Plastic surgery has changed the treatment standard of head and neck cancers. It allows for the treatment of cancers that were previously considered hopeless. The cancers of head and neck region usually lead to massive anatomical defects. These defects may involve skin subcutaneous tissue, bone and other parts like nose, tongue, or throat, in varying combinations affecting various important functions like swallowing, speaking and breathing.
Plastic surgeons reconstruct these complex defects using tissues from another area of patient’s body, eg. thigh, abdomen, forearm or lower leg. Through plastic surgery procedures, structural and functional restoration of human body parts could be achieved. Depending on the size and structures involved, the treatment options range from primary closure, skin grafting to free tissue transfer. When the defect is small and only soft tissue is involved, local tissue can be used to reconstruct the defect. Skin subcutaneus tissue, muscle or even bone can be used for reconstructon.
Free flaps are those in which the blood vessels are detached alongwith the flap tissue and connected to a vessel in the head and neck region. These are microvascular surgeries performed by a plastic surgeon, under magnification, using operating microscope and suture threads which are much smaller and finer than a human hair.
Pedicled flap - The flap is left attached to the original site by a base of tissue to provide blood supply to the flap. This base can be left in place when the flap is tunneled into the defect. But if the flap bridges over the intact skin, then the base has to be divided after 2-3 weeks.
Cancers of oral cavity
Cancers involving cheek, tongue, mandible, maxilla, alveolus (gums).
Cheek defects are reconstructed with a local ( tissue adjacent to the defect) or regional flap (tissue from the nearby regions, based on specific blood vessel). But when the defect is bigger in size and full thickness, then free flap (tissue from a distant region is used along with its supplying blood vessel) is used.
Tongue reconstruction - For the tongue to have some function, it requires adequate bulk, mobility and lubrication. Depending on the amount of tongue removed, the reconstruction can be done using free flap from forearm, thigh, abdomen ( rectus abdominis muscle). Part of stomach (gastro - omental flap) can be used for tongue lining which provides adequate lubrication.
Cancers of mandible, maxilla, nose and para - nasal sinuses and orbit require bony reconstruction. The various areas from where bone can be taken are leg (fibula), pelvis(iliac crest), shoulder blade(scapula), forearm (radius) and chest (sternum and ribs).
Mandibular reconstruction is essential for facial contour, dental rehabilitation and for the patient to eat properly. It is usually done using a long bone from the leg (fibula), alongwith its blood vessels as a free flap. The bone is the fashioned into the shape of mandible and fixed with plates and screws. The blood vessels of fibula are then connected to the neck blood vessles to restore the blood supply.
Maxilla assists in functions like mastication, deglutition and speech, also it is important for orbital integrity. Therefore maxillary reconstruction is important for restoring the shape of face, barrier between oral cavity and nose and support to the eyeball. The reconstructive options are mostly same as for mandible. When the defect is small then bone graft from ilium is used. When the roof of mouth (palate) defect is there, it is reconstructed by an adjacent soft tissue flap or a free flap from forearm or thigh.
Cancer of Pharynx
Pharyngeal defects can be circumferential or involving only part of the pharyngeal wall. These are reconstructed with pedicled pectoralis major flap( a muscle of chest region). In circumferential defects, a new foodpipe is created using tubed anterolateral thigh flap, which is folded on itself forming a tube. Other option is using a segment of jejunum (small intestine) as free flap.
Cancer of skin in head and neck region
Skin cancers which are common in head and neck region are basal cell carcinoma and squamous cell carcinoma. Basal cell carcinoma is commonest skin cancer which usually occur in the region around the nose and upper part of face. It requires wide excision after which the defect can be repaired by local or regional flaps. Most of the time a flap from forehead is used to reconstruct the nose. This technique of reconstruction of nose from forehead flap has been practiced in the Indian subcontinent since 600 BC,this technique alongwith many other reconstructive surgical procedures for head and neck region were first described by Mahrishi Sushruta from India.