Chapter 162: Head and Neck Reconstruction

INTRODUCTION

Epidemiology

Cancer of the head and neck is still a significant problem worldwide. Head and neck tumors are strongly associated with a history of smoking and alcohol consumption,¹ but recent evidence has shown that low socioeconomic status is a strong risk factor, comparable to tobacco and alcohol.² While the incidence of tobacco-related tumors appears to be decreasing, oropharyngeal (OP) cancers are increasing, primarily as a result of human papilloma virus (HPV) infection, particularly HPV-16 genotype. Recent estimates show that the incidence of HPV-related OP cancers is now greater than 50% of all OP cancers, and its incidence is increasing.³

Cancer of the head and neck can occur anywhere, but the areas most commonly involved are the skin, lip, oral cavity, oropharynx (tonsil and base of tongue), and larynx.⁴ Overall, roughly 50% of the tumors will be located in the oral cavity. Histologically more than 90% of all head and neck malignancies are squamous cell carcinomas, which makes them amenable to chemotherapy and radiation treatment. The standard treatment for OP and laryngeal cancers is primarily radiation and chemotherapy,⁵ but when this modality fails, surgery is much more difficult and frequently requires complex reconstruction. In contrast, squamous cell carcinoma of the oral cavity is more commonly treated with surgery,⁶ followed by radiation. In very advanced cases, chemotherapy and radiation are included.

Changes in Treatment Trends

Encompassing with the changes in the preferred treatment modalities for head and neck cancer, the management of surgical defects has changed significantly over the last decades. With the advent of improved perioperative management in the 1940s to 1950s, radical ablative surgery became the mainstay for treatment of advanced tumors, which was routinely followed by radiation therapy. Unfortunately, reconstructive surgery did not advance at the same pace, and there were no reliable reconstructive options to rehabilitate these patients. Furthermore, head and neck surgeons of the time did not consider reconstruction as an important part of the surgical treatment.⁷ As such, extensive surgical ablations in this era were notorious for their detrimental impact in patient's appearance and overall function. The field of reconstruction did not show significant advances until the development of the deltopectoral flap in 1965.⁸ This became the workhorse for head and neck reconstruction during that period. The following decade saw the introduction of pedicled myocutaneous flaps and free flaps, which revolutionized the management of head and neck cancer patients . Up to this point, the combined therapy was still considered the mainstay of treatment, but this changed in the late 1980s with the advent of organ-preservation strategies. The combination of chemotherapy and radiation therapy is still the standard treatment for laryngeal and pharyngeal cancers, limiting surgical ablation to a salvage role.⁹ In this setting, salvage surgery must be performed in the context of debilitated patients, radiated fields, and decreased functional status, adding ...