This article annotates a philosophy toward achieving best results for the patient with head and neck cancer, in particular relating to oral, mandibular, and maxillary resection. At the same time are highlighted the pitfalls that, if not avoided, are likely to result in a poor outcome even with a successful flap transfer. There is a paucity of evidence to support clinical practice in head and neck reconstruction such that much of the discussion presented is opinion-based rather than evidence-based.
Key points
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Soft tissue reconstruction of the oral cavity.
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Resect oncologically, aware that maintenance of the patient’s own tissue, with a maintained blood and nerve supply, is ideal.
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Excess tissue in partial tongue reconstruction can result in poorer function.
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The remaining oral tongue must have optimum movement.
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Extensive oral tongue resections require more bulk so that the swallow is initiated with little chance of effective chewing because the functioning tongue is more essential than an occluding dentition.
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The floor of the mouth and buccal tissues require a thin flap to allow good movement.
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Think of the oral tissues and soft palate as horizontal with less need of a sphincteric affect and the rest of the oropharynx as vertical where the sphincteric effect is paramount.
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Mandibular reconstruction.
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Segmental resections involving the anterior mandible present more significant challenges than the posterior mandible, where a variety of techniques are used. The height of remaining bone in the anterior mandible and its relationship to the circumoral musculature is critical in the degree of postoperative collapse and the likelihood of effective rehabilitation.
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Maxillary reconstruction.
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For low level defects (Brown class I and II), maxillary obturation is effective especially if supported by osseointegrated dental and zygomatic implants.
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Zygomatic implants can be used in conjunction with soft tissue free flaps to effectively rehabilitate patients without the need for composite reconstruction with the associated technical complications and additional morbidity.
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Maxillary defects involving the orbital floor (Class III) require composite free flaps to effect a satisfactory facial reconstruction and dental rehabilitation.
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When the orbit is removed (Class IV) the facial profile can be managed with a prosthesis, but dental rehabilitation may still require a composite flap.
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Collaboration with the team providing final rehabilitation and prosthetic support is essential before deciding on the reconstruction.
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