Head and neck cancers, which require excision, can often leave devastating defects that compromise critical functions such as speech, breathing and feeding. Complete cure and removal of the cancer often leaves the patients with severe disfigurement that can lead to psychological, physical and nutritional detriment. The anatomy of the head and neck region is challenging, where each structure eg. orbit, mouth, tongue has specialised functions which is unique and the use of adjuvant radiation and chemotherapy reduces the local flap availability and increases the demands for distant pedicled and free flaps. Reconstruction of these defects continues to be extremely challenging for plastic surgeons who aim to restore form and function whilst minimising further surgical morbidity.

With the advances made in surgical oncology, radiation medicine and chemotherapy, many previously irresectable tumours can now be resected giving patients a better chance at cure and conquering cancer. This also creates more challenging defects for the plastic surgery reconstructive team. With the advances made in reconstructive microsurgery, we are now able to use different compositions of tissues from the patient to create neo-organs replacing what was removed and restoring function. This is a list of defects that can be reconstructed:

Scalp and Cranial Defects. Small to moderate scalp defects can be reconstructed with local flaps from the hair-bearing scalp. Larger defects may require free tissue transfer and reconstruction from the thigh (Anterolateral Thigh Flap) or back (Latissimus Dorsi Flap). Cranial defects can be reconstructed with bone grafts or alloplastic material and currently, patient specific implants can be 3D-printed to create an accurate reconstruction.

Nose Defects. Nasal defects after skin cancers (Squamous cell cancer, basal cell cancer, melanoma) are common. Most of them can be reconstructed with local flaps from the adjacent areas of the face. A well-planned reconstruction minimises the scars and preserves the aesthetics and functions of the nose. Larger defects may require reconstruction with the paramedian forehead flap or free-tissue transfer. 

Orbit and Cheek Defects. Tumours affecting the maxillary sinuses or region of the eye may require resection of the maxilla (cheek bone) and parts of the orbit. Reconstruction of the orbit is critical to preserve the function of the eye, projection of the cheek and feeding. Depending on the defect, a tissue flap consisting of skin and fat from the thigh can be used to reconstruct the cheek skin or a chimeric flap comprising of skin, fat and bone can be taken from the fibula (one of 2 bones in the leg) to reconstruct the cheek bone and the overlying soft tissue.

Oral Defects – Tongue and Jaw. Tongue cancers will affect swallowing, speech and breathing. Reconstruction of the hemi-tongue or total tongue can be done with meticulous shaping of skin from the forearm (radial forearm flap) or thigh skin (anterolateral thigh flap) into a neo-tongue. Such tumours can also affect the mandible (jaw bone). The fibula flap provides a good skin, fat and bone which can be shaped into a neo-mandible for reconstruction. Our reconstruction team uses the latest technology in 3D-design to create cutting guides that enable an accurate reconstruction of the jaw.

Flaps are units of tissue that can comprise skin, fat, bone and even nerves. They have a unique blood supply and can be fashioned into neo-structures to reconstruct the missing parts after cancer resection. Smaller defects may be reconstructed with local flaps, utilising tissue from the adjacent skin e.g. using the cheek skin to reconstruct eyelid defects. Moderate to larger defects may not be suitable for reconstruction with local flaps and free tissue transfer from a distant location may be required e.g. tissue from the forearm, groin, thigh, leg, intestine.  Depending on the flap location, there will be a donor site morbidity involved. 

At AZATACA, we have a team of three reconstructive surgeons who have been trained in all aspects of reconstruction. We have been performing reconstructive surgery as a team in Singapore General Hospital, the largest restructured hospital in Singapore and we aim to replicate that in the private setting. The advantages of having a reconstructive team behind you are numerous. The surgeons can work on the donor (flap harvest) site and the recipient (cancer resection) site simultaneously hence reducing the surgery time required. The provision of 2 or more additional surgeons allow greater work-rest cycles for the doctors and also allows for more dedicated and elaborate reconstruction that would be difficult for single man teams.

We work closely with the head and neck resection surgeons and detailed planning is critical to a successful reconstruction. After close discussion with the resecting team and the patient, we will identify the defect and it missing tissue components before we decide on the ideal flap for reconstruction. CT scans computer assisted planning software are often used to visualised and plan a near perfect reconstruction. Blood investigations and anaesthetist reviews are also performed to ensure fitness for surgery. 

Depending on the extent of the resection and the complexity of the reconstruction, be prepared to spend 1-2 weeks in the hospital. On the first day after the reconstruction you may be kept in the intensive care unit or the high dependency ward for flap monitoring. Once everything has stabilised you will be transferred to the general ward where you can begin your recovery and rehabilitation. Depending on the donor site you may need to be on a wheelchair on a short duration before you are discharged with crutches.

On the first day after surgery, you will be drowsy and there will be several tubes draining blood from the recipient site as well as the donor site. You may have a tracheostomy tube to assist with breathing and a nasogastric tube for feeding. There will be intravenous lines to provide nutrition and hydration during your recovery. As you recover, these tubes will be removed and you will be transferred to the general ward. Our team of physiotherapists will assist you in rehabilitating the neo-organ e.g. speech and swallowing for tongue reconstruction, as well as, optimising recovery at the donor site e.g. ambulation after free tissue transfer from a thigh flap. Once you are coping well you will be discharged from the ward.

Head and neck cancer resection and reconstruction is a complex surgical procedure. The complications include complications from surgery and anaesthesia.

1. Bleeding requiring blood transfusions

2. Infections 

3. Flap complications and flap failure

4. Secondary flap in event of flap failure

5. Secondary revisions 

6. Scars at recipient site and donor sites

7. Facial Asymmetry

8. Loss of critical function such as speech, swallowing or breathing

9. Complications from prolonged bed rest

10. Complications from anaesthesia