Patient 1: (a) Incisional design for cheek flap and neck dissection procedures. This straight line, right angle at the level of the hyoid, will yield superior aesthetic results to all other designs. I had previously added an angle plasty to the cervical portion in order to discourage linear scar contracture, which never materialized, and which seemed to complicate wound healing. As the platysma is diastatic in the midline of many, this may be an explanation, as it is a watershed area in terms of vascularity. Designs, which curve into the neck portion characteristically, have a “trap door” or “pincushion” effect where upper flap edema persists and contributes an unnatural appearance and shadow. Incisions, which curve around the mentalis, tend to denervate that muscle on one side, resulting in abnormal dynamics in function. Radical salvage composite resection defect including upper neck skin. The treatment history rendered him vessel depleted in the search for recipient vessels. (b) Exposure for salvage hemiglossectomy – purple line denotes planned resection. (c) Hemiglossectomy defect. (d) Lateral arm flap reconstruction of glossectomy, inset, and closure. (e) Long-term peroral view, edentulous segment with osseointegrated implant in place, lateral arm glossectomy reconstruction. (f) Chronic trauma (protrusion) of the flap through edentulous segment led to fibromatous reaction which might resemble recurrent SCCA to some. This was treated with placement of the prosthodontic applicance, preventing protrusion. The area completely resolved over the following months. (g–i) Long-term aesthetic results after three surgical procedures, free flap reconstruction, RT, and CT. The patient remains active in the practice of law, his speech, articulation, and swallowing near-normal. He remains in NED status despite a PET scan that suggested recurrence in the interface tongue – likely representing actual relative hyperactivity in the retained native segment, relative to the hypometabolic fasciocutaneous flap
There are few, if any, circumstances that should require simultaneous multiple free tissue transfers and their inherent increased risk, regardless of extent. Microsurgical transfers may be combined with regional flap transfers (pectoralis major) to accomplish many goals. The sheet-grafted muscle-only pectoralis major flap is particularly useful for the resurfacing of the neck skin where neck failure and imminent tumor breakthrough is a problem. My strong preference has been to avoid “pie crusting” techniques, meshing, and bolsters as they are unnecessary, and the former lead to compromised aesthetics for those fortunate to achieve long-term control.
Nowhere is reconstructive expertise more important so as to minimize days-of-life lost for those who may not experience long-term survival.
10.1.6 Special Considerations: Vascular
Failure in the neck from oral cavity cancer commonly occurs in proximity to or at/involving the carotid bifurcation. Preemptive techniques to control catastrophic hemorrhage and to prepare for proximal external carotid sacrifice should be made and anticipated. Proximal and distal arterial control, where possible, should be secured preparatory to efforts to “peel” recurrent tumor from major structures. I have found that the steel scalpel may be the best instrument to perform such “carve-out” procedures as traditional dissection methods rely on undisturbed tissue planes that are nonexistent in these cases. I have also found the thermal “Shaw” scalpel to be used in this situation. In cases where in advertent major vascular entry results, mass ligation or bypass techniques may be required to avoid exsanguinating hemorrhage. I have had covered stents placed in such cases where carotid exarterectomy may be required. This requires presurgical planning, the availability of consultant physicians, and appropriate vascular imaging studies to assess the feasibility of such endeavors.
Extra-anatomic bypass for malignancies, while technically possible, has generally failed to extend control of disease and has often eventuated in catastrophe. Such ultra radical technical exercises should be avoided in this patient population, particularly in view of their grave prognoses.
Implications for microvascular technique should be realized preoperatively. The use of proper vascular technique and instrumentation (Gerald forceps, Satinsky and other partially occluding vascular clamps, Prolene suture material, round bevel (RB) needles, etc.) should be used and suture ligation applied to all major vascular structures that are sacrificed in these efforts.
10.1.7 The Role of Chemotherapy in the Treatment of Recurrent Oral Cavity SCCA
Active agents for palliative chemotherapy: Cytotoxic and targeted agents have shown activity in metastatic and recurrent head and neck cancer. Commonly used agents include platinum compounds (e.g., cisplatin, carboplatin), taxanes (docetaxel, paclitaxel), methotrexate, fluorouracil (5FU), and cetuximab, a monoclonal antibody that targets the epidermal growth factor receptor(EGFR). Small molecule tyrosine kinase inhibitors and checkpoint inhibition immunotherapy have shown activity in a second- or third- line setting.
The choice of therapy for patients with recurrent and metastatic head and neck cancer who have not received prior systemic therapy is dependent on the patient’s performance status and comorbidities. For patients with good performance status, combined cytotoxic chemotherapy regimens, usually combining a platinum agent with a taxane or 5FU , show increased objective response rates compared to single-agent chemotherapy, although no improvement in overall survival has been demonstrated. However, the addition of cetuximab to cisplatin or carboplatin plus fluorouracil increased overall survival compared with cisplatin or carboplatin plus fluorouracil in a phase III trial . In the study, chemotherapy plus cetuximab significantly prolonged overall survival compared with chemotherapy alone (median 10.1 versus 7.4 months, HR for death 0.80, 95 % CI 0.64–0.99). Small molecule tyrosine kinase inhibitors, gefitinib  and afatinib , have shown some activity in second- and third-line treatment.
Checkpoint inhibition immunotherapy: Multiple studies are ongoing in patients with advanced head and neck cancer with checkpoint inhibition. In a phase I/II study , in which 132 patients with advanced head and neck squamous cell carcinoma were treated with pembrolizumab (Keytruda – an anti-PD-1 antibody). In the study, 83 % of patients had received prior systemic therapy, and 59 % had received two or more regimens. Objective response rate was 25 %, and 56 % of patients had at least some evidence of tumor regression. Some of the responses were durable, and response rates were similar in those with HPV-positive and HPV-negative disease. Preliminary results of the recent international Phase III CheckMate 141 Trial examined the anti-PD-1 agent nivolumab (Opdivo) versus investigator’s choice of cetuximab, methotrexate, or docetaxel in platinum-refractory head and neck SCCA were recently presented at the 2016 Annual ASCO Meeting . The study was stopped early after increased overall survival (primary endpoint) was demonstrated. This class of drugs is of ever-increasing interest in the treatment of head and neck cancer after a decade (cetuximab the first targeted drug, and last FDA-approved, for HN SCCA, was approved for this indication in 2006) of limited progress in therapeutics for treating this previously hopeless, palliative-intent subset of unfortunate patients.
10.1.8 Perioperative Care
Aggressive attention to perioperative care is not insignificant in maximizing all efforts directed at such retreatment efforts and avoiding returns to the operative theater for related, avoidable complications. This includes the use of active suction drains, thoughtful placement, their meticulous post-op management, and the use of antibiotic mouth rinses to suppress oral flora during the healing of critical suture lines. Special attention to tracheotomy tubes, their maintenance, and the straps which secure them may avoid the occasional catastrophic obstructive or dislodgement event or flap outflow compromise.