As the management of head and neck cancer has evolved over the last decade, so too has the reconstruction of defects created by ablative surgery. Because of the level of confidence in transferring tissue of various types, thickness, and dimensions to achieve the desired goal, the overall level of sophistication has increased in the various subsites that are restored. As head and neck reconstructive techniques have evolved from the era of pedicled flaps to that of free tissue transfers, the focus has become less of simply covering a defect or “closing a hole” but rather addressing the multifactorial problems of restoring a region to a level of form and function that best replicates the predisease state.

The last two decades have been dominated by the application of microvascular surgery to the head and neck; the early emphasis was on discovering new donor sites for hard and soft tissue and later on a more detailed understanding of the recipient site required to select the best reconstructive technique. Just as head and neck cancer demands a multidisciplinary approach that tailors the treatment of the disease, so too does the reconstructive component in which there is a need for several disciplines working in a collaborative manner. The reconstructive/rehabilitative team should include a reconstructive surgeon, an oral and maxillofacial surgeon, an oral and maxillofacial prosthodontist, an oculoplastic surgeon, and a speech pathologist. Preoperative assessment of each patient by the appropriate disciplines helps ensure that all considerations are taken into account before embarking on the implementation of the reconstructive plan. A careful assessment of the tumor and a prediction of the anticipated three-dimensional defect will help the team anticipate the need for hard and soft tissue as well as prosthodontic rehabilitation. The reconstructive team must determine the goal for each individual patient, which is a balance determined by the components of the defect, the biology of the disease, the comorbidities and motivation of the patient, the wound-healing properties of the recipient site determined by exposure to prior therapy, the patient’s nutritional status, and their continued usage of alcohol and tobacco. The goals, therefore, may vary for different patients faced with the same subsite defect because of these variables. If bone is to be a part of the reconstruction, then determination of the method of fixation must be established to ensure flap stability until bony union has occurred. In pediatric patients, there are special considerations related to the impact of bone harvest on the donor site. In addition, there is often a preoperative plan to remove fixation hardware in the early postoperative period, so that growth of the maxillofacial skeleton can continue unencumbered by rigid framework. Meticulous execution of the reconstructive plan must be followed by the appropriate rehabilitative therapy to maximize the recovery of function. The reconstructive team must be dynamic in its approach so that unforeseen circumstances that arise can be addressed during surgery. A positive surgical margin, for example, can substantially alter the reconstructive plan; a larger flap or even one from a different donor site may be required to accomplish the desired goal. Outcome measures specific to each subsite should be critically evaluated to determine the level of functional recovery. The monitoring and evaluation of function that results from reconstructive efforts are essential to the continued progress of these sophisticated and essential techniques. The continued refinement of approaches and the determination of the optimal reconstructive strategies depend on it. Centers vary their approach based on the collective experience and professional expertise within their respective institution, ideally based on this process of critical assessment of the outcome of their reconstructive approach.

The classification of defects is a critical undertaking that allows the reconstructive team to organize its approach to a particular subsite and to communicate, predict, and evaluate functional outcomes. Just as cancer staging provides a common lexicon for treating physicians that leads to therapy selection, prognostication, therapeutic outcomes, and to grouping of similar patients for outcomes analysis, defect classification does the same in head and neck reconstruction. The staging systems that are used to define cancers in particular subsites of the head and neck do not allow sufficient definition of the defect to permit accurate treatment planning. The size of an oral cancer and whether it has invaded mandible or maxilla determines the T stage for that cancer, but it does not provide the necessary ingredients for an accurate selection of the optimal reconstructive technique. This is determined by predicting what soft tissues and how much bone is to be removed. By estimating this, a more meaningful determination of what tissues must be harvested to restore form and function. Cancers of similar dimensions arising in the tongue and the buccal mucosa may lead to similar oncologic staging, but create very different demands for the reconstructive endeavor. Similarly, invasion of bone of the hard palate and the mandible may lead to a comparable T4 oncologic stage, but very different needs and strategies for functional reconstruction/rehabilitation. Moreover, different portions of the mandible and the presence of dentition will lead to very different reconstructive considerations that must be accounted for in the classification of that defect, none of which is addressed in the tumor staging.

The desirability of using prosthetic restoration, whether it be for dental, auricular, nasal, ocular, or facial restoration, must be determined in the early stages of treatment planning and must be communicated to the patient in a very thoughtful discussion in which they are allowed to articulate their concerns regarding the use of prosthetics versus native tissue to achieve the final goal. Although the restoration of dentition with a conventional denture or more favorably with an implant-supported prosthesis is very well accepted, patients, more often than not, have very strong feelings regarding the application of a prosthetic solution, instead of their own tissues, for restoration of a part or all of the ear, nose, or face. In the past, the concern about loss of retention of the prosthesis to the facial tissues often led to less favorable patient satisfaction. This has largely been overcome by the application of osseointegration and fixation to achieve prosthetic stability and retention. However, there remains a significant bias by patients regarding the use of a prosthetic nose or ear that may lead them to select reconstruction, albeit with the acceptance of a less favorable aesthetic result. It is imperative that the reconstructive team embarks on very frank discussions with the patient and his or her family regarding the availability of a skilled prosthodontist and a skilled reconstructive surgeon with experience in restoring the particular defect at issue. Patients with devastating defects must be provided realistic counsel and perhaps offered alternative centers to undergo treatment. If implants are to be placed to achieve the desired outcome, then consideration must be given to the volume and quality of the underlying bone, the quality of the overlying soft tissue, and the timing of implant placement with respect to the institution of adjuvant radiation. Radiation alters the process of osseointegration and, therefore, compromises the overall success of the implants. Discussion of implant placement and radiation will be provided later in the chapter.

Although much of the emphasis in contemporary head and reconstruction surgery is placed on achieving an optimal restoration, the ability to shorten the recovery from ablative/reconstructive surgery has significant implications for the outcome of the cancer treatment. It is therefore essential for the reconstructive team to outline a restorative strategy that achieves a suitable “packaging” of the entire surgical treatment and recovery in an appropriate time period. The achievement of these goals depends, of course, on the performance of these reconstructive efforts by experienced teams of experts who are able to accomplish this in a predictable and reproducible manner.

The debate of whether it is more appropriate to perform a delayed or primary reconstruction has been waged over the past several decades as primary reconstruction has emerged as a highly predictable and reliable technique. The notion that a delay in reconstruction helps to make patients appreciate more fully the delayed reconstructive efforts may be valid in select subsites such as the nose and the auricle. More often than not, however, such an approach leads to inferior reconstructive results for mandible and maxilla, where primary reconstruction offers superior outcomes. The use of surveillance imaging performed in a sequential manner during the posttreatment period provides a useful method of monitoring the reconstructive site once the bone has been placed to restore the defect. Granted, the hardware that is used to achieve rigid fixation somewhat distorts, and therefore compromises the images, but despite these associated problems the value of improved function and dental rehabilitation that can be achieved by primary reconstruction far outweighs the drawbacks. Specific functional outcome studies for each of these two subsites will be discussed in detail later in the chapter.

In addition to the variables specific to the patient, the selection of donor sites for both hard and soft tissues will be influenced greatly by the experience level of the reconstructive team. The adage that “simple is better” continues to have relevance in reconstructive decision making, that is to say, the concept of starting with simple and moving to complex methods should be considered for each reconstructive challenge. Although selection of a simpler technique may utilize a less demanding procedure, it is imperative that all aspects of that procedure be anticipated and understood. A good example of that planning discipline is the decision-making process for reconstructing the floor of mouth. Although it may be tempting to use a split-thickness skin graft for the sake of expediency, the surgeon and the patient must understand the implications of failure of “graft take” on the mobility of the tongue and the architecture of the oral cavity. It must be understood that if an untoward outcome such as loss of a graft should occur, then wound contracture will result in a compromised functional result that can only be partially corrected by further reconstructive efforts.

There are a number of regional flaps that continue to play an important role in the management of patients with head and neck cancer. Certain donor sites, such as the forehead were commonly used as a source of flaps for head and neck reconstruction in the 1960s, but are rarely utilized in contemporary reconstruction. There does, however, remain an important role for the pectoralis major flap, the deltopectoral flap, the trapezius flap(s), and the latissimus dorsi flap. Additionally, there are newer regional sources of soft tissue such as the submental flap, the temporalis and temporoparietal flaps, and the posterior scalping flap. The role of regional flaps serving as carriers for vascularized bone has largely been eliminated due to the emergence of flaps harvested from the fibula, the scapula, the iliac bone, and the radius, which are all much more reliable donor sites for the restoration of the maxillomandibular skeleton.

In the contemporary era of head and neck cancer management, there are certain subsites such as the oropharynx and the laryngopharynx in which ablative surgery is usually reserved for the salvage setting or for less common types of neoplasms such as those arising from the minor salivary glands. There are centers where primary surgery, whether endoscopic, robotic, or open, is applied. It is safe to say, however, that for both the oropharynx and the laryngopharynx, the role of surgery is usually relegated to failures of primary radiation with or without chemotherapy. There are special considerations when performing reconstruction in a patient who has severely compromised tissues as a result of extensive prior treatment. An increased likelihood of wound breakdown and salivary fistula must be accounted for in the reconstructive strategy, and every effort to prevent these sequelae should be instituted. This usually includes the importation of healthy muscle to provide coverage of the carotid artery as well as the microvascular pedicle if a free flap has been transferred; this muscle may come with the free-flap donor site or may require a second donor site, often the pectoralis major muscle flap (Fig. 8-1). There are additional issues related to the availability of recipient vessels in patients who have undergone extensive prior surgery that often makes the conventional recipient vessels unsuitable for use in a microvascular transfer. Knowledge and experience in harvesting recipient vessels, such as the thoracoacromial vessels or the internal mammary artery and vein, are sometimes required to achieve a successful reconstructive result.^1,2

In keeping with the organization of much of this book, this chapter has been organized according to the various subsites of the head and neck. In each subsite discussion, the major considerations for reconstruction and the defect classification scheme that the authors feel best defines the extent of the reconstructive problem will be presented. In addition, functional outcomes studies, when available, will be reviewed to help understand the impact of the reconstructive techniques on the functional recovery of the patient. A section covering various topics in maxillofacial prosthodontics will be presented to complete a comprehensive
discussion of contemporary head and neck reconstruction/rehabilitation. Unfortunately, the constraints on the length of this chapter do not permit every subsite to be presented. The authors have selected the most common subsites and the topics in which new data are available since the publication of the prior edition of this text.