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In the past, ablative surgery for head and neck cancer, major facial trauma, and infections or inflammatory disorders resulted in significant functional and aesthetic problems that severely impacted patients’ quality of life, often leading to social isolation. Our ability to communicate via speech and facial expression is the basis for human connectedness. The number of tools the head and neck surgeon has in his or her armamentarium to address many reconstructive problems continues to grow. Achievement of the ideal reconstruction—tissue replacement that matches the quality and function of the resected tissue—has prompted the evolution of time-tested techniques and the development of new approaches based on these techniques. Reconstructive plans that took months and several operative procedures decades ago can now be accomplished at the time of resection with microvascular free tissue transfer. Chronic facial nerve paralysis may be addressed with nerve grafting, substitution techniques, or muscle substitutions that allow more natural movements of the face. The reconstructive plan follows a comprehensive defect analysis. This chapter will begin with a discussion of the important considerations and requirements for tissue replacement followed by descriptions of the multiple head and neck reconstructive techniques ranging from simple to complex.

Reconstructive Considerations

  • Missing tissue components

    1. Skin

    2. Mucosa

    3. Muscle

    4. Bone

    5. Cartilage

    6. Nerve(s)

  • Structural and functional considerations at the recipient site

    1. Bone stock for skeletal framework and/or osseointegration

    2. Soft tissue coverage of vital structures (eg, carotid artery, intracranial contents)

    3. Muscle continuity (eg, oral competence in lip reconstruction)

    4. Pliability of tissues

    5. Volume restoration

    6. Secretory mucosal surface

    7. Potential for a sensate tissue surface

    8. Vascularized tissue for support of free grafts, and/or treatment of fistulae, osteomyelitis, and/or osteoradionecrosis

  • Special conditions at the wound site

    1. Previous irradiation

    2. Infection

    3. Fistulae

The Reconstructive Ladder

The traditional concept of the reconstructive ladder calls upon the surgeon to consider various approaches to defect repair, using a hierarchical system that emphasizes simplicity. The surgeon chooses the technique that is most expedient for addressing the reconstructive problem with contingency plans in case of flap/graft failure or recurrence. It should be noted that sometimes the simplest plan has limitations in terms of aesthetics, long-term durability, and functionality. The reconstructive ladder must also be applied in the context of the patient’s overall health status, wishes, and desires. All of these factors will determine the final reconstructive choice.

  • Healing by secondary intention

  • Primary closure

  • Skin, cartilage, bone, nerve, and composite grafting

  • Local flaps

  • Regional flaps

  • Prosthetic reconstruction

  • Microneurovascular free tissue transfer

Healing by Secondary Intention

  • Development of granulation tissue in the wound

  • Myofibroblasts cause wound contraction

  • Final phase is epithelialization

  • Debris and scabbing of the wound (from dessication) delay ultimate epithelialization

  • Poor reconstructive option for sites of the face with free edges—nasal ala, upper/lower eyelid, lips—with resulting distortion


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