[Reconstructive surgery in the head-neck area with regional and free tissue transfer].

BACKGROUND: Operative treatment of head and neck cancer requires radical resection of the tumor with not only severe impairment of important functions like swallowing speech, and respiration but also aesthetic mutilation because of the exposed character of the head and neck region. Therefore the rehabilitation from a functional and cosmetic standpoint is an essential goal of treatment in addition to control of the malignant disease. Fortunately regional plastic surgery offers a variety of options for reconstruction of the defects to receive a solution tailored to each individual patient.

PATIENTS: Between the years 1986 and 1996, 107 patients with advanced head and neck cancer were treated surgically by radical resection of the tumor and plastic reconstruction. In this study we made a retrospective analysis of the functional and aesthetic outcome of the techniques of reconstructive surgery we used for rehabilitation. The sex ratio was 79 males to 28 females. Average age was 59.4 years (ranging from 39 to 78 years). Most of the patients suffered from squamous cell carcinoma of the upper digestive tract (97 cases). The others included an adenocarcinoma of the paranasal sinuses (three cases), adenoid cystic cancer of the palate (two cases), squamous cell carcinoma of the temporal bone (two cases), two deep infiltrating basaliomas in the area of the nose and forehead and one chondrosarcoma of the neck. Our oncological concept includes a radical resection of the tumor and a onestep reconstruction of the defect, if the patient's general condition enables this approach. The surgical techniques we used include the approved pedicled myocutaneous flaps like the pectoralis major flap, latissimus dorsi flap (which can be also applied as a free microvascular tissue graft), temporalis muscle flap, and the free radial forearm flap.

RESULTS: In previous years, the pedicled myocutaneous pectoralis-major- and latissimus-dorsi-flaps were used for reconstruction (n = 67), but the arc of rotation and the huge bulk of the graft are limiting factors for the indication of these techniques. The free forearm flap has increasingly been used to provide an excellent closure of large pharyngeal defects (n = 16), whereas the temporalis flap is useful for restoration after limited resection of the palate (n = 18). Beside these rather invasive procedures, aesthetic rehabilitation may be achieved with bone-anchored epithesis especially after exenteration of the orbit and ablation of the external ear in case of elderly patients with multiple morbidities (n = 5). In most cases, sufficient rehabilitation from the anatomical and functional point of view was possible even after large tumor resections. A main problem can be longstanding aspiration after resection of large areas of the pharyngeal mucosa (n = 8). Complications included eight cases of necrosis of the flaps and seven patients who developed significant seromas at the donor site.

CONCLUSIONS: The potential of modern regional reconstructive surgery enables the surgeon to achieve anatomically and functionally rehabilitation in a one-step procedure in most cases, even after extended resection for head and neck cancer. One should be aware of the fact that these techniques do not offer a significant improvement of prognosis. As such, the aggressiveness of surgical therapy should remain in reasonable relation to the prognosis of the malignant disease.