Head and Neck Reconstruction
Reconstruction of the head and neck accounts for some of the more complicated reconstructions on the human body as it involves working in an area where one must consider oral cavity competence, swallowing, breathing, and speech while at the same time being mindful of how a patient will look following reconstruction. In addition, there is not a great deal of local tissue that can easily be utilized for reconstruction in this area. While adjacent tissue rearrangement (local flaps) may be utilized for small to medium sized defects of the skin or lips, large defects of head and neck tissue often require the importation of tissue for their reconstruction.
Reconstruction of the lips is one of the few places on the head and neck where utilizing local tissue is not only possible, it is actually preferable as this typically allows for better postoperative movement, eating and speech compared to other options. Because of the amazing ability for the lips to adapt, even relatively large defects can simply be closed. When lip defects are too large to close primarily they may require moving tissue from the lower to the upper lip, or mobilizing and advancing cheek tissue to allow closure with lip that remains innervated and mobile.
Reconstruction of the oral cavity may involve reconstruction of the cheeks (buccal mucosa), roof (hard of soft palate), tongue or floor of the mouth. Large defects of the oral cavity typically are the result of surgery for cancer and usually require bringing in tissue from other parts of the body with free tissue transfer (“free flaps”). This involves designing and harvesting tissue from elsewhere on the body along with the artery and vein that supply it. The tissue and its blood supply are disconnected, and the blood supply is then reconnected to blood vessels in the neck, allowing the newly brought in tissue to be used for reconstruction. While there are many options for this type of reconstruction depending on the type of tissue required, most commonly tissue from the arm (radial forearm free flap) or the thigh (anterior lateral thigh flap) are utilized in this area.
Reconstruction of the jaw (mandible) may be required in cases where full-thickness bone has to be removed secondary to benign destructive tumors of the bone or teeth (i.e. ameloblastoma), cancers of the mouth where the bone has been invaded, or in rare cases of radiation injury (osteoradionecrosis) where the jaw bone cannot be saved with less invasive options. While not every case of partial mandible resection requires reconstruction, the best option for reconstruction of the mandible when required is the fibula. The fibula is the smaller of two bones in the lower leg and can be harvested as a free flap to provide plenty of bone to replace missing mandible and reestablish stability. Additionally skin from the leg is often included in the design of the flap to allow for thin, vascular tissue to also reconstruct an associated oral cavity defect if needed.
Complete removal of the pharynx or upper esophagus (swallowing tube) will require reconstruction in an attempt to get the patient swallowing again following surgery. This can be accomplished in several ways. Our preferred method involves the use of a short segment of small intestine which is removed with its supplying artery and vein, and the remaining bowel is put back together. The blood flow is reestablished by connecting the blood vessels of the intestine being transferred to vessels in the neck. The imported bowel is then used sewn into the swallowing tube defect, bridging the gap and accomplishing the first step toward swallowing rehabilitation. In cases where a simpler solution may be required, another option is to use muscle (pectoralis major) from the chest and its attached skin. This tissue is not disconnected as a free flap, but simply tunneled under the skin up to the defect in the neck with the skin used to reconstruct the swallowing tube gap, and the muscle used to wrap the repair and protect it. The pectoralis muscle flap is not our first choice for this problem, but it does provide a reliable second choice when the use of intestine is not an option for a patient with this problem.