Oropharyngeal reconstruction: current state of the art

Oropharyngeal reconstruction represents one of the greatest challenges in the surgical rehabilitation of patients with head and neck cancer. This article reviews several reconstruction methods, starting with the primary closure and healing by secondary intention all the way to the complex sensate microvascular flap reconstructions. Small defects such as tonsillar, small tongue base, and partial palatal defects may be closed primarily or left to granulate. This is assuming that there is no communication with the neck or bone exposure. Local flaps such as the palatal island, submental, and buccal mucosal flaps are used to close small to moderate-sized defects. Split-thickness skin grafts are also appropriate for small to moderate-sized defects. Larger defects such as total palatal, more than 50% of the tongue base, and composite tongue base/palatal/pharyngeal defects may be closed with regional myocutaneous pedicled flaps such as the pectoralis major, lower trapezius, or latissimus dorsi pedicled flaps. Microvascular tissue transfer is an excellent alternative for closure of moderate to large-sized defects. Free tissue transfer includes the radial forearm and the lateral arm free flaps. Both of these can have a sensory component. Free jejunal flaps are used for total or subtotal hypopharyngeal defects. Free gastro-omental flaps may be used for oropharyngeal and hypopharyngeal reconstruction as well. For defects involving bone, fibular flaps are an excellent option and can provide sensation. The scapular free flap may be used as well and offers the advantage of having two skin paddles (scapular and parascapular) for internal and external lining. Following a reconstructive ladder is extremely important in ensuring good function and, hence, improved quality of life.     

Extensive defects of the sino-orbital region. Results with microvascular reconstruction.

We performed microvascular free-tissue reconstruction of extensive defects in the sino-orbital region in 11 patients. Reconstructions were immediate in 10 patients and delayed in one patient. There was loss of orbit in eight patients, maxilla in eight patients, cranial base in two patients, and skin and soft tissue of the face in six patients. Nine rectus abdominis flaps, one radial forearm flap, and one lateral arm flap were used. Palatal reconstruction with autologous tissue was successful in all patients. Cranial base repairs healed without sequelae or evidence of meningitis. Cosmetically, soft-tissue repair of facial skin was only satisfactory. For large defects, it was difficult to reconstruct the palate and facial soft tissue and to maintain nasal airway patency with a single microvascular procedure. Free-tissue transfers remain the safest and most versatile reconstructive procedure for massive sino-orbital defects after ablation of a tumor.     

The use of palatal island flaps as an adjunct to microvascular free tissue transfer for reconstruction of complex oromandibular defects

OBJECTIVE: To determine the efficacy of using palatal island flaps in combination with free tissue transfer for reconstruction of large, complex oral cavity defects. STUDY DESIGN: Prospective evaluation of patients with large, combined defects of the oral cavity reconstructed with palatal flaps in conjunction with microvascular free tissue transfer. METHODS: Elevation of a palatal flap was performed after completion of tumor resection. The flap was rotated and secured into place. A free flap was then harvested and inset to reconstruct the remaining oromandibular defect. Free flaps included the rectus abdominis (6), fibula (16), and radial forearm (6). RESULTS: Large complex oral cavity defects were repaired with a palatal island flap in conjunction with microvascular free tissue transfer in 28 consecutive patients. There were no complications associated with this flap. CONCLUSION: Maximal functional rehabilitation of large, complex oral defects requires independent reconstruction of the various regions of the oral cavity rather than single flap reconstruction. When used as an adjunct to free tissue transfer, the palatal island flap offers a reliable method for reconstructing large combination defects.     

Microvascular tissue transplantation of the ear, nose and throat

Free tissue transfers are a versatile method of reconstruction in head and neck surgery. In the pharynx and oral cavity the functional result dictates the choice of flap. For these sites thin and pliant fasciocutaneous flaps are ideal tissue transfers, and we favour the radial forearm flap which is raised from the distal volar forearm. This flap is easy to dissect and the donor defect, which is grafted with split skin, does not inconvenience the patient. For reconstruction of thicker defects we prefer bulky myocutaneous flaps such as the latissimus dorsi, which has a reliable pedicle of adequate length. The rectus abdominis flap, if taken with peritoneum, is useful for reconstruction of large cheek defects involving all layers; the peritoneum replaces the oral mucosa. For hypopharyngeal reconstruction the free jejunal loop has advantages compared with local skin or myocutaneous flaps, since it is a one-stage procedure with a low rate of post-operative fistulae. In some cases of reconstruction of the oral cavity and oropharynx we have used a jejunal patch, but in general we prefer the radial forearm flap, since it is more resistant to mechanical trauma. The advantage of a free tissue transfer is its excellent blood supply, which makes it possible to apply these flaps in irradiated and infected tissue. It is important in microvascular tissue transfer to choose an appropriate flap for the size and depth of the resection. It is only necessary to be familiar with those transfers most commonly used in this region.     

Improving outcomes of locoregional flaps: an emphasis on anatomy and basic science

PURPOSE OF REVIEW: There has been renewed interest by surgeons in locoregional flaps for facial renconstructive problems previously thought to be optimally managed by microvascular tissue transfer. Complication rates of locoregional flaps are similar to those of free flaps. Successful reconstruction using local flaps is largely based on an understanding of regional vascular anatomy. RECENT FINDINGS: Sternocleidomastoid and trapezius muscle flap studies have elucidated patterns of arterial and venous anatomy to allow for improved flap design. Perioral vascular studies in cadavers demonstrate consistent and reliable patterns of blood supply. The terminal vascular anatomy of the submental island flap has been recently studied. The reverse-flow submental artery flap has been used to reconstruct periorbital soft tissue defects. Preliminary studies show that a full-thickness forehead flap can be utilized to simultaneously reconstruct both the external and internal surfaces of the nose. Basic fibroblast growth factor has been found to have a protective effect on random skin flap viability. SUMMARY: Locoregional flaps remain a useful tool for head and neck reconstruction, and often provide unique characteristics not available with free flap reconstruction. A sound understanding of vascular anatomy and recent basic science discoveries will significantly improve success of locoregional reconstruction.     

Pedicled temporoparietal fascial flap reconstruction of select intraoral defects

OBJECTIVES/HYPOTHESIS: Multiple modalities exist for reconstruction of oral cavity defects following resection. Although microvascular free tissue transfer is often the first choice for complex intraoral defect reconstruction, not all patients are suitable candidates for "free flaps." The authors present their experience with the pedicled temporoparietal fascial flap (TPFF) for reconstruction of selected intraoral defects. STUDY DESIGN: Retrospective chart review. METHODS: Charts of patients who underwent a TPFF for reconstruction of intraoral defects at a tertiary academic institution between 2001 to 2003 were reviewed. Information regarding tumor, surgical procedure, complications, and results was gathered. The anatomy and surgical technique of using the TPFF for intraoral reconstruction were reviewed. RESULTS: Three patients underwent reconstruction of an intraoral defect with a TPFF. All defects were on the lateral buccal space with significant anterior or posterior extension. All patients had specific contraindications for free flaps, including compromised donor site or recipient site vascularity and medical comorbidity. The procedures were uncomplicated. There was no incidence of flap failure, and all flaps accepted a split-thickness skin graft. The average hospital stay was 7 days. An oral diet was begun on the fifth postoperative day. The cosmetic result at the donor site was excellent. Follow-up has ranged from 7 to 30 months. Mild contracture of the flap developed in two patients, limiting mandibular motion. CONCLUSION: The TPFF is a thin, vascular, durable flap that is a viable option for reconstruction of selected intraoral defects in patients who are not suitable candidates for other methods.     

Utilidad y versatilidad del colgajo en isla de la arteria supraclavicular en reconstrucción de cabeza y cuello

Introduction

The supraclavicular island flap is a rotational pedicled flap and may have some advantages in head and neck reconstruction compared with free-tissue transfer when this kind of reconstruction is not affordable or recommended.

The free scapular flap for head and neck reconstruction

The free scapular flap is a versatile flap for soft tissue and bony reconstruction of the head and neck. It has a very reliable blood supply and is easy to harvest. In this paper, we present our cumulative experience with the use of five cutaneous flaps and 31 osteocutaneous flaps.     

Flap Reconstruction of the Upper Face: Free Flaps VS. Lower Trapezius Myocutaneous Flap

ABSTRACT. The immediate one-stage reconstruction of the upper facial cutaneous defects were performed by using two different flaps. In the first representative patient a microvascular free flap was used; in a second case, the lower trapezius myocutaneous flap was used. Free flaps probably are ideal for the correction of such defects in one stage. This procedure requires specially trained surgical teams and longer operative time. A reliable alternative is the lower trapezius myocutaneous island flap. This offers a flap that is thin, hairless and of uniform thickness. The length and thickness of its pedicle allows excellent mobility and leaves no bulky neck deformity. Both these reconstructive techniques satisfy the need for viable replacement in large upper facial and scalp defects coupled with a satisfactory cosmetic outcome.     

The scapular osteofasciocutaneous flap: a 12-year experience.

OBJECTIVE: To elucidate the factors that play a role in the decision-making process to use the scapular donor site, we have reviewed our 15-year experience with 57 clinical cases, to our knowledge the largest case series to date. DESIGN: Retrospective, single-surgeon medical record review. PATIENTS AND METHODS: Retrospective review of 57 consecutive cases (53 patients) involving mandibular and maxillary reconstruction using bone-containing scapular free flaps over a 15-year period. Composite flap composition as well as donor and recipient site complications were recorded. RESULTS: Forty-one reconstructions were performed for mandibular defects, 11 were performed for maxillary defects, and 5 for combined defects involving the mandible and maxilla. Seven flaps were composed of 2 separate bone flaps using the angular branch and the circumflex scapular artery. A total of 6 flaps were failures in 5 patients, giving an overall success rate of 89%. CONCLUSIONS: The subscapular system of flaps is a versatile donor site that offers distinct advantages in the older patient population as well as in patients with a preexisting gait disturbance. It is particularly advantageous in patients requiring a large surface area of soft tissue to restore their defect.     

Vascularized bone graft is a better option for the reconstruction of maxillary defects

We read the article of Kinnunen et al., which evaluated the result of maxillary defects, and feel some objections. We present our considerations of their operative indication and thoughts based on our surgical experiences. Defects after palatectomy, which have left no dentition for the retention of an obturator, require vascularized bone-containing free flaps. Local flaps are available in only small defects of Class 1 and 2a. Most palatomaxillary defects following malignant tumor abrasion are classified as 2b, 2c, 3, or 4, which require microsurgical free flap transfer combined with bony reconstruction. Regarding bony reconstruction, non-vascularized bone grafts tend to be absorbed. Thus, we believe that bony reconstruction should be performed with vascularized bone. We agree with the authors’ comment that PTMF may be useful in repairing defects due to complications in microvascular procedures in the palatal area. However, even when bone segment is required for salvage surgery, using a vascularized bone flap is more preferable. A parietal bone-fascial-periosteal flap based on the superficial temporal vessels is a suitable and reliable bone flap for the reconstruction of a maxillary defect following free skin flap transfer to the palate.     

The rhombotrapezius myocutaneous and osteomyocutaneous flaps

As more radical surgery is being performed for head and neck cancer, an increasing variety of flaps for reconstruction have been developed. The more common myocutaneous flaps for large defects are the pectoralis major, trapezius, and latissimus dorsi flaps. The lower trapezius flap, which is used for reconstruction of large lateral facial defects, is a relatively thin flap. The rhombotrapezius flap described in this article provides bulk for augmentation of facial defects. The flap, which includes the trapezius and rhomboid muscles, also offers a longer pedicle with a greater arc of rotation. This flap may include the medial border of the scapula when bone is necessary. The addition of the rhomboid muscles incorporates the dorsal scapular artery, which gives an additional blood supply to the flap. We believe that the rhombotrapezius, myocutaneous, and osteomyocutaneous flaps have a significant advantage over previously described flaps in the treatment of defects that need greater bulk and length for adequate reconstruction.     

The combined latissimus dorsi-scapular free flap in head and neck reconstruction.

Microvascular free tissue transfer techniques offer great versatility in the selection of tissue for reconstruction of head and neck defects. The system of flaps based on the subscapular artery and vein provides the widest array of composite free flaps. The possible flaps that can be harvested based on this single vascular pedicle include the scapular and parascapular skin flaps, the serratus anterior and latissimus dorsi muscle flaps, and the lateral scapular bone flap. In addition, a segment of vascularized rib can be transferred with the serratus anterior and latissimus dorsi muscles. Large cutaneous defects can be resurfaced by combining the latissimus dorsi and scapular flaps. Another advantage of this combined flap is the independent vascular pedicles of its components, which allow freedom in orientation of the various tissue segments. Thus, the combined flap can be helpful in reconstructing complex three-dimensional composite defects of the head and neck. In addition, by reinnervating the muscle portions of this flap, bulk can be preserved and an improved functional reconstruction of the oral cavity achieved. A review of the literature shows three previous reports utilizing this combination of flaps in five patients. We report the use of the combined latissimus dorsi-scapular free flap in six patients to reconstruct massive composite defects of the oral cavity, midface, and scalp. There was one flap failure, which was successfully reconstructed with the contralateral latissimus dorsi-scapular flap. The anatomy of this flap is reviewed, and the indications for its application are discussed.     

Functional outcomes after free flap reconstruction of the upper aerodigestive tract

PURPOSE OF REVIEW: When the complex structures of the upper aerodigestive tract are disrupted after resection of head and neck tumors, an appropriate reconstructive option should be chosen in an attempt to regain maximum function. Reconstructions using microvascular free tissue transfer offer unparalleled flexibility, both in tissue composition and in placement. This article will examine functional outcomes after free flap reconstruction of the upper aerodigestive tract. RECENT FINDINGS: With the maturation of free tissue transfer techniques, functional outcomes are being analyzed with increasing frequency. Recent reports show promising results for free flap reconstruction of oral cavity, oropharyngeal, and hypopharyngeal soft tissue defects, as well as for bony mandibular and maxillary defects. SUMMARY: For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free flaps provide good functional outcomes. In the future, randomized studies are needed to compare the functional outcomes of microvascular free flaps with those of other reconstructive options.     

Reconstruction of the through-and-through anterior mandibulectomy defect: indications and limitations of the double-skin paddle fibular free flap

Objectives/Hypothesis: The purpose of this report is to describe our recent experience using a double‐skin paddle fibular free flap (DSPFFF) for reconstruction of the through‐and‐through anterior mandibulectomy defect and to present a reconstructive algorithm based on the extent of lip and mental skin resection. Study Design: Retrospective review of 10 consecutive patients with through‐and‐through anterior mandibulectomy defects. Methods: Outcomes that were examined included methods of reconstruction based on the cutaneous defect, flap complications, fistula rate, and donor site complications. Results: Seven patients were reconstructed with a DSPFFF. For lip reconstruction, two patients were also concomitantly reconstructed with Karapandzic or lip advancement flaps. Three patients were reconstructed with both a fibular free flap and a second free flap (1 radial forearm fasciocutaneous flap and 2 anterolateral thigh flaps). The transverse dimensions of the DSPFFFs were as great as 15 cm. None of the patients developed a fistula. All free tissue transfers were successful. One patient developed partial loss of the fibular skin paddle used for submental skin replacement. Conclusions: DSPFFF is a safe and reliable way to reconstruct an anterior through‐and‐through mandibular defect. Indications for using a DSPFFF are 1) a cutaneous defect that lies at or below the plane of the reconstructed mandible, 2) a transverse width of the oral mucosa and cutaneous defect that does not exceed 15 cm (the approximate distance from the mid‐calf to the anterior midline), and 3) a lip defect that, if present, can be reconstructed with local flaps.     

The palatal island flap for reconstruction of palatal and retromolar trigone defects revisited.

BACKGROUND: Although a host of local soft tissue flaps have been described for the reconstruction of postoperative palatal defects, tissue-borne palatal obturators remain the most common form of rehabilitation of these defects. The palatal island flap, first applied to the reconstruction of the retromolar trigone and palatal defects, was first described by Gullane and Arena in 1977. This single-staged mucoperiosteal flap offers a reliable source of regional vascularized soft tissue that obviates the need for prosthetic palatal rehabilitation. OBJECTIVE: To describe a series of 5 cases in which the palatal island flap was used as a primary palatal or retromolar reconstruction. METHODS: We have retrospectively reviewed 5 consecutive cases between March 1998 and August 1999 wherein palatal island flaps were used for the primary reconstruction of postablative palatal defects. Each case was reviewed for primary pathologic findings, postoperative wound complications, postoperative speech and swallowing, and donor site morbidity. Selection of this reconstructive technique was based on the size and location of the defect and the assessment by the surgeon that the arc of rotation and amount of residual palatal mucosa were appropriate. RESULTS: Six local palatal island flaps were performed on 5 patients who had not undergone irradiation (1 patient underwent bilateral flaps). The primary pathologic findings included T1 N0 squamous cell carcinoma, T4 N0 squamous cell carcinoma, T2 N0 low-grade mucoepidermoid carcinoma, pigmented neurofibroma, and T2 N0 low-grade clear cell carcinoma. All of the lesions were located on the hard or soft palate or the retromolar trigone, and the average defect size was 7.2 cm(2). All 5 patients began an oral diet between postoperative days 1 and 5 (mean, 2 days), and all patients were discharged home without postoperative donor site or recipient site complications between days 1 and 6 (mean, 3 days). Donor site reepithelialization was complete by 4 weeks in all 5 patients. CONCLUSIONS: The palatal island flap offers a reliable method of primary reconstruction for limited lesions of the retromolar trigone and hard and soft palate. The mucoperiosteal tissue associated with this flap is ideal for partitioning the oral and nasal cavities and obviates the need for prosthetic palatal obturation.     

Reconstruction with peroneal free flap after ablation of head and neck cancer]

One-stage reconstruction of head and neck defects following radical surgery was performed for two patients with the peroneal flaps which had the peroneal artery, vein and their branches as a pedicle. These flaps were viable without any post-operative complications. The advantages of these flaps are described as follows. (1) The subcutaneous fat is thin, and thus the flap is flexible and not bulky. (2) The diameters of the peroneal artery and vein are relatively large and the pedicle is long. (3) A pretty large size of the flap can be utilized. (4) A relatively long bone can be obtained together with skin at the same time, and the angle of the fibula can be easily changed. (5) Bleeding is little when the flap is taken out. (6) The resection of the tumor and the harvest of the flap can be done at the same time, due to different surgical areas. (7) The skin graft to the donor defect is not necessary, and the defect can be closed at one-stage. (8) The donor site does not stand out. Thus, this method is cosmetically excellent. This procedure has many advantages. Reconstruction with the peroneal flap offers a safe, reliable, and versatile method.     

The anterolateral thigh flap: radial forearm's "big brother" for extensive soft tissue head and neck defects

OBJECTIVE: The anterolateral thigh flap has recently been rediscovered in Asia as a perforator flap. The objective of this study was to describe the reliability and donor morbidity of the anterolateral thigh flap for head and neck reconstruction without transmuscular perforator dissection. DESIGN: Consecutive case series by a single surgeon. SETTING: A regional tertiary-referral head, neck, and skull base surgical oncology center. PATIENTS: The first 34 consecutive patients. INTERVENTION: Microvascular reconstruction with an anterolateral thigh free flap. MAIN OUTCOME MEASURES: Primary insufficiency, partial necrosis, complete necrosis, and donor morbidity rates. RESULTS: Two flaps necrosed partially (6%). No flaps demonstrated primary insufficiency, necrosed completely, or incurred significant donor morbidity. CONCLUSIONS: The anterolateral thigh flap can be reliably harvested without transmuscular perforator dissection and without incurring serious donor morbidity. It possesses workhorse attributes (no repositioning, remote from defect, long pedicle) and is extremely versatile (one is able to independently tailor the skin and muscle), making it ideal for the heterogeneous group of extensive soft tissue head and neck defects. When a forearm flap will likely be too thin or too morbid, the anterolateral thigh flap can be considered its "big brother."     

Buccinator Myomucosal Flap for Treatment of Osteoradionecrosis of the Mandible

The use of a myomucosal flap from the buccinator muscle is a valuable reconstruction method for intraoral defects. In this paper, we report the clinical advantages of using a buccinator myomucosal flap for the treatment of partial mandibular defects caused by osteoradionecrosis. We implemented a buccinator myomucosal flap for the reconstruction of a partial mandibular defect in a 55-year-old man with tonsil cancer and partial mandibular defects caused by osteoradionecrosis. The total operating time was 90 minutes. Twelve months after the reconstruction, the patient remains free of disease. A buccinator myomucosal flap can be used for the reconstruction of partial mandibular defects caused by osteoradionecrosis. It is a reliable method for reconstructing small mandibular defects.     

The radial forearm flap in head and neck reconstruction

The radial forearm flap has proven to be a very reliable and versatile technique for reconstructing head and neck defects. It is of particular value where segmental defects in the mandible and intraoral mucosa exist, and in reconstructing defects within radiated tissue. The skin of the flap drapes well over the radial bone to allow denture fitting. The radial bone provides an adequate bony strut to allow essentially normal mandibular function. In a previously radiated bed, the flap (from a non-irradiated area) has the virtue of being highly vascular, thus benefiting wound healing. The lack of bulk in the flap prevents separation at the site of inset as wound healing occurs. It is a one-stage reconstruction, and since the donor site is on the upper extremity, early patient mobilization is possible. The donor defect is cosmetically acceptable, and since it lies against the body in the position of rest, it is not frequently exposed. The osseous portion of the flap in a postmenopausal woman should be approached with caution and patients should be warned of the risk of radius fracture. This flap is capable of providing tissue for reconstruction of the head and neck and should be considered for closure of all major defects, particularly those with bone defects or in defects created postirradiation.