|Year : 2018 | Volume
| Issue : 2 | Page : 177-178
The head-and-neck reconstructive surgeon
Consultant Oral & Maxillofacial Surgeon, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
|Date of Web Publication||26-Dec-2018|
Dr. Aakshay Gulati
Consultant Oral & Maxillofacial Surgeon, Queen Victoria Hospital NHS Foundation Trust, East Grinstead
|How to cite this article:|
Gulati A. The head-and-neck reconstructive surgeon. Ann Maxillofac Surg 2018;8:177-8
Reconstruction of postcancer ablation defects in the head-and-neck region poses a challenge but is a key in the patients' rehabilitation. The defects can have a devastating effect on appearance and function and can be disabling socially as well as adversely impact quality of life. The complex anatomy within this area makes us as surgeons continue to adopt newer, more novel techniques which restore anatomy and function while minimizing donor morbidity and ensure faster return to function.
Whereas previously pedicled and regional flaps formed the majority of reconstructive repertoire in the head and neck, the advent of microvascular free tissue transfer has largely superceded these techniques. As a result, the younger and newer breed of surgeon may not be so familiar with pedicled and regional flap reconstruction which can still prove to be invaluable in conditions such as vessel-depleted neck and patient suitability and in circumstances with limited resources. The pedicled pectoralis major, latissimus dorsi, and deltopectoral flaps have all proved to be reliable reconstructive options over the years with good outcomes. Locoregional flaps such as submental, nasolabial, supraclavicular, and facial artery musculomucosal flaps among others have their own indications and once again can be invaluable adjuncts in patient management. Knowledge and a certain degree of proficiency in these techniques will not go amiss with the modern reconstructive surgeon as they can prove to be an invaluable “bailout” in certain situations.
Nonetheless, ever since microvascular free tissue transfer was first described in oral cavity reconstruction in 1976,, the techniques and application have since progressed immensely and have become the gold standard in head and neck reconstruction., Conventionally used free flaps in the head-and-neck region include the radial forearm flap (RFF), rectus abdominis, fibula, and deep circumflex iliac artery free flaps. With improved familiarity and surgical training, universally reported higher survival rates of free tissue transfer (>90%–95%) have resulted in these techniques becoming increasingly reliable and the standard of care in the most head-and-neck centers. Reduction of the length of operating times with simultaneous two-team operating has contributed toward this as well fewer overall complications. The focus has thus gradually shifted from free flap survival to minimizing morbidity and maximizing faster return to function.
Adoption of newer techniques such as perforator dissection (as used in breast and extremity reconstruction) has hugely increased the number of free flap options in the head and neck. Innovators have demonstrated the reliability of the anterolateral thigh (ALT) free flap in head-and-neck reconstruction. Certainly, the versatility of the ALT free flap including the ability to repair relatively large defects and to use it in various chimeric combinations to reconstruct composite defects makes this flap the workhorse in my department. Tubed ALT flaps for circumferential pharyngeal reconstruction are also the preferred option in many centers. Other perforator flaps are also coming into vogue such as medial sural artery perforator flaps with the advantage of reducing donor morbidity compared to RFF due to the avoidance of a skin graft. Other perforator flaps such as peroneal artery perforator flaps can be used in conjunction with conventional fibula flaps again in chimeric combinations to reconstruct complex defects which previously would have required two free flaps.
Incorporation of computer-aided design technology is further helping in improving accuracy in bony reconstruction of the facial skeleton. Surgeons are becoming familiar with a different concept of “backward planning” (as used in dental implantology) with planning the occlusion and working backward to planning the optimal site and location of the osseous reconstruction of the mandible. The final aim of course is to provide the patient with the optimal dental and skeletal rehabilitation and restoration of function as closely as possible.
The average head-and-neck patient may have underlying medical comorbidities and the added insult of prolonged surgery and hospital stay can take its toll. Therefore, any strategy to optimize perioperative care and management of these patients is welcome. The use of noninvasive and minimally invasive hemodynamic cardiac output monitoring techniques and enhanced recovery pathways are employed routinely in our institution with the sole aim of providing a faster recovery and quicker return to function.
The modern reconstructive surgeon and team must be prepared to innovate and adopt newer techniques to improve outcomes for their patients while ensuring contemporary standards are met. However, at the same time, a sound knowledge and experience of the older techniques is a must to become a complete reconstructive surgeon.
| References|| |
Panje WR, Bardach J, Krause CJ. Reconstruction of the oral cavity with a free flap. Plast Reconstr Surg 1976;58:415-8.
Harashina T, Fujino T, Aoyagi F. Reconstruction of the oral cavity with a free flap. Plast Reconstr Surg 1976;58:412-4.
Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219-26.