Liverpool Opinion on Unfavorable Results in Microsurgical Head and Neck Reconstruction: Lessons Learned

Key points

Comment on nonmicrovascular reconstruction for the patient with head and neck cancer

The most important decision for the patient typically via a tumor board (North America) or multidisciplinary team (United Kingdom) is the offer of ablative surgery as part of their cancer treatment. There must be clarity as to whether this is a curative or a palliative option because the resection and reconstruction are complex and the sequellae long lasting. The role of microvascular reconstructive surgery is discussed later; however, it is essential that the surgeon be aware of, and carefully

Avoiding poor results after successful flap transfer for mandibular reconstruction

In the microvascular reconstruction of the mandible the predominant donor sites are the fibula, iliac crest, scapula, and radial.⁵ Table 1 shows the flaps best suited to each defect of the mandible as recently classified.⁵ In Liverpool we generally prefer the iliac crest to the fibula for dentate patients requiring a hemimandibulectomy (including the ipsilateral canine but not the condyle [class II]), and for the central defect [class III] to maintain adequate height to support the chin and

Avoiding poor results after successful flap transfer for reconstruction of the maxilla and midface

It is clear in the literature and from my own experience that reconstructing the maxilla and midface is complex and there are several suggestions of how best to achieve optimum results for the patient.20, 21, 22 Table 2 summarizes the Liverpool ethos toward maxillary and midface defect reconstruction based on the Lancet classification (Fig. 4).²³

Class I (low-level maxillectomy not involving maxillary sinus)

Free tissue transfer is generally not needed for class I defects because these do not cause an oroantral fistula if laterally located. If the defect is central, however, then it may be advantageous to reconstruct the loss on the nondental part of the hard palate but only a soft tissue flap is needed (Fig. 5).

Class II (low-level maxillectomy not involving the orbital or nasal bones)

Similarly there is good evidence that with implant-retained obturation excellent results are obtained for all class II defects not involving the orbit.²⁴ These should be considered carefully with the maxillofacial prosthodontist and due discussion with the wishes of the patient and family. These are relatively low defects with little change to the external appearance or the orbit and so the main factor to be restored is the dentition to enable adequate chewing and dental appearance. The

Class III (high-level maxillectomy retaining the orbit)

If there is no substantial loss of overlying skin then the most satisfactory reconstruction that can provide adequate bone for implants, good support for the orbital floor reconstruction, and a satisfactory long-term result is the iliac crest with internal oblique muscle.27, 28 I have not used the scapula tip with teres major, latissimus dorsi muscle, or serratus anterior for the class III defect mainly because the bone is not sufficient to take implants reliably and longer term results have

Class IV (high-level maxillectomy and orbit)

This defect includes the removal of part of the dental alveolus and the maxilla, and includes an orbital exenteration. This means that there is no need to provide reliable support for the orbital floor to reduce the risk of contracture, ectropion, and enopthalmos, which greatly simplifies the reconstruction and opens the options. Much depends on whether prosthetic and prosthodontic rehabilitation is planned for the oral cavity and orbit and we still favor the iliac crest with internal oblique,

Class V (orbitomaxillary)

With the loss of the eye a prosthesis must be considered unless the patient is happy with a patch. If a prosthesis is planned then it is advantageous not to fill the orbit so as to allow space for the prosthesis to be placed, often with the benefit of implants. There is no need to restore the bone contour because this can be restored with the prosthesis if the patient prefers. Once again the whole reconstruction is simplified because the alveolus and dentition remain intact; there is little

Class VI (nasomaxillary)

This defect includes the standard rhinectomy, which is easily replaced with prosthesis if appropriate anchorage is planned at the time of the resection. In our unit we favor the use of immediate horizontally placed zygomatic implants allowing for early loading of the prosthesis in function (Fig. 8). However, problems may arise when the resection is higher and includes the skin and bone separating the orbits. In this situation the lower part of the nose, sometimes including the alar region, can

Summary

Microvascular reconstructive surgery requires a combined approach with sufficient number of cases and complexity to develop into a team to cover midface and maxilla and oral/oropharyngeal soft tissue and mandibular reconstruction. Short-term results are often reliable but be prepared to look at longer term results (greater than 2 years) when, after radiotherapy, less substantial and well-vascularized reconstructions may start to fail.