Development of reconstructive head and neck surgery: special emphasis on novel applications of microsurgery

Research output: ThesisDoctoral ThesisMonograph

Abstract

Introduction: Managing extensive bone and soft tissue defects in head and neck region remains a reconstructive challenge. The aim of the reconstruction is to manage the three-dimensional tissue defect and preserve functions like swallowing, talking, breathing and aesthetics. The modern microsurgical practice is reported to be highly reliable. Still, when complications occur, they can be devastating. Understanding the advantages and disadvantages of the different reconstruction alternatives ensures the optimal choice of treatment. Aims: This thesis comprises four studies from Helsinki Head and Neck Center Department of Plastic Surgery, analysing the pratice of head and neck reconstruction from 1995 to 2012, comparing the iliac crest (DCIA), the scapular and the fibular flap in maxillomandibular reconstruction, presenting local pedicled submental artery flap (SAF) in oral cancer reconstruction and analysing novel ear-based alternatives in maxillofacial microvascular reconstruction. Patients and methods: The first study included 541 patients receiving 594 head and neck free flaps from 1995 to 2012. The second study compared 163 patients with a scapular, fibular or DCIA flap for mandibular, maxillary or orbital reconstruction. The third study investigated the outcome of reconstruction with SAF in a series of 10 patients with early or locally advanced intraoral cancer. In the fourth study three external ear-based free flaps in facial reconstruction were described in a series of 19 patients with 20 reconstructions with temporal artery posterior auricular skin (TAPAS), helical or hemiauricular flaps. Results: The most commonly used free flap from 1995 to 2012 was the radial forearm flap. The number of different flap types and combinations expanded from 15 during the first study trimester to 24 during the last study trimester. The flap survival remained constant being 97%. The prevalence of surgical complications decreased. The overall survival rate of scapular, fibular and DCIA flaps from 2000 to 2012 was 91%. The most reliable flap was scapular flap with 100% survival, followed by the fibular with 97% survival and the least reliable was the DCIA with 85% survival. The overall complications favoured fibula and scapula. Two patients with SAF reconstruction developed major complications of which one was total flap loss. The SAF was lifted in three cases in combination with sentinel lymph node biopsy to rule out positive neck disease and in two cases there was nodal sampling combined. The follow-up showed no signs of metastatic neck disease, but six patients developed local recurrences. Three of patients were treated primarily with palliative intent. The free flaps lifted from ear region included 12 helical flaps, 7 TAPAS flaps and 1 hemi-auricular flap. Flap survival rate was 95%. Donor-sites healed uneventfully, and aesthetic and functional outcomes were good in all flaps. Conclusions: Head and neck microsurgery was established in our institution during recent decades. The flap selection has been constantly expanding along with the increasing mean age of the patient population, without sacrificing outcome. In composite reconstructions, fibular, scapular, and DCIA flaps are all useful and reliable tools, with DCIA being least favorable in terms of flap survival and complications. Local flap reconstruction with SAF is an alternative tool in selective patients not suitable for conventional microvascular surgery. Development of free flaps from the ear region has added versatile flap alternatives in the armamentarium.
Original languageEnglish
Supervisors/Advisors
  • Lassus, Patrik, Supervisor
  • Mäkitie, Antti, Supervisor
Award date29 Jun 2018
Place of PublicationHelsinki
Publisher
Print ISBNs978-951-51-4341-9
Electronic ISBNs978-­951-­51-­4342-­6
Publication statusPublished - 2018
MoE publication typeG4 Doctoral dissertation (monograph)

Bibliographical note

M1 - 102 s. + liitteet

Fields of Science

  • Reconstructive Surgical Procedures
  • Microsurgery
  • +methods
  • Surgery, Plastic
  • Cervicoplasty
  • Mandibular Reconstruction
  • Head
  • +surgery
  • Transplants
  • Free Tissue Flaps
  • Scapula
  • Fibula
  • Ilium
  • Head and Neck Neoplasms
  • Orbit
  • Ear, External
  • Treatment Outcome
  • 3126 Surgery, anesthesiology, intensive care, radiology

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