Head and Neck Reconstruction

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Why is reconstructive surgery needed?

The aim of the oncology surgeon is to remove the tumour with a margin of healthy tissue. This will however result in a defect that needs to be covered by replacing the lost tissue through reconstructive surgery. Reconstructive surgery is a necessary part of cancer surgery for various reasons. Depending on the location and size of the defect, these include sealing off the oral or nasal cavities; restoring the continuity of the gullet; restoring functions such as chewing, swallowing and speech; protect critical structures like blood vessels and nerves from saliva and bacteria; and improving the aesthetic appearance after surgery.

How is reconstructive surgery performed?

Reconstruction is performed by "borrowing" tissue from other parts of the body to cover the defect. Such a tissue is called a flap, which must be harvested together with its delicate blood vessels to ensure it will continue to have blood circulation and can thus survive.

Flaps harvested near the site of the defect can be rotated or pulled to where it is needed. Often, however, more suitable flaps are harvested far away from the head and neck region. In such instances, the blood vessels have to be cut to allow the flap (now called a free flap) to be brought over to the defect. The flap vessels are then connected to other blood vessels in the vicinity to restore blood flow to the flap, through a process called microsurgery, using a microscope and extremely fine sutures to stitch the tiny blood vessels together.

The reconstructive surgery will be performed concurrently with the surgery to remove the tumour while you are under general anaesthesia.

Types of flaps

Some commonly used flaps in head and neck reconstruction include the following:

Pectoralis Major flap (chest)

Latissimus Dorsi flap (back)

Anterolateral Thigh Flap (outer thigh)

Radial Forearm flap (forearm)

Fibula flap (calf)

 The locations where the flaps are harvested from usually heal well with proper wound care. There may be temporary side effects after surgery, such as stiffness, weakness or numbness, but these usually improve well with rehabilitation from our physiotherapy colleagues. There are typically no major long term side effects; once fully recovered, your daily activities and your ability to exercise should not be affected.

Risks of reconstructive surgery

Besides bleeding, infection, and scarring that can occur in any surgery, reconstructive surgery has specific risks involved. These include:

Flap failure
The blood circulation to the flap may be poor resulting in part or all of the flap tissue not surviving. This risk is highest in the 1st 1-3 days after surgery. Emergency surgery may be needed to salvage the flap. If the flap cannot be saved, it will unfortunately have to be discarded, and a 2nd flap surgery will be needed to reconstruct the defect, as the defect cannot be left uncovered.

Infection / salivary leak
Due to their location in the aerodigestive tract, the wounds from the surgery are often in contact with saliva and bacteria. Saliva may seep through the stitched wounds causing deep infection in the jaw or neck. This tend to occur starting from day 3 to 5 after surgery. Repeat surgeries may be needed to control and eventually clear the infection.

Poor wound healing
The exposure of the wounds to an environment of saliva and bacteria may result in poor wound healing, wound breakdown and subsequent infection. Mild cases may be just treated with dressings while they heal, but severe cases may require repeat surgeries or even a 2nd flap surgery to plug the area of breakdown.

Immobility
Being immobile for a period of time after surgery increases risk of chest or urine tract infections, as well as blood clot formation in the legs and lungs. The aim is to reduce these risks by getting you to mobilise and walk as soon as it is safe to do so.

What to expect after surgery?

 After waking up from anaesthesia, you will be nursed in the High Dependency unit.

• There will be frequent checks by the doctors and nurses to ensure both you and the flap is healthy and doing well
• There will be many monitoring lines and drainage tubes on your body
• Discomfort will be minimal, as adequate painkillers will be given
• A feeding tube is used as you will be unable to take food normally at the beginning
• A tracheostomy tube to help you breathe will also mean you cannot speak for a few days until the tube is removed

You will be bedbound initially after the long surgery. But over the subsequent days, the various lines and tubes will be progressively removed one by one, and you will soon be getting up and about with the help of the physiotherapists and nurses. Thereafter you will be transferred to the General Ward, where you will continue to recover and recuperate. The estimated length of stay in hospital is usually up to 1.5 to 2 weeks if no significant complications occur after surgery.

Home care after surgery

• Avoid strenuous activities, and rest and recuperate at home.
• Sometimes, depending on the extent and location of the surgery, your swallowing may still be affected by the time of discharge, and you will need to continue tube feeding to obtain adequate nutrition. If so, you, as well as your carer, will undergo training before discharge on how to look after the feeding tube. After discharge, continue with the diet regime as instructed by the dietician.
• If there are any remnant wounds that require dressings, to keep the dressings clean and dry, and have them changed at a clinic as instructed by your doctors.
• Continue any exercises and other self-therapies as taught by the Physiotherapist, Occupational Therapist and Speech Therapist.
• Remember to return for all the outpatient appointments to the hospital.

When to seek medical consultation after discharge?

• Fever
• Change in status of wounds – increased pain, redness, discharge or odour
• Problems with feeding tubes, drains or other catheters
• New abnormal symptoms

You can call the Specialist Outpatient Clinic and ask to see your doctor earlier. For more urgent situations, please go to the hospital Accident and Emergency for help.