General Principles of Surgical Reconstruction in Head and Neck Cancers

  • Chang-Cheng Chang
  • Yu-Tsung Chen
  • Jen-Hsiang Shen
Part of the Head and Neck Cancer Clinics book series (HNCC)


Head and neck reconstruction is the challenge to surgeon, due to the complicated functional anatomy of the head and neck, and cosmetic concern. Till the 1960s, local or regional flap was used for replacement of head and neck soft tissue. Transbuccal flap, tongue flap, and nasolabial flap were chosen for small tissue defect, whereas forehead flap, temporal flap, and deltopectoral flap were chosen for larger ones. These flaps were selected based on proximity rather than on pattern or blood supply, which caused wound unhealing and higher complication rate. Regional pedicle myocutaneous flaps were introduced in the 1970s. In 1983, Souter reported a case of using free radial forearm flap for oral reconstruction. This provides compound reconstruction with multiple types of tissue including the skin, mucosa, muscle, and bone. In these two decades, the free flap and, more recently, the perforator flap have become gold standard for not only reconstructing the defects but also offering the functional restoration and superior aesthetic result.

In the light of microvascular free tissue transfer, the external carotid branches are commonly used. The facial vein has good caliber and is useful as a recipient for a free tissue transfer. Under the circumstance of neck dissection, the alternatives could be of the recipient vein, such as the internal jugular vein, external jugular vein, and transverse cervical vein. Details for each reconstruction area are listed as below. The protocol of flap surveillance should be inspecting the flap every hour, and any vascular compromise or indication for re-exploration can be noted easily.


  1. 1.
    Chamber RG, Jaques DA, Mahoney WD. Tongue flaps for intra-oral reconstruction. Am J Surg. 1969;118(5):783–6.CrossRefGoogle Scholar
  2. 2.
    Cohen IK, Edgerton MT. Transbuccal flaps for reconstruction of the floor of the mouth. Plast Reconstr Surg. 1971;48(1):8–10.CrossRefGoogle Scholar
  3. 3.
    McGregor IA. The temporal flap in intra-oral cancer: its use in repairing the post-excisional defect. Br J Plast Surg. 1963;16:318–35.CrossRefGoogle Scholar
  4. 4.
    Ariyan S. The pectoralis major myocutaneous flap a versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63(1):73–81.CrossRefGoogle Scholar
  5. 5.
    Demergasso F, Piazza MV. Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: an original technique. Am J Surg. 1979;138(4):533–6.CrossRefGoogle Scholar
  6. 6.
    Quillen CG. Latissimus dorsi myocutaneous flaps in head and neck reconstruction. Plast Reconstr Surg. 1979;63(5):664–70.CrossRefGoogle Scholar
  7. 7.
    Nylean CO. The microscope in aural surgery, its first use and later development. Acta Otolaryngol. 1954;43(S116):226–40.CrossRefGoogle Scholar
  8. 8.
    Wei FC, Jain V, Suominen S, et al. Confusion among perforator flap: what is a true perforator flaps? Plast Reconstr Surg. 2001;107(3):874–6.CrossRefGoogle Scholar
  9. 9.
    Neligan PC. Head and neck reconstruction. Plast Reconstr Surg. 2013;131(2):260e–9e.CrossRefGoogle Scholar
  10. 10.
    Curran AJP, Neligan P, Gullane PJ. Submental artery island flap. Laryngoscope. 1997;107(11):1545–9.CrossRefGoogle Scholar
  11. 11.
    Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004;114(4):910–6.CrossRefGoogle Scholar
  12. 12.
    Mardini S, Tsai FC, Wei FC. The thigh as a model for free style free flaps. Clin Plast Surg. 2003;30(3):473–80.CrossRefGoogle Scholar
  13. 13.
    Chang CC, Wong CH, Wei FC. Free-style free flap. Injury. 2008;39(Suppl 3):S57–61.CrossRefGoogle Scholar
  14. 14.
    Furnas H, Lineaweaver WC, Alpert BS, Buncke HJ. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg. 1990;24(5):431–44.CrossRefGoogle Scholar
  15. 15.
    Ueda K, Harii K, Nakatsuka T, Asato H, Yamada A. Comparison of end-to-end and end-to-side venous anastomosis in free-tissue transfer following resection of head and neck tumors. Microsurgery. 1996;17(3):146–9.CrossRefGoogle Scholar
  16. 16.
    Gordon L, Buncke HJ, Alpert BS. Free latissimus dorsi muscle flap with split-thickness skin graft cover: a report of 16 cases. Plast Reconstr Surg. 1982;70:173–8.CrossRefGoogle Scholar
  17. 17.
    Triana RJ, Uglesic V, Virag M, et al. Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects. Arch Facial Plast Surg. 2000;2:91–101.CrossRefGoogle Scholar
  18. 18.
    Futran ND, Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006;7:249–58.CrossRefGoogle Scholar
  19. 19.
    Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Head Neck. 1996;18:412–21.CrossRefGoogle Scholar
  20. 20.
    Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg. 2002;128(2):161.CrossRefGoogle Scholar
  21. 21.
    Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2001;108(5):1197–208.CrossRefGoogle Scholar
  22. 22.
    Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg. 1993;22(1):2–6.CrossRefGoogle Scholar
  23. 23.
    Chang SCN, Miller G, Halbert CF, Yang KH, Chao WC, Wei FC. Limiting donor site morbidity by suprafascial dissection of the radial forearm flap. Microsurgery. 1996;17(3):136–40.CrossRefGoogle Scholar
  24. 24.
    Mäkitie AA, Nigel JP, Neligan PC, Lipa J, Gullane PJ, Gilbert RW. Head and neck reconstruction with anterolateral thigh flap. Otolaryngol Head Neck Surg. 2003;129(5):547–55.CrossRefGoogle Scholar
  25. 25.
    Song YG, Chen GZ, Song YL. The free thigh flap: a new flap concept based on the septocutaneous artery. Plast Reconstr Surg. 1984;37:149.Google Scholar
  26. 26.
    Koshima I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh flaps: variations in its vascular pedicle. Br J Plast Surg. 1989;442:260.CrossRefGoogle Scholar
  27. 27.
    Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg. 1996;97(5):985–92.CrossRefGoogle Scholar
  28. 28.
    Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg. 1993;92(3):411–20.CrossRefGoogle Scholar
  29. 29.
    Liao CT, Chang JT, Wang HM, et al. Surgical outcome of T4a and resected T4b oral cavity cancer. Cancer. 2006;107(2):337–44.CrossRefGoogle Scholar
  30. 30.
    Stark B, Nathanson A, Hede’n P, Jernbeck J. Results after resection of intraoral cancer and reconstruction with the free radial forearm flap. ORL J Otorhinolaryngol Relat Spec. 1998;60:212–7.CrossRefGoogle Scholar
  31. 31.
    Santamaria E, Wei FC, Chen IH, Chuang DC. Sensation recovery on innervated radial forearm flap for hemiglossectomy reconstruction by using different recipient nerves. Plast Reconstr Surg. 1999;103:450–7.CrossRefGoogle Scholar
  32. 32.
    Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109(7):2219–26. discussion 2227–30CrossRefGoogle Scholar
  33. 33.
    Chana JS, Wei FC. A review of the advantages of the anterolateral thigh flap in head and neck reconstruction. Br J Plast Surg. 2004;57(7):603–9.CrossRefGoogle Scholar
  34. 34.
    Engel H, Huang JJ, Lin CY, Lam W, Kao HK, Gazyakan E, Cheng MH. A strategic approach for tongue reconstruction to achieve predictable and improved functional and aesthetic outcomes. Plast Reconstr Surg. 2010;126(6):1967–77.CrossRefGoogle Scholar
  35. 35.
    Wei FC, Mardini S. Flaps and reconstructive surgery. Philadelphia: Saunders; 2009. p. 439–56.CrossRefGoogle Scholar
  36. 36.
    Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen HC. Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg. 2003;112(1):37–42.CrossRefGoogle Scholar
  37. 37.
    Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy. Cancer. 2010;116(7):1718–24.CrossRefGoogle Scholar
  38. 38.
    Chen KT, Mardini S, Chuang DCC, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007;120(1):187–95.CrossRefGoogle Scholar
  39. 39.
    Kerrigan CL, Stotland MA. Ischemia reperfusion injury: a review. Microsurgery. 1993;14(3):165–75.CrossRefGoogle Scholar
  40. 40.
    Siemionow M, Arslan E. Ischemia/reperfusion injury: a review in relation to free tissue transfers. Microsurgery. 2004;24(6):468–75.CrossRefGoogle Scholar
  41. 41.
    Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg. 1996;98(7):1230–3.CrossRefGoogle Scholar
  42. 42.
    Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092–100.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2019

Authors and Affiliations

  • Chang-Cheng Chang
    • 1
    • 2
  • Yu-Tsung Chen
    • 3
    • 4
  • Jen-Hsiang Shen
    • 3
    • 5
  1. 1.Collage of Medicine, School of MedicineChina Medical UniversityTaichungTaiwan
  2. 2.Division of Plastic and Reconstructive SurgeryChina Medical UniversityTaichungTaiwan
  3. 3.Division of Plastic and Reconstructive SurgeryChang Gung Memorial HospitalChia YiTaiwan
  4. 4.Department of DermatologyShuang Ho Hospital, Taipei Medical UniversityTaipeiTaiwan
  5. 5.Department of OphthalmologyChang Gung Memorial HospitalLinkouTaiwan

Personalised recommendations