Considerations for Reconstruction of the Head and Neck Oncologic Patient

The history of treatment of head and neck cancer has been one of continual applications of new techniques in the hope of improving cure rates and functional rehabilitation after tumor ablation. Before the 1960s the drive to resect head and neck cancer (seemingly at all costs) frequently resulted in radical ablation with horrendous deformities and often significant morbidity. During the 1960s and 1970s combination therapy, using radiotherapy and surgery, yielded higher cure rates than aggressive ablative surgery alone in many circumstances. At that same time, several surgeons established the concept that less tissue could be removed in many cases without compromising the cancer cure rates.1–12 Since the 1970s, however, there has been a virtual plateau in the cure rates for tumors of most regions of the head and neck.

Modern head and neck surgery is characterized by its emphasis on reconstruction and rehabilitation. Over the past two decades there have been steady advances in the available surgical techniques for reconstruction of the head and neck. The 1970s introduced the pectoralis major myocutaneous flap, which rapidly became the “work horse” flap in head and neck reconstruction.13,14 Although microvascular transfer of freetissue grafts to the head and neck were performed as early as 1959 by Sidenberg et al.,15 it was not until the 1970s that microvascular free-tissue transfer became recognized as a versatile tool in head and neck reconstruction.16–20

The 1980s and 1990s have seen continued refinement in surgical techniques, particularly in the area of microvascular surgery.21–31 With microvascular free-tissue transfer achieving rates of graft viability greater than 95% in many centers, the reconstructive emphasis is to tailor these free flaps to create the best form and function possible.32–39 Many investigators continue to look for new and improved donor sites for free-tissue transfer as well.

Currently, head and neck surgeons find themselves paying much more attention to reconstruction and rehabilitation in their treatment of the patient with head and neck cancer. The surgeon can perform major resection of neoplasms in the head and neck without the degree of concern for restoration of form and function experienced by clinicians in earlier decades. The surgeon no longer views the often horrendous deformities cre-

ated by radical ablative surgery of the head and neck region as an inevitable consequence of tumor control. Presently, the focus is oriented toward obtaining the ideal reconstruction whenever possible.

The criteria by which we judge outcomes in the reconstruction of the craniomaxillofacial skeleton are related to function, aesthetics, and satisfactory quality of life. Ideally, the techniques used to achieve these goals should minimize the tissue damaged or removed, and they must imitate the form, geometry, and quality of the injured structures. Normal function should also be restored as completely as possible.

All patients, however, may not be suitable candidates for the “ideal” reconstruction. Patient age, associated medical problems, diet, performance status, the individual’s motivation, and family dynamics are all factors that must be considered when planning the surgical complexity of the recon- struction.23–25,34,38 The extent of the disease dictates the extent of surgical resection although the size and location of soft tissue defects, as well as concomitant partial or total loss of adjacent nervous, muscular, vascular, and skeletal tissues are a few of the anatomic variables that must also be considered.

Many of these patients undergo radiation therapy to the head and neck as part of the overall treatment plan.1–5,8–12 The decreased vascularity of radiated tissue limits the use of alloplastic materials alone to successfully reconstruct soft tissue and bony defects. Regional or distant vascularized flaps are usually necessary to promote adequate healing, especially when any contamination is present.24,31,34,40–42

Physician factors also play a role in determining the materials and techniques utilized in head and neck reconstruction. Although microvascular free flaps allow for the transfer of a variety of tissue types to the head and neck, many centers do not have physicians and support personnel with the necessary microvascular skills. These procedures require longer operative time than many traditional reconstructive techniques. The surgeon must be cognizant of the potential morbidity associated with each donor flap harvested. The expected success rate of the transposition must be weighed against the difficulty of performing each procedure, which translates into operative time for the surgeon and the patient. This is particu-

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larly dependent on the patient’s general medical status. On the other hand, distant donor sites far removed from the head and neck provide an opportunity for synchronous double team surgery and actual shortening of operative time, which is often not possible with many regional flaps.21–25,28,31–34,42

The availability of a qualified maxillofacial prosthodontist also may determine the type of reconstruction used, especially in midface defects. Precisely fabricated prostheses can provide an excellent and sometimes superior method of reconstruction with much less morbidity than many tissue transfer techniques.

The craniomaxillofacial skeleton can be divided into thirds: lower, middle, and upper. Most bony defects from extirpation of head and neck cancers involve the lower oromandibular complex and midface structures. Considerations for reconstruction of each region will now be delineated.

Oromandibular Complex Reconstruction

The goals of reconstructing the oromandibular complex are to reconstitute its three-dimensional shape, preserve or restore lower facial contour, provide a denture-bearing surface, and maintain or re-create occlusal relationships and oral continence. The oral cavity is unique in that several host factors come into play when considering which techniques will be used to achieve these goals. The problem of salivary contamination must be addressed in every case, particularly in radiated patients. The area of mandible to be reconstructed is a significant factor in the timing of definitive bony reconstruction. Immediate bony reconstruction of the denture-bearing surface may allow primary placement of osseointegrated implants and earlier dental prosthetic rehabilitation than delayed techniques.26,30

Resection of the anterior mandibular arch produces the “Andy Gump” deformity, a debilitating functional and aesthetic problem. Oral competence suffers from the patient’s inability to manage oral secretions, speak, eat, or swallow. This is, therefore, the most important mandibular defect to reconstruct primarily. The need for bone, intraoral soft tissue, and external skin coverage must be assessed carefully, with attention paid to the relative amounts of each tissue required. Reconstruction of this defect with a microvascular, bone-con- taining free flap is the optimal method for achieving the best

result.17,19,21–24,26–28,30,31,33–36,40,42 Bony stabilization can be

achieved before initial resection. In those cases where the neoplasm has not penetrated through the buccal cortex of the mandible, an AO reconstruction plate may be adapted to the mandible prior to resection of the tumor. Holes are drilled, screws are placed, and then the plate and screws are removed. Early fixation maintains essentially perfect contours. Futran et al.43 recently showed fewer long-term plate complications when using the titanium hollow screw reconstruction plate (THORP) or titanium AO reconstruction plate than with the AO stainless steel plate. After tumor resection, the plate is

D.W. Klotch and N.D. Futran

reapplied to the mandible. The surgical specimen is then available as a visualized reference for graft shaping as well as serving as a template for graft size and length. Although this is our preferred method, some cases dictate and authors advocate the use of miniplates to fixate the graft to the residual mandible.22,28 Once the composite graft is revascularized, primary placement of osseointegrated implants allows more rapid dental rehabilitation. They provide the most rigid form of stabilization to withstand the forces of mastication. In situations in which soft tissue reconstruction or the height of the alveolar ridge is not sufficient for a tissue-borne denture, implants offer the most suitable alternative.26,30 Four to 6 months after surgery, when the integration process has occurred and postoperative radiation therapy has been completed, the implants are uncovered, loaded, and ready for prosthetic placement.

Immediate restoration of the mandible prevents the development of muscle contracture. In postresection situations, scarred masticatory muscles pull the mandibular segments upward and medially, distorting occlusion. Once this process has occurred, restoration of a normal configuration is difficult. Graft shaping in secondary reconstruction is a mystery at best, as a result. It is also not in the patient’s best interest to live with a devastating aesthetic and functional deformity and to be subjected to two long operative procedures instead of one.

When the posterior lateral mandible, the angle, and the ascending ramus are removed, the defect can be dealt with in a variety of ways with equal restoration of form and func- tion.34,40–42,44–51 Free flaps have no demonstrable superiority in the reconstruction of this defect. In fact, not all of these patients need to be reconstructed. Simple collapse of the segments often allow closure of the soft tissue defect primarily. Although facial contour is slightly disturbed by shift of the anterior mandible to the affected side, these patients maintain very adequate speech and swallowing. This technique is especially suitable for the medically compromised patient and will minimize operative time.

Intraoral tissue concerns are a higher priority than immediate restoration of the bony defect in these areas of the mandible.32,52 The use of reconstruction plates in conjunction with soft tissue free flaps or pedicled flaps allow an expedient method to obtain an excellent cosmetic and functional result with minimal donor site disability.41,42,47,48,52,53 It is best for lateral and posterior lower volume defects in the debilitated, the elderly, and in patients with a poor prognosis. This method is no panacea. Failure usually requires rescue with a vascularized bone graft. With the proper selection of patients, however, this will rarely be necessary. A major weakness in the plating systems available at present is their tendency to fracture if they remain in place too long, although the newer THORP plates appear to be more resistant to this problem than their stainless steel predecessors.43,49 Complications including fistulae, late plate extrusions, and required plate removals are also reportedly higher for reconstructions in irradiated fields.41,48

Restorations of coexistent temporomandibular joint (TMJ) and mandibular defects is a challenging undertaking. Ideally, this joint is necessary for unencumbered function. Realistically, immediate restoration with the articulation of the glenoid fossa may not significantly contribute to cosmetic or functional improvement following radical ablative surgery.

Several approaches are available to synchronous reconstruction of the TMJ and auxiliary mandibular defects. Initially, intermaxillary fixation is applied to the preexisting dentition to maintain occlusion. The use of reconstruction plates with a condylar head (AO-titanium, THORP) allows for a hemijoint reconstruction in conjunction with skeletal fixation of a vascularized bone graft or residual mandible.49 The surgeon must be aware that condylar head alloplastic devices are now FDA approved. Soft tissue arthroplasty using temporalis tissue or other tissue during bony transfer has facilitated TMJ reconstruction, especially in older patients. In younger patients, and especially in children, costochondral grafts can be used along with the vascularized bone technique. Any technique must address the risk to the facial nerve both during the procedure and with subsequent mandibular function. Fortunately, very few oral cancers other than sarcomas involve the TMJ and require resection of the condyle. When squamous cell cancers involve the jaw joint, removal of the meniscus and even the glenoid fossa may be required. These patients usually require high-dose radiotherapy. The senior author does not advocate the use of alloplastic condylar reconstruction for these situations.

When the neoplasm extends anteriorly through the mandibular buccal cortex and into the soft tissues, contouring the reconstruction plate to maintain ideal mandibular form is impossible prior to resecting the tumor. To maintain proper position of the condyles in the glenoid fossae, external fixation devices such as the Joe-Hall-Morris or Anderson biphasic splint may be applied.45,47 The AO condylar positioning device is also available to provide positioning of the mandible stumps and the condyles with the unobstructed ability to resect tumors with anterior extension. Following resection of the mandible a bridging plate and/or bone flap can be precisely applied, with preservation of the precise occlusal and condylar relationships. Alternatively, a universal reconstruction plate may be used to achieve the same result. Adequacy of the anterior mandibular projection is determined by the judgment of the surgeon as the bone grafts and plates are placed in relation to the anterior maxillary arch.

One other method that deserves mention has occurred with the advent of three-dimensional computed tomography (CT) imaging. Special software packages allow three-dimensional reconstruction of the oromandibular complex. An alloplastic mandible can then be generated and used as a template or temporary spacer prior to definitive reconstruction.

The primary advantage of delayed reconstruction is the avoidance of wound contamination by saliva.46,50 Lateral and posterior defects are the simplest to repair. In 1982 Lawson et al.46 found that reconstruction of the mandible with allo-

plastic materials and free bone grafts achieved an improved rate of restoring mandibular continuity in the delayed setting, than when using these techniques primarily. Few patients, however, achieved a significant functional benefit or used dental appliances.

The presence of scar contracture after tumor extirpation causes malalignment of the remaining mandibular segments, if not initially maintained by an AO reconstruction plate or external fixation device. Realignment and precise reconstruction of the defect become a more formidable task in this setting.

Many patients who undergo delayed reconstruction will have had radiation therapy immediately after extirpative surgery. The resultant decreased tissue vascularity and fibrosis dictates the need for vascularized tissue transfer to achieve the desired reconstructive goals. Invariably, the results are not as optimal as reconstruction in the primary setting. Although restoration of mandibular continuity can be achieved, these factors indicate an inevitable delay in functional dental rehabilitation. Reconstructive problems are similar to those in delayed reconstruction when repairing oromandibular defects created by salvage surgery. Frequently, these patients have extensive scarring from previous procedures and/or radiation therapy reducing the host tissue’s ability to support alloplastic materials. Free vascularized tissue transfer is almost always necessary in this type of patient if definitive reconstruction is to be undertaken.27,31,36,54

Whenever possible, therefore, immediate single-stage reconstruction is always preferable to delayed reconstruction when the former can be achieved with acceptable success rates and low morbidity. This is especially important for patients who have advanced neoplasms, for whom prognosis is poor, and for whom early palliation is crucial to maintain the quality of life.

Midface and Skull Base Defects

The midface can be characterized as the juxtaposition of three cavities in complex bony mucosal units: the oral cavity, nasomaxillary complex, and the orbital cavity with its contents. Many neoplasms in this area extend to the skull base and may enter the cranial cavity. A broader spectrum of approaches to the skull base with improved exposure has permitted safer and more complete ablative procedures in this area. The goal of reconstruction is to restore to normal the physical and functional relationship of these massive defects.

The complexity of immediate reconstruction is largely dependent on the defect created. Conventional management of maxillectomy defects when the globe is spared includes resurfacing the inner cheek with a skin graft and obturating the palate and sinus defect with a maxillofacial prosthesis.55 This allows functional reconstruction for mastication, swallowing, and speech. Recurrence of tumor is readily identified by visualization of the maxillary cavity. The globe may be sup-

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ported by a variety of autologous or alloplastic materials. These defects are also easily managed by the patient and require only gentle irrigation of the cavity when fully healed.

Some authors do advocate free tissue transfer reconstruction of this defect, citing problems of crusting, infection, or osteoradionecrosis in a skin-grafted cavity.22,25,29,38,39,56–59 Although the palate may be sealed with soft tissue, fitting of a dental prosthesis may require further soft tissue revision surgery to achieve a successful result.

The radical orbitomaxillectomy results in communication of the oral cavity, nasal cavity, maxillary sinus space, and orbit. Abnormal airflow is created and saliva or food bolus can escape through the nose/sinus cavities. The support of the globe (if present) and nasal support may be undermined. Extension to the overlying skin may result in more severe food and airway flow disorders. In addition, contraction of the lips and soft tissues of the face may occur, resulting in grossly abnormal speech and appearance. The three-dimensional complexity of these skin-covered, mucosa-lined areas of bone is ordinarily much too demanding for perfect reformation.

The nasomaxillary region may be considered as the transitional zone, and can be replaced with well-vascularized tissue (with or without bone). The most relevant functional areas are determined and the main volume is obliterated. Support of the globe is provided. The hard palate, lateral nasal wall, and infraorbital rim can be recreated. In selected cases, primary or secondary placement of osseointegrated implants will allow improved support and stability of maxillofacial prostheses. When the orbit is exenterated, preservation of the eyelids allows for improved cosmetic results with an orbital prosthesis than if the eyelids are sacrificed with the tu-

mor.25,29,34,56

The most important goal of reconstructing most defects of the skull base, especially when dura is exposed or the cranial cavity entered, is to provide coverage with vascularized tissue.38,58,59 The risk of cerebrospinal fluid leak, and even more importantly the risk of a secondary infection, necessitate the anatomic and functional separation of extracranial and intracranial cavities. Delayed reconstruction is usually reserved for the improvement of aesthetics and function not attainable by maxillofacial prosthetics. Vascularized soft tissue with bone grafts (vascularized or nonvascularized) or alloplastic materials may be used to re-create the orbital components, nasal dorsum, and/or palate.

Frequently, these tissues have been irradiated, and the presence of scar tissue and fibrosis limits the ability to provide optimal aesthetics and function.

The issue of oncologic surveillance has been raised regarding the use of free-tissue transfer to reconstruct skull base defects. The placement of any flap to fill a defect certainly inhibits the physician’s ability to detect recurrent disease by physical examination. However, the repeated use of sophisticated imaging techniques helps to detect changes postoperatively, which may direct further diagnostic studies.59 The use of free-tissue transfer for reconstruction of the skull base

D.W. Klotch and N.D. Futran

should be reserved for situations in which vascularized tissue is required and when regional flaps are not suitable. In addition, when the application of a free flap holds the promise of a better quality of life than can be achieved with alternative techniques, then this, too, represents a worthy indication. Arguments based on the philosophy that patients should be forced to live with their deformity for a finite period of time prior to definitive reconstruction hearken back to similar arguments regarding primary mandibular reconstruction. These arguments should be deplored for two reasons: the results of secondary reconstruction are almost always inferior to primary reconstruction, and in many patients with skull base malignancies the detection of recurrent disease is often a theoretical exercise. Many of our patients have exhausted other therapeutic modalities, including prior surgery, when they are referred for skull base surgery. The anatomic areas where these patients are most likely to recur are those that are least amenable to safely achieving clear margins. It is unlikely, in most cases, that salvage surgery or meaningful alternative therapy would be feasible or beneficial. It therefore seems unreasonable to condemn such patients to an inferior quality of life for the time that they have remaining.

Although advances in technology, physician training, and sophisticated surgical techniques have broadened our ability to extirpate advanced neoplasms and provide functional and aesthetic reconstruction, the buzzword in medicine for the remainder of the decade and beyond is “cost-effectiveness.” Each patient and defect to be reconstructed must be evaluated and treated individually. Surgeons must use those techniques that are best suited to their abilities, or that reconstructive goals can be achieved in a timely, efficient manner. Morbidity and patient hospitalization must be minimized to meet the demands of economic medicine.

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