Today, plastic surgery has achieved great strides in restoring appearance and function.1 In patients with cancer, reconstructive surgery must allow for adequate resection of tumor with clear margins, facilitate initiation of adjuvant therapy, and maximize quality of life by making the most of function and esthetics. For patients with head and neck cancer, the goals of reconstructive surgery combine enhanced cosmesis and improved overall functionality. As discussed in part 1 (October 2010), considerations for timing and type of reconstruction include patient age, gender, and body habitus; tumor stage and prognosis; functional status of patient; available donor sites; and psychosocial state. The patient defect should be matched with the most appropriate reconstructive method2 (Figure 1). Part 2 of this article will focus on surgery for head and neck reconstruction.
Head and neck reconstruction Reconstructive surgery allows surgeons to complete a thorough “cancer” surgery—adequate resection of tumor with clear margins, facilitation of adjuvant therapy—on the patient. Removing all of the cancer often involves removal of vital organs, and reconstructive surgery permits the patient to appear and function as close to “normal” as possible. Patients who are diagnosed at an early stage generally do well with surgery and radiation treatments. Debilitating and disfiguring treatments can, however, cure patients of their disease only to have to live a long life with functional and cosmetic issues.1,3
Contraindications for reconstructive surgery include insufficient cardiac or respiratory reserves needed for 8 to 12 hours of surgery and inadequate peripheral vascular circulation to the limbs. There are many different areas in the head and neck region, and thus there are some areas that are easier to reconstruct than others.1,3
Skin grafts The simplest form of reconstruction in the head and neck region involves a skin graft, which can often be performed by a general surgeon. When an area cannot be sutured by primary intention, whether it is a surgical incision or a trauma injury such as a burn, a skin graft is often used. This consists of removing skin from one area and placing it over another area. This will provide stability and security to an open area. If the entire dermis is used to cover the defect, it is referred to as a full-thickness skin graft. If just a portion of the dermis is used, it is referred to as a split-thickness skin graft (STSG). These grafts are used in the head and neck region to close floor-of-mouth resections, some tongue resections, some resections of the buccal mucosa, and, after the maxilla is removed, to help close that defect and line the cavity in preparation for a prosthesis placement.4,5
A full-thickness skin graft has the advantages of some bulk, which may be needed in certain areas for stability; better color in areas that will be visible; and less contraction. Full-thickness skin grafts also tend to stretch and grow as needed. Therefore, they are often used in pediatric cases. Often, however, an STSG from another area is needed to close the defect from the full-thickness skin graft. Donor sites for a full-thickness skin graft include the upper thigh or upper inner arms; the scalp is often used for small grafts.5
STSGs are much thinner and therefore are used more frequently. STSGs can be used on the small spaces in the head and neck region, such as the tongue; and can survive in situations that are not ideal. STSGs are fragile, however, and can break down easily; they often contract similar to scar tissue, which can prevent appropriate mouth opening; and their color is pale, which often does not match the skin tone of the visible areas. Donor sites for STSG spontaneously heal because of the remaining cells and blood supply to that area. The anterior and lateral thigh is often the donor site for STSGs because of the large skin surface.4
Skin or acellular dermal matrix (ADM) have been used along with a patient’s own thin layer of skin to act as the foundation for more stable coverage of a primary opening after surgery. 4 This combination can often be used as a stronger, more viable, substitute in place of an STSG.
To care for the graft and donor sites with an STSG alone or in concert with an ADM, nurses should work to prevent constriction of the area that has been grafted. This will help maintain an adequate blood supply to the new tissue as well as allow the tissue to establish its own blood supply over time. The donor site is cared for according to surgeon preference. The site will be raw and painful, and tends to have a substantial amount of drainage. Some surgeons prefer to cover the donor site for several days with a transparent porous dressing. Others prefer to allow the site to be open to air. The goal is to keep the site as dry as possible, allowing for new cell and dermis growth.
Free myocutaneous flaps Myocutaneous flaps are frequently used in the reconstruction of head and neck defects after surgical resection. The use of muscle provides bulk and protection for the surgical area. The bulk and constriction in the head and neck area limits the use of pedicle flaps (flaps that maintain their native blood supply). In addition, pedicle flaps do not achieve the cosmetic goal. There fore, myocutaneous free flaps are often used to reconstruct the tongue, floor of the mouth, and the upper portion of the esophagus that connects to the larynx. A free flap must have vessels connected in the new area to provide new blood supply to this completely removed and re attached muscle. A portion of the quadriceps muscle, the anterolateral thigh flap, can be used and formed into a tube to reconstruct the top of the esophagus.1 The workhorse muscle for the head and neck region is the radial forearm free flap. This muscle tends to be the optimal size and thickness to replace the resected portion of the tongue, for example, after a hemiglossectomy (Figure 2). Without use of a major portion of the tongue, a patient’s speech and swallowing are affected. Patients are unable to speak clearly and are not able to propel the food into the back of the throat to be swallowed.3,6
Immediately after the surgery, a muscle free flap is very swollen because it is no longer performing its original function of lifting and carrying objects. Eventually it will assist the remaining tongue to thrust food boluses into the back of the mouth to be swallowed. The muscle flap will atrophy over time to match the size and shape of the original portion of the remaining tongue. These free muscle flaps have no nerve transference, and therefore, no feeling in that portion of the tongue. With postsurgical decrease in edema and strict patient adherence to speech rehabilitation, patients should be able to learn to use the tongue remnant to help with swallowing and speaking intelligibly.1,3,6
Free muscle flaps in other areas of the head and neck will have a similar course. A muscle free flap will always atrophy and then with therapy permit the patient to be able to swallow or function in as close to preoperative fashion as possible. For a patient with a free myocutaneous flap, nurses need to observe the surgical area closely. Characteristics to assess include color, time for capillary refill, Doppler reading, temperature, and flap or tissue fullness (Table). Flap checks are performed at least hourly, if not more frequently, for the first 48 hours to allow for an intervention. This can mean taking the patient back to the operating room for a replacement flap or repair to the flap’s blood supply. If the flap is to replace a portion of the tongue, the nurse must observe for bleeding because the tongue is very vascular. Patients at Fox Chase are kept sedated and intubated to allow for decreased patient movement of the new flap and quick response for a compromised flap. Patients may need a tracheotomy for the edema immediately following surgery. The radial forearm area that had the muscle removed will have an STSG over the site for protection and require wound care and dressing changes as well as limited use of that limb for a period of time. As mentioned previously, patients will need the services of a capable speech therapist after an initial 5 to 7 days of rest to regain speech and swallowing function.
Bone free flaps The mandible is generally the only area that is reconstructed with bone. Usually, mandibular reconstruction requires both bone and muscle for adequate facial formation and reconstruction. Over the years, reconstructive surgeons have tried foreign substances such as bars and plates to form the missing portion of bone. The body may recognize this substance as foreign, however, and try to reject it. Other complications with these types of materials are breaking or cracking of the bar or plate, extrusion or forcing the material through the skin, and most commonly exposure of the object where the skin might wear away. Using nonvascularized autologous bone grafts does not allow for the usual function of bone, such as resorption. In addition, there is no real soft-tissue coverage as well as less stability. Therefore, free flaps including both bone and muscle are the most reliable form of reconstruction with the best outcome.8-10
Donor bone for a mandibular reconstruction can be harvested from several different areas of the body; however, the two most common areas are the iliac crest and the fibular osteocutaneous flap. Iliac crest sites have excellent size, shape, and blood supply, but the muscle from that area may be large and bulky. In addition, the surgery to harvest the flap tends to cause a great amount of abdominal pain when dissecting through the abdominal wall muscles.8,9
Surgeons often prefer the fibular osteocutaneous flap for reconstruction of the mandible. The size and shape of the fibula is optimal, the possible length being up to 25 cm of usable bone. It has a good blood supply and muscle size, and the bone is nonweight- bearing, which optimizes fairly rapid mobility and decreases normal postoperative side effects. Peripheral vascular disease will definitely hinder the use of the fibula as the donor site. The flexor hallucis longus muscle that sits along the fibula can be used for the muscle portion of the surgery. A portion of the fibula must be left at both the knee and ankle to provide stability to those joints in the future. Disadvantages to this type of flap are pain and numbness at the donor site and the foot. An STSG must be used to close the defect on the leg. Reconstructive surgeons use titanium, either as one large shaped piece or in smaller sections, to assist in connecting the fibular bone into the open defect left at the mandible. If the titanium is used in one long piece, it can be shaped closely to match the patient’s original jaw line. The titanium supplies stability to the bone while the blood vessels are healing. Similar to the free muscle flap, the area will be very edematous immediately postoperatively. In addition, that portion of the jaw will be edentulous.8
There is exciting new technology available to assist the head and neck and reconstructive surgeon when performing lengthy and extensive mandible surgeries. Three-dimensional images and actual models of the surgical site are provided to the surgeon before the surgery to assist in determining where to make the cut, and knowing where to make the cuts to align the bone correctly. This advanced planning aids in decreasing surgical time, which may translate into decreased length of stay for the patient. Surgeons find these models extremely useful and expect they will assist in leading to better outcomes.
After a bone flap surgery, the patient will require intubation and sedation for 24 to 48 hours. Nurses should perform flap checks every hour during the first 48 to 72 hours, which allows for rapid intervention as needed. Patients will have a tracheotomy because of edema in the neck area as well as need for a feeding tube, which could be in place for up to 6 to 8 months. Patients will not be able to swallow enough nutrition by mouth for healing and survival. The newly reconstructed jaw will not be able to be used to masticate food or have any pressure placed on it until the bone heals. The patient may never be able to chew anything firmer than chopped food, and will have to wait at least 1 year before dental implants or dentures can be completed. Again, therapy by a qualified speech therapist is required to adequately rehabilitate jaw opening, speech, and swallowing. Patients will not be allowed to bear weight on the affected leg for 5 to 7 days after surgery. Partial weight bearing with a walker is permitted for 2 to 4 weeks, with a slow increase to full weight bearing. Full healing after these types of reconstructive surgeries takes time and effort for cosmetic and functional outcomes.
Surgery of the maxilla Patients who have their maxilla removed as a result of cancer have various anatomical deformities. The hard and soft palates provide stability for teeth and divide the nasal passage from the oral cavity. After the maxilla is removed, something has to fill that defect. Often an STSG is used to reinforce the maxillary sinus cavity, and then a prosthesis, referred to as an obturator is formed by a prosthodontist to fill that defect. The obturator is molded and reshaped over time as the patient heals postoperatively, until the final product is produced. Dentures can be added to the obturator for a better cosmetic result. Patients are taught to remove the obturator and clean the cavity and the prosthesis after eating.11
If radiation is needed after any of these reconstructive surgeries, 6 weeks of healing must take place before radiation can begin. The flap must be observed closely during radiation for signs of skin breakdown. Patients will require speech therapy again after radiation is completed because of fibrosis on skin and tissues.
Summary Especially in patients with head and neck cancer, reconstruction can restore some lost function and enhance appearance. This improvement in quality of life requires diligent attention to detail by all members of the healthcare team as well as physical rehabilitation by the patient. Reconstruction can, however, help reestablish normalcy for a patient who experienced psychological, physical, and nutritional detriment.
References
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