Reconstructive Principles

Ideally, reconstruction of a surgical defect should be performed immediately—at the time of tumor resection. Immediate reconstruction prevents retraction and fibrosis of the defect, allows administration of adjuvant therapy, minimizes the number of surgical procedures and favors psychologic rehabilitation. Some authors, claiming easier identification of tumor recurrence, have advocated delayed reconstruction, which might otherwise be difficult to monitor if the cancer defect is covered with a flap. With development of better diagnostic techniques (ie, computed tomographic scanning, magnetic resonance imaging and positron emission tomography), delayed reconstruction to detect tumor recurrence earlier is no longer valid.1 Likewise, it is not acceptable to favor delayed reconstruction, arguing better appreciation of the oncologic defect by the patient.

The basic tenets of reconstructive surgery include restoration of form and function while minimizing donor site deformity. Whenever possible, this should be accomplished with similar tissue rather than allografts or synthetic materials.2 An additional principle in head and neck reconstruction is to respect facial esthetic units or subunits by placing scars following a crease or transition skin in the face3,4 (Figure 18-1). Although sacrificing adjacent normal tissue occasionally is necessary, final results are more esthetic when adhering to this basic principle.

Surgical options for head and neck reconstruction have been described schematically as a ladder: starting from direct closure and skin grafting and moving forward to local flaps, regional cutaneous and myocuta-neous pedicled flaps, and finally to the wide variety of microvascular free flaps (Figure 18-2). Historically, it

Figure 18-1. Esthetic subunits of the face.

has been recommended to start from the simplest method and if required, or the first option fails, to move over to the next step on the reconstructive lad-der.2,5 The current approach, however, is to select the reconstructive option which best provides the patient with the ideal reconstruction, thus maximizing functional and esthetic results primarily. For example, a young, healthy patient with a mandibular defect is best reconstructed using an osteocutaneous free flap at the time of tumor resection, instead of using a reconstruction plate covered with a pedicled myocutaneous flap (Figure 18-3). One-stage microvascular reconstruction of the mandible allows the surgeon to replace bone and soft tissue primarily with like tissue. Osseointegrated dental implants can be inserted on a secondary basis to optimize oro-facial rehabilitation. Alternatively, a local or regional flap is generally preferred over a free flap when there is no significant functional or esthetic advantage of the latter.2 In general, regional flaps and free flaps are equally reliable as experienced surgeons accomplish free tissue transfer with success rates higher than 95 percent.6 However, regional flaps often demand less technical expertise and operating time.

In selecting the best option for reconstruction of head and neck defects, these basic principles should always be followed for a successful outcome. In addition, other issues such as age, functional status, concomitant medical conditions and extent of disease must be taken into account.7

RECONSTRUCTIVE OPTIONS

Primary Closure

Many defects that result from excision of small skin cancers may be closed primarily with excellent esthetic results. The skin in the face and neck is very elastic and its laxity allows extensive undermining and direct closure, particularly in elderly patients. In order to minimize the visible scar, the excision should be designed to fall within the relaxed skin tension lines (Figure 18-4). Whenever possible, primary closure should be used for repair of defects of the eyelids and lips. Up to one-third of the eyelid and lip can be resected in a V fashion, with primary closure.5

Figure 18-2. The reconstructive ladder.

Straight-line repair perpendicular to the lid or lip margin will result in the best esthetic and functional result (Figure 18-5). These critical areas are difficult to reconstruct using distant tissue that is different both structurally and functionally. When the defect becomes larger, adjacent or distant tissue should be used to restore form and function.2

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