ann Surg Oncol 2012;20:891-898.
  18. Behan FC, Rozen WM, Wilson J, Kapila S, Sizeland A, Findlay MW. The cervico-submental keystone island flap locoregional head and neck reconstruction. J Plast Reconstructive Aesth Surg 2013;66:23-28.
  19. Cormack GC, Lamberty BG. The arterial anatomy of skin flaps. Churchill Livingstone, Edinburgh, 1986,398-400.

 

Table 1. Common free flaps and their applications for complex reconstructive needs (1,6).

Flap

Application

Fascio-cutaneous radial forearm
  • Floor of mouth
  • Tongue
  • Major facial defects
Osteocutaneous radial forearm
  • Oromandibular
Osteoseptocutaneous fibular
  • Oromandibular
Cutaneous or myocutaneous anterolateral thigh
  • Floor of mouth
  • Tongue
  • Face
Osteocutaneous

  • Scapular
  • Parascapular
  • Midface
  • Oromandibular, particularly when two skin paddles are needed
Osteocutenous iliac crest
  • Large bony and soft tissue defects
Muscle latissiumus dorsi
  • Massive scalp reconstruction
  • Skull base defects
Muscle rectus abdominis
  • Skull base
Muscle temporalis
  • Skull base
Jejunal
  • Circumferential pharyngo-cervical esophageal

 

 

 

 

Table 2. Common pedicled perforator flaps and their applications for reconstructive needs in the head and neck (13,14).

Flap

Application

Submental artery perforator flap
  • Lower face
Facial artery (nasolabial) flaps
  • Perioral defects
Superficial temporal artery based flaps
  • Many variations and applications of forehead and                                                                            scalp flaps
  • Central face
  •  Upper face
Occipital artery based flaps
  • Upper neck
  • The hair-bearing quality of these flaps                                                                         enables restoration of a beard
Supraclavicular artery perforator flap (may be pre- expanded)
  • Lower and lateral face
  • Neck
  • Upper chest

 

 

 

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Figure 2.

 

 

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Figure 4.

 

 

 

 

 

 

 

 

 

 

 

 

Figure 5.

 

 

 

Figure 6.

 

 

 

FIGURE LEGEND

Figure 1. A.) Twenty-four old female with right hemifacial mass (odontogenic myxoma). B.) Three dimensional computed tomographic (CT) scan demonstrates the extent of mandibular involvement. The patient underwent composite resection with hemimandibulectomy and reconstruction utilizing free fibular osseocutaneous flap. Superimposition of structures outside the area of interest is eliminated, because of the inherent high-contrast resolution., Appearances of  tissues that differ in physical density by less than 1% can be distinguished. Data from a single CT imaging procedure provides multiple contiguous images in the axial, coronal, and sagittal planes, depending on the diagnostic task. This is referred to as multiplanar reformatted imaging.

Figure 2. A.) A 59 year old patient with history of kidney transplantation and cyclosporine induced immunosuppression was treated with cetuximab for multiple, originally inoperable squamous cell carcinomas of the scalp and cranial bones B.) Photograph obtained two months later. Multiple scalp biopsies: 4-6 cm radial to edges of the ulcer revealed squamous cell carcinoma. The patient achieved a partial response to treatment with involution of the left mastoid scalp carcinoma – a cessation of gross growth of the scalp vertex carcinoma), however cranial bone disintegration progressed and three months after his presentation there was evidence of dura mater involvement by squamous cell carcinoma (Panel C). C.) Concern about dural disruption (arrow), cerebrospinal fluid leak and brain exposure, a palliative major soft tissue resection dura repair with allograft and latissimus doris flap for major scalp reconstruction were performed. D.) Extensive scalp damage due to previous disease, radiation and local lesion excisions, necessitated the preparatory step for microvascular surgery: preparation of the flap recipient vessels. Utilizing autologous greater saphenous vein graft the arteriovenous fistula was created between the right superior thyroid surgery and external jugular vein. E.)  Two weeks later the malignancy was removed, however, despite extensive resection, margins remained positive in multiple areas (scalp and dura). Dural patch (allograft) replaced disintegrated and removed dural segment. F.) Latissimus dorsi free flap was used for dural, dural patch and exposed bone coverage. G and H.) Split thickness skin grafts were used for coverage of the raw surface of the muscle flap.

Figure 3. Twenty-one year old male with maxillary-mandibular defect: simulated surgical procedure for mandibular reconstruction using fibular free flap and maxillary reconstruction using fibular bone grafts.

Figure 4. A.) A Forty year old female with squamous cell carcinoma of floor of the mouth. B.) Intraoperative specimen resected includes mandibular symphysis and right body and overlying soft tissues. C.) Preparation for the myo-osseocutaneous fibular flap harvest. D.) After transection of the vascular pedicle the flap osteotomies were performed and skin paddle was divided. Osteotomies –  based on simulated anatomy images -were performed utilizing a fibula cutting guide with metal slot inserts and the osteotomized bone flap intersegmental fixation by means of a prefabricated plate. E.) Prefabricated plate (manufactured based on simulated preoperative anatomy images). F.) Fitting of the plate. G.) Flap inset and stabilization. H.) Completion of the reconstruction.

Figure 5. A.) The supraclavicular artery island-perforator flap (SCAIF). The origin of supraclavicular artery can be traced by a Doppler probe to the triangle bordered by the sternocleidomastoideus muscle, external jugular vein and medial clavicle (arrow). The course of the artery was confirmed by Doppler probe. B.) The supraclavicular artery arises 3-4 cm from the origin of the transverse cervical artery, but may arise also from the suprascapular or the superficial cervical artery (15,19).

Figure 6. A.) A forty-five year old male with history of radiation therapy for intraoral squamous cell carcinoma developed recurrent cancer. B.) En bloc resection of the right cheek, hemimandible, and mucosa and with fibular osseocutaneous flap with skin paddle for oral lining reconstruction. C.) Major skin defect of the right cheek and submental area reconstructed with the supraclavicular artery island flap. D.) Six-months follow-up: no cancer recurrence, stable fibular flap external coverage with good color match and contour of the reconstructed face.