HEAD AND NECK CANCER AND RECONSTRUCTION

Author: Dr Adrian Ooi
Head and neck cancers account for 3% of all cancers and consist of tumors affecting any region of the head and neck, including the scalp, skin, oral cavity, nasopharynx, paranasal sinuses, oropharynx, larynx, hypopharynx and esophagus. Depending on tumor type and extent, treatment modalities include a combination of surgery, radiotherapy and chemotherapy. Plastic surgeons are heavily involved in the management of head and neck cancer patients, most notably for reconstruction of defects post tumor removal. Many of these defects can be large and potentially extremely debilitating. The goal of the plastic surgeon is to restore appearance and function to as close to normal as possible.

To achieve these goals, plastic surgeons utilize a range of surgical techniques, such as grafting and flap surgery, to restore like-with-like. The kind of reconstructive method will vary according to the defect characteristics. Flap surgery involves mobilizing healthy tissue with a known blood supply from another part of the body reconstruct the defect which results from cancer removal. This may involve mobilizing local or regional tissue (pedicled flaps), or involve the use of reconstructive microsurgery (free flaps) where specialized operating microscopes and precision instrumentation are used to repair intricate structures such as blood vessels and nerves less than a few millimeters in diameter. The versatility which microsurgery provides gives plastic surgeons the best options for restoring any defect.

  • Examples of local/regional flaps used in head and neck reconstruction
    • Scalp rotation flaps
    • Forehead flaps
    • Cheek advancement flaps
    • Nasolabial flaps
    • Facial artery musculo-mucosal (FAMM) flaps
    • Submental flaps
    • Supraclavicular flaps
    • Pectoralis major flaps
    • Deltoacromial flaps
    • Trapezius flaps
    • Latissimus dorsi flaps
  • Examples of free flaps used on head and neck reconstruction
    • Anterolateral thigh (ALT) flaps
    • Fibula osteocutaneous flaps
    • Forearm flaps
    • Medial sural artery perforator flaps

TREATMENT

  • During the pre-operative consultation, the following may occur
    • Evaluation of your general health status and any pre-existing health conditions or risk factors
    • Examination of recipient and donor sites
    • Medical photography
    • Discuss your options and recommend a course of treatment
    • Discuss likely outcomes of the specific microsurgical procedure and any risks or potential complications

  • Surgery

    Head and neck reconstructive procedures are usually performed under general anesthesia for patient comfort due to the extent of the procedure and the often extended duration.


    The extirpative surgeon will perform the tumor removal, while the reconstructive surgeon harvests the tissue required for replacement at the defect (this is often done simultaneously. These are long procedures which can span 10-14 hours.

  • Post-Surgery Care

    In the immediate post-operative period, you will have wounds at the head and neck region and the donor sites, with multiple drains and possibly feeding and tracheostomy tubes. You will be nursed in a high dependency unit for a couple of days, and once more stable, transferred to the general ward. You will be adequately covered with pain relief, and therapists will help with your recovery. Gradually, you will be allowed to mobilize. There will be expected swelling at the operative sites in the initial period, which subside over the course of the following weeks. When to return to oral feeding is dependent on the surgery performed. Many head and neck cancers require other treatments such as radiotherapy and chemotherapy. These modalities can be discussed with your surgeon post-operatively.


    Please follow instructions from your doctors and the allied health teams regarding your recovery. Keep your wound sites clean and dry, and use any splints as instructed. It is imperative that you do not smoke for at least 1 month after surgery. Seek immediate help if you develop a fever >38 degrees C, there is a change in the colour of your flap, or there is abnormal redness, pain or swelling at the operative sites.


COMPLICATIONS AND MANAGEMENT

Healing after skin tumour excision with or without reconstruction is usually uneventful. Minor complications such as localized infection and Healing after external defect reconstruction is usually uneventful. Minor complications such as localized infection and bleeding may occur, and in most instances can be managed with antibiotics and local pressure respectively. Very rarely is an unplanned return trip to the operating room required. You may require follow up procedures for touching up of the reconstruction to get things just right.

For internal/intra-oral defects, early complications include issues with flap circulation, neck abscess formation and salivary leak. These should be addressed emergently and you may require a re-operation. While your surgeon will always try their best to ensure all the goals are achieved in a single surgery, there is always a risk of complications.

General risks of microsurgery include, but are not limited to:
  • Bleeding
  • Infection
  • Poor healing of incisions
  • Hematoma
  • Anesthesia risks
  • Fluid accumulation (seroma)
  • Skin loss or tissue necrosis
  • Numbness or other changes in skin sensation