Update on Major Reconstruction of the Head and Neck

Abstract

Reconstruction of soft-tissue defects in the head and neck is best accomplished using similar composite tissue. In the head and neck, this tissue is usually available in the form of adjacent tissue transfer. The local adjacent tissue resembles the resected tissue in color and composition. In some circumstances, the local tissue is not suitable for transfer. This may be due to previous surgery, exposure to radiation, or a defect that is too large for local tissue transfer. In these cases, free tissue transfer may be needed. Free tissue transfer allows for the replacement of similar composite tissue that has not seen previous treatment. The diversity of sites that may be harvested allows a relatively similar tissue match. This article discusses recent advances in the reconstruction of 3 areas that in the past have presented many problems to the reconstructive surgeon. Total nasal and lip reconstruction have been problematic. In heavily pretreated patients, the reconstruction often results in suboptimal outcomes. Large scalp defects in the setting of previous excisions or irradiation are difficult to reconstruct and rehabilitate. In all of these cases, the ability to transfer composite tissue has improved the functional and cosmetic outcomes.

Upper extremity resurfacing via an expanded latissimus dorsi musculocutaneus flap for large circumferential defects: the “spiral” reconstruction technique

“…The use of tissue expansion has been popularized among plastic surgeons and has become the treatment method of choice for many congenital and acquired defects in children and adults [1–3]. …”

“…The reconstruction of many congenital and acquired defects has been made possible through the use of this technique [3]. In selecting patients, consideration must be given to certain difficulties such as: limited donor site, involvement of several areas, patients who are emotionally unstable, the need for repeated surgical procedures or several expanders, and long-term treatment or follow-up.…”

“…The introduction of tissue expanders (TE) was the start of a new era and a breakthrough in the treatment of patients with burns, scars, nevi and other lesions; for they provide skin of the same color and texture, sensitive and with adnexes, facilitating harmless primary closure of the donor site. The procedure can be repeated on the same segment (re-expansion) if necessary [1–3]. However, n nearly all the literature at hand are for face and neck reconstruction or covering extremity defects by expanded free or pedicled flaps.…”

Perioperative Hypercoagulability in Free Flap Reconstructions Performed for Intracranial Tumors

“…Patients with intracranial tumors undergoing craniotomy procedures carry a risk of poor wound healing at the craniotomy site, which is increased if radiation is required or if alloplastic materials are utilized in reconstruction 13–16 . When defects are large or surrounding tissue is devitalized by previous treatment, free tissue transfer is required for adequate coverage of cranial reconstruction materials 17–23 . Free tissue transfer is particularly challenging in patients with hypercoagulable states, with elevated rates of immediate flap thrombosis and flap failure 24,25 .…”

“…[13][14][15][16] When defects are large or surrounding tissue is devitalized by previous treatment, free tissue transfer is required for adequate coverage of cranial reconstruction materials. [17][18][19][20][21][22][23] Free tissue transfer is particularly challenging in patients with hypercoagulable states, with elevated rates of immediate flap thrombosis and flap failure. 24,25 Given the aforementioned hypercoagulability risk in patients with intracranial tumors, we postulated that this population carries an increased risk of immediate flap complications and flap loss.…”