Introduction:

A/Prof Damian Marucci performs head and neck reconstruction as part of the regional Head and Neck Cancer Service at St George Public and St George Private Hospitals. The Head and Neck Multidisciplinary Team (MDT) comprises ENT surgeons, plastic surgeons, radiation oncologists, oncologist, radiologists, speech therapists, clinical nurse consultants and pathologists.

Head and neck reconstruction is a complex and intricate field of plastic surgery that focuses on restoring form and function to these critical areas of the body. Patients undergoing head and neck reconstruction often face challenges stemming from cancer treatment, both functional and cosmetic issues. Below is a summary of various aspects of head and neck reconstruction, including flap options, associated risks, the recovery process, and essential considerations in choosing a plastic surgeon for this specialized procedure.

I. Understanding Head and Neck Reconstruction:

     A. Indications for Head and Neck Reconstruction:

The Head and Neck MDT at St George Public Hospital predominantly deals with the treatment of cancers. The most common types of cancers are:

• skin cancers which may involve deeper structures like nerves or bone or spread to the glands of the neck
• oropharyngeal cancers which may spread to the glands of the neck
• rarer cancers of the soft tissues of the head and neck

Removing these cancers will leave a defect, or hole, in the tissues – whether that be the skin or mucosa. Sometimes critical structures, like tongue muscles, or parts of the jaw bone need to be removed. The ENT surgeon is responsible for removing the cancer and creating the “hole”. The reconstructive plastic surgeon’s role is to reconstruct the “hole”, trying to restore form and function and best as possible. Every patient is different. Every defect is different. The reconstructive plastic surgeon has a number of options to treat each defect, and the treatment will be tailored to the patient’s needs.

     B. The Role of Flap Options in Head and Neck Reconstruction:

Flaps are a crucial component of head and neck reconstruction, involving the transfer of tissue from one part of the body to another to reconstruct or replace damaged or missing structures. Different types of flaps are employed based on the specific needs of the patient and the complexity of the reconstruction.

1. Local Flaps: These involve using nearby tissues to repair defects. Examples include advancement flaps and rotation flaps, which are suitable for smaller defects.
2. Regional Flaps: Tissue is borrowed from a nearby but non-adjacent area. Common examples include pectoralis major myocutaneous flaps and deltopectoral flaps. These two specific flaps involve taking tissue from the chest and tunnelling that tissue into the neck to reconstruct defects of either the neck or lower face.
3. Free Flaps: In this advanced technique, tissue is completely detached from its original blood supply and reconnected at the recipient site using microvascular surgery. Examples include radial forearm flaps (where tissue is taken from the front of the forearm) and anterolateral thigh flaps (where tissue is taken from the outer side of the thigh). The fibula bone can also be taken out of the leg and used to reconstruct the bones of the jaw with its blood vessels connected to arteries and veins in the neck using microsurgery.

II. Risks and Complications:

While head and neck reconstruction can significantly improve a patient’s quality of life, it is important to be aware of potential risks and complications associated with the procedure. These may include:

1. Infection: Any surgical procedure carries a risk of infection. Antibiotics will be given around the time of surgery, but despite this, infections can occur in the skin, deeper down near the bone and any plate or screws that have been placed, in the lungs or in the bladder. Some infections require surgical drainage.
2. Poor Wound Healing: Factors such as smoking, diabetes, malnutritionand radiation therapy can contribute to delayed or compromised wound healing. If structures in the mouth have been reconstructed, poor wound healing may lead to saliva draining into the neck (salivary leak), which can erode into major blood vessels causing catastrophic bleeding. The goal of the reconstructive surgeon is to seal the mouth and oral cavity from the sensitive structures in the neck.
3. Flap Failure: In rare cases, the transferred tissue may not receive adequate blood supply, leading to flap failure. This risk is minimized with meticulous surgical technique and postoperative care. In cases of flap failure, more often than not, a second flap will be required to reconstruct the defect.
4. Functional Impairment: Depending on the extent of the reconstruction, there may be temporary or permanent changes in speech, swallowing, or other functions.

III. The Recovery Process:

Recovery from head and neck reconstruction is a gradual process that requires patience and adherence to postoperative care instructions. The timeline can vary depending on the complexity of the procedure, the patient’s overall health, and the presence of any complications.

1. Hospital Stay: The initial recovery period typically involves a hospital stay to monitor the patient for any postoperative issues and to provide appropriate pain management. If is a free flap has been performed, the nursing staff will examine the vascularity of the flap every hour to ensure that the blood vessels have not clotted off. If they do, the reconstructive team will have to take the patient back to the operating theatre to try to re-establish circulation before the flap tissue dies.
2. Pain Management: Effective pain management is crucial during the early stages of recovery. Patients may be prescribed pain medications and are advised to follow the prescribed dosage and schedule.
3. Follow-up Appointments: Regular follow-up appointments with the outpatient clinic and Head and Neck MDT to monitor the healing process, address any concerns, and remove sutures or drains as needed. Many patients require further cancer treatment once they have adequately recovered from their surgery, like radiotherapy or sometimes chemotherapy.
4. Rehabilitation: Depending on the extent of the reconstruction, patients may benefit from physiotherapy or speech therapy to regain optimal function in the head and neck region.
5. Emotional Support: Head and neck reconstruction can have a significant impact on a patient’s self-esteem and emotional well-being. Support from friends, family, and mental health professionals can be invaluable during the recovery process.

IV. Choosing the Right Plastic Surgeon for Head and Neck Reconstruction:

Selecting a qualified and experienced plastic surgeon is a critical step in ensuring the success of head and neck reconstruction. A/Prof Marucci completed a Fellowship in Oxford where he was a part of their prestigious Head and Neck Reconstruction Service. He is a registered Plastic and Reconstructive Surgeon with AHPRA. He is an Associate Professor of Surgery at the University of Sydney. He is a member of the Australian Society of Plastic Surgeons and is on their Education Committee. He has been performing head and neck reconstruction for 20 years.

V. Conclusion:

Head and neck reconstruction is a complex and multifaceted field that requires specialized skills and expertise. By understanding the various flap options, being aware of potential risks, and actively participating in the recovery process, patients can enhance their chances of successful outcomes. Equally important is the selection of a qualified plastic surgeon who possesses the necessary skills, experience, and commitment to guide patients through this transformative journey. Through careful consideration and thorough research, individuals can make informed decisions that positively impact their overall well-being and quality of life.