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Tissue Replacement Surgery

When tissue is removed as part of your cancer treatment, known as ablative surgery, you may need a reconstruction with replacement of tissue. The reconstructive surgery will be performed either by the same surgeon who performed the ablative surgery or a surgeon who specializes in head and neck reconstruction.

When considering the best reconstructive option, issues of safety (protecting vital structures), form (restoring or improving appearance) and function (optimizing breathing, chewing and swallowing) will be taken into account. In general, the simplest reconstruction that achieves all of these goals is the best reconstruction.

To that end, if you are undergoing ablative surgery for treatment of a head and neck cancer, it is important to understand some basic reconstructive methods.

Healing by secondary intention

Healing by secondary intention is when the wound created by removing the cancer is allowed to heal and scar on its own.

A wound that heals by secondary intention requires close care and daily follow-up. Any packing or wound closure devices must be changed regularly to remove any dead tissue and promote healthy healing. You or a family member should be able to care for the wound on your own, but it might require the help of a nurse.

A few examples of when healing by secondary intention might be used are as follows:

  • Robot or laser-assisted transoral resection of oropharynx, tonsil, base of tongue or larynx tumors.
  • Resection of minor salivary gland cancer of the hard palate (roof of the mouth) that does not require removal of bone.
  • After removal of a skin cancer in very select areas of the face (such as the area between the corner of your eye and nose), letting the defect granulate on its own can result in an improved appearance.

Primary closure

The wound that is created by removal of the cancer is closed by bringing the edges together with stitches, staples, tape or special skin glue. These are the most common wound closure techniques when an incision is made in the skin without removing any skin. The end result is a thin scar located where the surgical incision was made.

Aftercare of a wound that is sealed by primary closure is quite simple. Your surgeon might ask you to avoid getting it wet for one to three days to prevent infection. Then, keep it out of the sun and/or apply sunscreen when you go outside to prevent discoloration of the scar. Over-the-counter scar creams can be used to help to improve the appearance of the scar.

Primary closure might be used when:

  • A surgical wound or incision is made to remove tissue somewhere in the neck or face, without removing skin.
  • There is an excision of small areas of skin along with removing deeper tissue in the face or neck.
  • There are small cancers of the oral cavity—such as on the tongue, inner aspect of the cheek or floor of mouth—that will not result in tongue tethering.

Skin graft

The wound that is created by removal of the cancer is covered with a thin layer of skin taken from another part of the body. A skin graft is a method of covering a wound with a very thin layer of skin that is removed from another part of the head or neck or another part of the body. The skin graft does not have its own blood supply, and it survives by the growth of blood vessels into the graft from the wound. This occurs over the course of approximately one week, during which time a dressing is usually sutured in place over the skin graft to keep it tight against the wound. If the graft does not pick up a new blood supply, then it will not “take” to the wound. A few disadvantages are associated with skin grafts. They can contract and lead to scar bands. When a skin graft contracts inside the mouth, it can lead to difficulty with speaking as well by tethering the tongue. Skin grafts must be placed over tissue with a healthy blood supply.

There are a few different types of skin graft that might be used:

Split thickness skin graft

Full thickness skin graft

Skin substitute

A split thickness skin graft involves cutting a very thin sheet of skin, usually from your thigh. The epidermis and a thin part of the dermis are removed as a sheet using a dermatome, a special instrument that cuts extremely thin slices of tissue. The wound is left to heal on its own but will require daily dressing changes to keep it clean. Once the skin graft is placed, your surgeon might place a bolster over the graft to secure it. A full thickness skin graft involves cutting a piece of skin from a healthy area using a scalpel. The epidermis and entire dermis are taken as a single sheet.Depending on the size of the full thickness skin graft that is removed, the wound created can be closed by primary closure, secondary intention or with a split thickness skin graft. Instead of taking a skin graft, some surgeons will use artificial, or synthetic, skin substitutes. While nothing works better than your own skin, using artificial skin reduces the risk of problems associated with taking a graft from another part of your body.

There are advantages and disadvantages to each of these techniques. The main advantages of a split thickness skin graft are:

  • A split thickness skin graft is more likely to “take” than a full thickness graft because it is thinner and thus easier for blood from the surrounding tissue to feed it.
  • The donor site (area from which the skin was taken) is left to heal without any sutures.
  • Large grafts can be taken with little problems (such as scarring and problems healing) at the donor site..

The advantages of full thickness skin grafts are:

  • There is less contracture (or shrinkage) of the graft.
  • If taken from a well-planned area, the final color match (and thus appearance) of the skin can be better than a split thickness skin graft.

A skin graft might be used to:

  • Cover exposed muscle or fascia after another form of reconstruction.
  • Line the remaining maxillary sinus after a maxillectomy to help with retention of a prosthesis.
  • Reconstruct thin eyelid skin.
  • Improve appearance after facial skin excisions.

Local (skin) flaps

 

A local flap involves rotating or moving skin from an area close to a surgical defect to close the surgical wound. A local flap—also referred to as a random flap—is not based on a defined artery and vein. The advantages of a local flap are that they are technically easier (but still require expertise and careful planning to get the best outcome) and are generally a better color match of the skin compared to skin grafts, regional flaps or free flaps. A disadvantage of using a local flap, based on a random blood supply of blood vessels under the skin, is that the size of the flap is quite limited, and there is always a risk that part of the flap might not survive.

Local flaps are typically used after skin cancer removals or removal of small superficial tumors on the face or neck.

Regional flap

 

A regional flap is tissue transferred from a part of the body in or near the head and neck region and rotated into the surgical defect. The blood supply to the flap is left attached, and the flap of skin and/or muscle is simply rotated with the blood supply as a pedicle. This does not require removing the flap entirely from the body prior to transplantation, which is what is required in performing a free flap.

Advantages of a regional flap are that post-operative care and monitoring are much less intense compared with a free flap; they are usually quicker than a free flap; large amounts of skin and/or muscle can be obtained; and if free flap surgical expertise is not available, regional flaps can provide a favorable result.

The disadvantages are that since the flap must remain tethered on its blood supply, you might have difficulty reaching the entire defect, and there is less flexibility in thickness of the flap compared with a range of available free flaps that can be brought up from all over the body.

Regional flaps used in head and neck surgery include:

  • Pectoralis major muscle flap (with or without skin)
  • Deltopectoral flap
  • Submental artery island
  • Supraclavicular artery island flap
  • Temporalis flap
  • Sternocleidomastoid flap
  • Scalping Flap
  • Trapezius flap
  • Latissimus dorsi pedicled flap
  • Paramedian forehead flap
  • Palatal Island Flap

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A regional flap might be used in a number of situations, for example:

  • For closure of a large defect in a patient who is not suited for free flap surgery due to other health problems or the lack of an available microsurgeon.
  • For closure of a salivary leak after reconstructive surgery, healthy muscle from the pectoralis major muscle is brought into the neck to protect vital structures from saliva and infection.

Free flap surgery

 

A free flap, also called free tissue transfer or microvascular reconstruction, involves removing a piece of tissue from one part of the body along with an artery and vein and transplanting it to another part of the body. The artery and vein of the flap are sewn to an artery and vein near the wound to give the flap a new blood supply. This is performed under the microscope using very fine sutures. Since the start of free flap surgery in the 1960s and 1970s, there have been numerous advances that include refinements in the surgical microscope and microsurgical instruments and microsutures used to sew together very tiny blood vessels as small as a millimeter in diameter. These refinements have enhanced the safety and predictability of microvascular surgery. However, expertise in performing microvascular surgery is required and is usually obtained through advanced fellowship training.

There are many advantages to using a free flap in the reconstruction of a defect after ablative surgery for cancer. Some advantages include:

  • The tissue is healthy and located at a distance from the site of any previous surgery or radiation.
  • Bone, muscle, skin, fat and nerves can all be transferred to the donor site to match the tissue that was removed as precisely as possible.
  • The flap can cover extremely large or small defects.
  • The skin of a free flap does not contract as is does with a skin graft.

The main disadvantages of a free flap are the requirements for special technical expertise, extra surgical time and close monitoring of the flap to identify and correct any blood supply problems. The artery and vein that are sewn together are only a few millimeters in size, and they can clot and lead to failure of a free flap. When this happens, you will require either an additional free flap or another type of reconstruction that might not be as good as a free flap.

Free tissue can be taken from just about anywhere in the body as long as there is a good artery and vein feeding the flap. Some of the more common types of free flaps and examples of their use in head and neck reconstruction include:

MUSCLE AND MUSCLE+SKIN FREE FLAPS

Rectus Abdominus Either thick skin with healthy muscle or healthy muscle alone
  • Total tongue
  • Skull base
  • Scalp
Gracilis A small, thin muscle with a nerve
  • Facial nerve reanimation (link to next section)
Latissimus Dorsi A very large, thin sheet of muscle, with or without overlying skin
  • Scalp
  • Skull base
  • Protection of neck contents

FASCIA AND FASCIA + SKIN FREE FLAPS

Radial Forearm Very thin, pliable skin that can line large defects or be turned into a tube
  • Oral cavity defects
  • Partial tongue
  • Skull base
  • Partial or total pharynx
  • Hard and soft palate
  • Lip

 

Anterolateral Thigh Thicker skin for slightly larger defects
  • Total or subtotal tongue
  • Partial or total pharynx
  • Skull base
  • Midface

 

Temporoparietal Fascia Ultra-thin, well-vascularized fascia that has great draping and coverage features
  • Temporal bone
  • Orbit
  • Ear
  • Partial larynx

 

Lateral Arm Similar to anterolateral thigh, in which skin slightly thicker than a radial forearm free flap is required
  • Oral cavity
  • Partial tongue

 

BONE + ADDITIONAL TISSUE FREE FLAPS

Fibula Reliable long bone, with or without skin
  • Mandible
  • Maxilla
  • Most bone defects of the head and neck

 

Scapular System Multiple mobile components including bone, skin and muscle
  • Bone defects that require a lot of tissue
  • Bone defects where the fibula cannot be safely used

 

Iliac Crest Very large bone and soft tissue components
  • Total mandible
  • Very large bone and soft tissue defects

 

Radial Forearm with Bone Thin, pliable skin combined with a thin piece of bone
  • Maxilla
  • Orbital floor

 

VISCERAL FREE FLAPS

Jejunum Part of the small intestines, already tubed like a pharynx or esophagus
  • Total pharynx and esophagus

 

 

Free Omentum and Gastro-Omentum Lots of healthy fatty tissue that can fill crevices in the head and neck
  • Protection of the neck contents
  • Facial contour