Preoperative Planning in the Reconstruction of Post-oncologic Head and Neck Defects

  • Parviz Lionel Sadigh
  • Seng-Feng Jeng
Part of the Head and Neck Cancer Clinics book series (HNCC)


In head and neck reconstructive procedure, the type of reconstruction selected should be tailored to the defect in order to achieve an optimal functional and aesthetic result. It is important to choose a reconstructive strategy that not only is tailored to the defect but also the patient. We know that a large proportion of patients presenting with head and neck cancer are the elderly with multiple co-morbidities, and therefore the decision-making process with regard to flap selection must take these patient-related factors into account, in order to minimize morbidity. Preoperative planning in the reconstruction of head and neck defects could be based on an emphasis on tumour-related and patient-related factors and how these can help us select the most appropriate reconstructive option for our patients.
  1. 1.

    Tumour-related factors relating to the site and stage of the primary tumour guide the surgeon in the initial preoperative planning of the likely reconstruction required.

  2. 2.

    Systemic and local patient-related factors such as relevant co-morbidities and previous radiotherapy must be considered at the planning stage in order to minimize preoperative risk and ensure that the most suitable reconstruction is selected.

  3. 3.

    Defect analysis allows the surgeon to classify the post-resection deficit into simple, complex or composite defects, which can then be reconstructed based upon the required tissue components.

  4. 4.

    By using the workhorse flap options such as anterolateral thigh flap, fibula osteocutaneous flap and radial forearm flap, most defects of the head and neck can be reconstructed, achieving favourable functional and aesthetic outcomes.




The authors have no financial interest to declare in relation to the content of this article.


  1. 1.
    Hurvitz KA, Kobayashi M, Evans GR. Current options in head and neck reconstruction. Plast Reconstr Surg. 2006;118:122e–33e.CrossRefGoogle Scholar
  2. 2.
    Vos JD, Burkey BB. Functional outcomes after free flap reconstruction of the upper aerodigestive tract. Curr Opin Otolaryngol Head Neck Surg. 2004;12:305–10.CrossRefGoogle Scholar
  3. 3.
    Sinha UK, Young P, Hurvitz K, Crockett DM. Functional outcomes following palatal reconstruction with a folded radial forearm free flap. Ear Nose Throat J. 2004;83:45–8.PubMedGoogle Scholar
  4. 4.
    Makitie AA, Beasley NJ, Neligan PC, Lipa J, Gullane PJ, Gilbert RW. Head and neck reconstruction with anterolateral thigh flap. Otolaryngol Head Neck Surg. 2003;129:547–55.CrossRefGoogle Scholar
  5. 5.
    Chicarilli ZN. Sliding posterior tongue flap. Plast Reconstr Surg. 1987;79:697–700.CrossRefGoogle Scholar
  6. 6.
    Chana JS, Wei F-C. A review of the advantages of the anterolateral thigh flap in head and neck reconstruction. Br J Plast Surg. 2004;57:603–9.CrossRefGoogle Scholar
  7. 7.
    Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study. Plast Reconstr Surg. 2005;116:1845–55.CrossRefGoogle Scholar
  8. 8.
    Vavares MA, Cheney ML, Gilklich RE, et al. Use of radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngo-oesophageal reconstruction. Head Neck. 2000;22:463–8.CrossRefGoogle Scholar
  9. 9.
    Reece GP, Bengtson BP, Schusterman MA. Reconstruction of the pharynx and cervical oesophagus using free jejunal transfer. Clin Plast Surg. 1994;21:125–47.PubMedGoogle Scholar
  10. 10.
    Boyd JB, Mulholland RS, Davidson J, et al. The free flap and plate in oromandibular reconstruction: long-term review and indications. Plast Reconstr Surg. 1995;95:1018–28.CrossRefGoogle Scholar
  11. 11.
    Deschler DG, Hayden RE. The optimum method for reconstruction of complex lateral oromandibular-cutaneous defects. Head Neck. 2000;22:674–9.CrossRefGoogle Scholar
  12. 12.
    Wei F-C, Celik N, Yang W-G, Chen I-H, Chang Y-M, Chen H-C. 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;112:37–42.CrossRefGoogle Scholar
  13. 13.
    Hanasono MM, Zevallos JP, Skoracki RJ, Yu P. A prospective analysis of bony versus soft-tissue reconstruction for posterior mandibular defects. Plast Reconstr Surg. 2010;125:1413–21.CrossRefGoogle Scholar
  14. 14.
    Schusterman MA, Reece GP, Miller MJ. Osseous free flaps for orbit and midface reconstruction. Am J Surg. 1993;166:341–5.CrossRefGoogle Scholar
  15. 15.
    Muzaffar AR, Adams WP Jr, Hartog JM, Rohrich RJ, Byrd HS. Maxillary reconstruction: functional and aesthetic considerations. Plast Reconstr Surg. 1999;104:2172–83.CrossRefGoogle Scholar
  16. 16.
    Cordeiro PG, Santamaria E, Kraus DH, Strong EW, Shah JP. Reconstruction of total maxillectomy defects with preservation of the orbital contents. Plast Reconstr Surg. 1998;102:1874–87.CrossRefGoogle Scholar
  17. 17.
    Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base reconstruction. Plast Reconstr Surg. 1996;98:1159–68.CrossRefGoogle Scholar
  18. 18.
    Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC cancer staging manual. 7th ed. New York: Springer; 2010.Google Scholar
  19. 19.
    Paleri V, Wight RG, Silver CE, Haigentz M Jr, Takes RP, Bradley PJ, et al. Comorbidity in head and neck cancer: a critical appraisal and recommendations for practice. Oral Oncol. 2010;46:712–9.CrossRefGoogle Scholar
  20. 20.
    Singh B, Bhaya M, Zimbler M, Stern J, Roland JT, Rosenfeld RM, et al. Impact of comorbidity on outcome of young patients with head and neck squamous cell carcinoma. Head Neck. 1998;20:1–7.CrossRefGoogle Scholar
  21. 21.
    Castro MA, Dedivitis RA, Ribeiro KC. Comorbidity measurement in patients with laryngeal squamous cell carcinoma. ORL J Otorhinolaryngol Relat Spec. 2007;69:146–52.CrossRefGoogle Scholar
  22. 22.
    Sanabria A, Carvalho AL, Vartanian JG, Magrin J, Ikeda MK, Kowalski LP. Comorbidity is a prognostic factor in elderly patients with head and neck cancer. Ann Surg Oncol. 2007;14:1449–57.CrossRefGoogle Scholar
  23. 23.
    Marshall WH, Fahey PJ. Operative complications and mortality in patients over 80 years of age. Arch Surg. 1964;88:896–904.CrossRefGoogle Scholar
  24. 24.
    Serletti JM, Higgins JP, Moran S, et al. Factors affecting outcome in free-tissue transfer in the elderly. Plast Reconstr Surg. 2000;106:66–70.CrossRefGoogle Scholar
  25. 25.
    Howard MA, Cordeiro PG, Disa J, et al. Free tissue transfer in the elderly: incidence of perioperative complications following microsurgical reconstruction in 197 septuagenerians and octogenarians. Plast Reconstr Surg. 2005;116:1659–68.CrossRefGoogle Scholar
  26. 26.
    Stephen CR. Risk factors and outcome in elderly patients: an epidemiological study. In: Stephens CR, Assat RAE, editors. Geriatric anaesthesia: principles and practice. Boston: Butterworth; 1986.Google Scholar
  27. 27.
    Muravchik S. Anesthesia for the elderly. In: Miller RD, editor. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 2140–56.Google Scholar
  28. 28.
    Bridger AG, O’Brien CJ, Lee KK. Advanced patient age should not preclude the use of free flap reconstruction in head and neck cancer. Am J Surg. 1994;168:425–8.CrossRefGoogle Scholar
  29. 29.
    Chick LR, Walton RL, Reus W, et al. Free flaps in the elderly. Plast Reconstr Surg. 1992;90:87–94.CrossRefGoogle Scholar
  30. 30.
    Beausang ES, Ang EE, Lipa JE, et al. Microvascular free tissue transfer in elderly patients: the Toronto experience. Head Neck. 2003;25:549–53.CrossRefGoogle Scholar
  31. 31.
    Kuo YR, Jeng SF, Lin KM, Hou SJ, Su CY, Chien CY, et al. Microsurgical tissue transfers for head and neck reconstruction in patients with alcohol-induced mental disorder. Ann Surg Oncol. 2008;15:371–7.CrossRefGoogle Scholar
  32. 32.
    Shih HS, Hsieh CH, Feng GM, Feng WJ, Jeng SF. An alternative option to overcome difficult venous return in head and neck free flap reconstruction. J Plast Reconstr Aesthet Surg. 2013;66:1243–7.CrossRefGoogle Scholar
  33. 33.
    Ugurlu K, Ozcelik D, Huthut I, Yildiz K, Kilinc L, Bas L. Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure. Plast Reconstr Surg. 2004;114:339–50.CrossRefGoogle Scholar
  34. 34.
    Rosen HM. The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg. 1985;75:318–27.CrossRefGoogle Scholar
  35. 35.
    Angrigiani C, Grilli D, Karanas YL, et al. The dorsal scapular island flap: an alternative for head, neck and chest reconstruction. Plast Reconst Surg. 2003;111:67–78.CrossRefGoogle Scholar
  36. 36.
    Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconst Surg. 2004;113:1580–90.CrossRefGoogle Scholar
  37. 37.
    Liang CC, Jeng SF, Yang JC, Chen YC, Hsieh CH. Use of anteromedial thigh flaps as an alternative to anterolateral thigh flaps for reconstruction of head and neck defects in cancer patients. Ann Plast Surg. 2013;71:375–9.CrossRefGoogle Scholar
  38. 38.
    Jeng SF, Tan NC. Optimizing aesthetic and functional outcomes at donor sites. Chang Gung Med J. 2012;35:219–30.PubMedGoogle Scholar
  39. 39.
    Warner MA, Offerd KP, Warner ME, et al. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary bypass patients. Mayo Clin Proc. 1980;64:609–16.CrossRefGoogle Scholar
  40. 40.
    Yamamoto K, Tsubokawa T, Shibata K, et al. Predicting difficult intubation with indirect laryngoscopy. Anesthesiology. 1997;86:316–21.CrossRefGoogle Scholar
  41. 41.
    Hollenberg M, Mangano DT, Browner WS, et al. Predictors of postoperative myocardial ischaemia in patients undergoing non-cardiac surgery: the study of perioperative ischemia research. JAMA. 1992;268:205–9.CrossRefGoogle Scholar
  42. 42.
    Fowkes FG, Lunn JN, Farrow SC, et al. Epidemiology in anesthesia. Mortality risk in patients with coexisting physical disease. Br J Anaesth. 1982;54:819–25.CrossRefGoogle Scholar
  43. 43.
    Williams RL. Drug administration in hepatic disease. N Engl J Med. 1983;309:1616–22.CrossRefGoogle Scholar
  44. 44.
    Reilly JJ. Does nutrition management benefit the head and neck patient? Oncology. 1990;4:105–15.PubMedGoogle Scholar
  45. 45.
    Williams EF, Meguid MM. Nutritional concepts and considerations in head and neck surgery. Head Neck. 1989;11:393–9.CrossRefGoogle Scholar
  46. 46.
    Donald PJ. Complications of skull base surgery for malignancy. Laryngoscope. 1999;109:1959–66.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2019

Authors and Affiliations

  • Parviz Lionel Sadigh
    • 1
  • Seng-Feng Jeng
    • 1
  1. 1.Department of Plastic Surgery, E-Da HospitalI-Shou UniversityKaohsiung CityTaiwan

Personalised recommendations