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Reconstructive Procedures

Reconstructive Procedures

Reconstructive Procedures

Head And Neck Reconstructive Surgery

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What is head and neck reconstruction?

Head and neck reconstruction refers to the restoration of form and function of the head and neck region due to defects caused by cancer, trauma or congenital diseases. Head and neck cancers account for a large proportion of cases requiring reconstruction and include squamous cell carcinoma, salivary gland cancers and sarcomas of the head and neck region. These are difficult conditions to treat, and the mainstay of treatment is surgical resection, often combined with radiotherapy and /or chemotherapy. Resection of these cancers quite often lead to large and complex wounds can be debilitating and disfiguring. With advanced reconstructive techniques, plastic surgeons are able to utilize a variety of tissues and implants to return most patients to close to normal speech, swallowing, appearance and lifestyle.

What parts of the head and neck can be reconstructed?

The regions of the head and neck include the oral cavity, oropharynx, nasopharynx, nasal sinuses, larynx (voice box), hypopharynx (throat) and oesophagus (gullet). The scalp and external face and neck, including the ears and nose, are also part of the head and neck, and can be reconstructed using facial plastic surgery techniques.

The head and neck are made up of complex anatomical structures responsible for vital functions such as breathing, eating, and speech. For example, the tongue has multiple intrinsic and extrinsic muscles as well as external lining, which needs to be reconstructed appropriately to enable swallowing and speaking.

Together with you and the resecting surgeon (if any), your plastic surgeon will assess the expected defect and discuss the appropriate options for reconstruction with you.

What can I expect from my procedure?

Head and neck reconstructive surgery aims to restore anatomy, function and appearance to the patient, enabling the patient to continue to lead full lives post-surgery.

To achieve this, the reconstructive surgeon utilizes a combination of procedures including grafts, prosthetics, and tissue transfer (flaps) from the patient to replace missing structures with similar tissue, akin to transplantation within the individual. Flaps refer to tissue with their own blood supply taken from one part of your body that does not need it to replace missing tissue in an area which requires it. These flaps can be from around the area of the defect (local flaps), further away but keeping their blood supply intact (regional or pedicled flaps), or from distant sites where blood supply is re-established at the defect site (free flaps). The type of flap used will be dependent on location, size, and composition of the defect. Our board-certified plastic surgeon is very familiar with free flap reconstruction of the head and neck and will discuss the options for your reconstructive surgery.
BEFORE SURGERY
The treatment modalities will be decided in close discussion with you, the reconstructive surgeon, and the resecting surgeon (if any). Factors such as defect size, location, and tissues involved will be considered, and the best therapeutic plan formulated. The various options will be discussed with you to achieve the most harmonious and acceptable outcome whilst minimizing any morbidity.

Some investigations may need to be conducted to help with diagnosis and planning, such as CT scans, MRI scans, and biopsies. In cases where complex bony reconstruction is required, computer-aided planning and models may be used to ensure perfect reconstructive outcomes.
DURING THE PROCEDURE
The type of anaesthesia given to you will be dependent on the expected defect and length of surgery. Head and neck reconstructive procedures are usually considered major surgery and require general anaesthetic and a period of stay in hospital of at least 1 to 2 weeks. Additionally, any pre-existing medical conditions must be optimized, and any smoking or alcohol consumptions should be stopped a few weeks before the procedure. Your surgeon will ensure that you are optimized medically for your procedure, with referral to other specialists as appropriate.
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Post-operative care and recovery

Following the surgery, the patient and the reconstructed defect will be monitored closely, especially for the first few days, with emphasis on patient and flap health, rest, and nutrition. Gradually, you will be allowed to mobilize, and rehabilitation will be instituted in a controlled fashion to restore normal function. Total hospital stay can take up to 2 weeks. There will be a multi-disciplinary team of specialists involved in your care including speech, occupational, and physical. Full recovery is generally expected after 2 to 6 months.

Potential risks and complications

Head and neck reconstruction has progressed leaps and bounds in the last few decades, with success rates at 98 to 99%. However, it is still a major surgery and risks include uncontrolled bleeding and infection post-operatively. In addition, flap procedures are delicate operations, and if there are signs of trouble with the flap, re-operation may be needed. Other potential complications in the early post-operative period include neck infection, salivary leak, or pneumonia due to prolonged bedrest. If you are progressing well after the first week post-operatively, the risk of these complications are very minimal.

Further on in recovery, the focus will be on functional and aesthetic rehabilitation including minimizing the impact of scars and any radiotherapy effects, if the adjuvant therapy is performed. Any adjuvant radio- or chemotherapy needed can be commenced at the one-month post-operative mark once healing is shown to be going well.

Why choose Polaris Plastic Surgery?

Our plastic surgeon is trained in head and neck reconstruction and has learned from the East and West during his training. Dr Adrian has published widely on the topic and given invited lectureships in the USA, Europe, and Asia. He has performed a high volume of head and neck microsurgical procedures and tailor-makes each procedure to ensure the optimal return of function and appearance to each patient. He has developed advanced head and neck reconstructive techniques in Singapore including robotic-assisted head and neck reconstruction and computer-aided design (CAD).

Schedule a consultation with Dr Adrian to assess your needs and goals. Through a thorough discussion, the appropriate reconstructive procedure to achieve the desired functional and aesthetic outcomes can be chosen.

FAQ

What is Computer-Aided Design (CAD) in head and neck reconstruction?

CAD in head and neck reconstruction involves the use of pre-operative scans, computer programs and 3D printers to create surgical aids and implants that aim to give the patient as close to a perfect reconstruction as possible. It is most used for head and neck defects requiring bony reconstruction. By bringing the surgical planning to the computer, this effectively increases the accuracy of tissue and bony shaping to the millimetre and cuts down operative time due to the printing of precise cutting guides, templates, and implants. An additional benefit is the ability for immediate dental restoration in select cases. Our plastic surgeon works closely with local and international teams in creating these surgical aids and will discuss their use and necessity with you.

What is minimally invasive and/or robotic-assisted head and neck reconstruction?

Minimally invasive head and neck reconstruction entails the use of small, well camouflaged incisions, commonly intra-orally, along with adjuncts such as the endoscope or surgical robots, to reconstruct hard-to-reach areas of the head and neck whilst minimizing scarring and surgical morbidity. This is performed for select cases where the avoidance of visible cuts in the face or through the facial skeleton is desirable, for example in cases where there has been previous radiotherapy. Dr Adrian is one of the only plastic surgeons in Singapore trained in the use of the surgical robot and will discuss whether this is a feasible option for your reconstruction.

Can radiation injury to the head and neck be treated?

Radiotherapy (RT) is an important adjunctive treatment in many cancers. In the head and neck, RT can be performed before or after surgery, depending on the cancer characteristics. Whilst RT can help eradicate microscopic cancer cells, it can also have a deleterious effect on normal tissue by inducing scarring and fibrosis. This can lead to debilitating symptoms such as neck tightness and pain, and the inability to fully open the jaw (trismus). Using treatments including botulinum toxin and fat transfer, our plastic surgeon can help to mitigate some of the effects of unwanted radiation injury, which can otherwise be a huge barrier to daily function.

Does head and neck reconstruction interfere with cancer surveillance?

In short, head and neck reconstruction does not interfere with cancer surveillance, even in hard-to-see regions. Besides visualization of the suspect area, there are other methods to detect cancer recurrence including clinical palpation and scans such as CT or PET scans.

Can I delay my head and neck reconstruction?

Head and neck defects often expose vital structures such as vessels, nerves, tendon, and bone. Oftentimes, they also expose the neck structures to salivary leak and potential infection and can be very aesthetically disfiguring. Whilst some head and neck reconstructive procedures can be delayed, it is seldom that the defects can stay prepped for reconstructive beyond the first 24 to 48 hours before definite reconstruction is required.

I previously had head and neck reconstructive procedures but am dissatisfied with some of the outcomes. Can I have reconstruction again?

Yes, you can. Most times, it is not possible to completely restore normality in one surgery. You can have secondary reconstructive procedures months or even years after the first procedure. Your surgeon will assess you and work with you to achieve your expectations using the best available methods. These may involve fat grafting, prosthesis, and/or flap procedures.


References
1. Ooi A SH, Butz D R, Teven CM, Gottlieb LJ. Re-introducing the delto-acromial perforator flap: Clinical experience and cadaver dissection. J Plast Reconstr Aesthet Surg 2018;71:402-9

2. Ooi A SH, Teven CM, Inbal A, Chang DW. The Utility Of The Musculocutaneous Anterolateral Thigh Flap In Pharyngolaryngeal Reconstruction In The High-Risk Patient. J Surg Oncol 2017;115;842-47

3. Ooi A SH, Butz D, Gooi Z, Chang D W. Modification of the radial forearm fasciocutaneous flap in partial pharyngolaryngeal reconstruction to minimize fistula formation. Plast Reconstr Surg 2016;138:903-907
 
4. Koh HK, Tan NC, Tan BK, Ooi A SH. Comparison of outcomes of fasciocutaneous free flaps and jejunal free flaps in pharyngolaryngoesophageal reconstruction: a systematic review and meta-analysis. Ann Plast Surg. 2019 Jun;82(6):646-652

5. Ooi A, Feng J, Tan HK, Ong YS. Primary treatment of mandibular ameloblastoma with segmental resection and free fibula reconstruction: Achieving satisfactory outcomes with low implant-prosthetic rehabilitation uptake. J Plast Reconstr Aesthetic Surg. 2014;67:498-505

6. Ng MJM, Goh CSL, Ooi A SH. A Head-to-Head Comparison of the Medial Sural Artery Perforator versus Radial Forearm Flap for Tongue Reconstruction. J Reconstr Microsurg. 2020 Oct (doi: 10.1055/s-0040-1718551)

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