Surgical oncologic treatment of head and neck cancer has advanced considerably, but the overall cure rate has not improved proportionally (1). To increase the cure rate, new therapies and techniques have been developed and more emphasis is being placed on the improvement of the overall quality of the treatment of these onco-logically challenging patients. Thus, success should be measured not only by disease control, but also by the restoration and maintenance of the patient to as normal as possible conditions. Such improvements in a patient's quality of life can temporarily offset continued frustrations with controlling head and neck cancer.
The impetus for change in head and neck cancer treatment has underscored the significance of the reconstructive portion of the surgical treatment. Enhancements in our reconstructive abilities have paralleled advances in anesthetic safety, perioperative care of medical comorbidities, and progress in adjuvant therapies. These concurrent advances have pushed the threshold of resectability higher as demands increase for larger and more complex reconstructions.
It is advantageous but not required that surgical treatment of the oral cancer patient involve a two-team approach, a direct extension of the modern multi-disciplinary approach to oncologic patient management. For high-stage lesions or those neoplasms in regions of significant functional import, this approach is not only time-efficient and minimizes caregiver fatigue, but maximizes the specific sub-specialty expertise available to the patient. In order to provide the most expeditious care, evaluation of the reconstructive aspects of the cancer patient's care must also begin at presentation. Although, the patient usually first meets the extirpative oncologic surgeon, early introduction of the reconstructive surgeon partner is paramount because the reconstructive portion of the surgery is ultimately dependent on the result of the extirpative procedure. The reconstructive surgeon's desire to preserve locoregional native tissue and organs should not compromise the extirpative surgeon's interpretation of the adequacy of oncologic resection. Maintenance of this successful, but often tenuous, balance is dependent on good communication among and interdisciplinary knowledge within the extirpative and reconstructive surgeons. In addition, given the current radiographic technology, appropriate reconstruction should not interfere with oncologic surveillance. A joint treatment plan should be discussed among the surgeons and the patient, with several layers of contingency plans, depending on both preoperative and intraoperative findings.
EVALUATION AND PLANNING History and Physical Examination
At first referral, acute issues such as airway maintenance and hemorrhage, if compromised, need to be dealt with immediately. Any significant history or signs of immediate or impending airway compromise (i.e., stridor, cyanosis, sturgor, choking or dyspnea episodes) warrants expeditious and focused airway evaluation and possible urgent surgical airway stabilization. Similarly, sentinel or sizeable bleeding requires focused workup and treatment. A more comprehensive history and physical should wait until the patient is safe to evaluate. Malnutrition should also be recognized early and aggressively treated with proper nutritional support. Although, the age of the patient is not a contraindication, age is a factor affecting post-treatment complications (2,3). Thus, special attention should be paid to fine-tuning any medical condition, especially those that are poorly controlled (i.e., diabetes, hypertension, sepsis), preoperatively. This is also the time to recruit and inform family and friends for the necessary physical and emotional support that complements medical therapy, with the appropriate precautions in place to safeguard the patient's privacy. Understanding the patient's occupation and recreational activities are important considerations during the evaluation of extirpative and reconstructive options in the event that the patient desires to maintain a crucial skill and/or hobby.
An extensive history of symptoms and signs will not only help determine the location and T-stage of the current neoplastic problem, but will also yield information about potential synchronous primary or metastatic disease. All of these factors directly influence the types of viable reconstructive options. Complaints of unilateral conductive hearing loss, hyponasal speech, breathy voice, ptosis, trismus, chin numbness, otalgia, and contralateral symptoms are frequently indicators of deep or extensive disease that is not immediately apparent. In addition, compromised anatomy, such as after radical neck dissections, neck incisions, and previous flaps, may limit the reconstructive options (4). This information frequently requires both careful review of old operative reports and discussion with previous surgeons to supplement the patient's memory. Similarly, extensive radiotherapy can compromise the vascularity and healing, and thus the reliability of local flaps (5). Finally, previous radiotherapy can increase the risk and aggressiveness of mandibular invasion (6,7).
The history of premorbid oral cavity function, compared to oral function at presentation, is important. Not only will this suggest involved structures, but it also dictates the possible functional goal of any reconstruction. The reconstructive functional result in terms of deglutition, taste, mastication, voice, breathing, and cosmesis cannot be improved beyond the premorbid state. In patients with compromised premorbid function due to neurologic disability or prior treatments, preoperative counseling about potential reconstructive outcome is even more crucial to provide realistic expectations.
Several objective measures of oral function have been proposed (8-10). The lack of consensus, equipment, or expertise necessary for detailed measurements has made most of these assessments difficult to perform. Such measures can be useful for comparison to actual post-operative outcome. Unfortunately, such studies are frequently limited by lack of adequate numbers of patients with uniform surgical defects and premorbid conditions.
The reconstructive surgeon should also perform a complete head and neck exam. Direct visualization of the neoplasm, along with bimanual palpation, should complement the tumor mapping anticipated by the symptom history. This should also include mirror and fiberoptic evaluation of hidden structures. This initial survey allows an educated intercourse with the extirpative surgeon in terms of the anticipated surgical defect size and potential structures to be removed (mucosa, skin, and bone) and/or exposed (brain, orbit, carotid artery). A secondary survey can then focus on the anticipated fine-tuning reconstructive procedures necessary during either the primary or secondary setting to maximize functional and aesthetic outcome. This includes status of the parotid and submandibular ducts, lip vermillion, and oral commissure integrity, dental status and occlusion, exposed maxillary sinus, anticipated palatal defect, Eustachian tube dysfunction with conductive hearing loss, facial sensation, and motor nerve sacrifice. The extent of neck disease determines not only prognosis, but also the type of neck dissection. This influences changes in neck volume, contour, and potential available recipient vessels for microvascular anastomosis. A superinfected area of cutaneous involvement should be treated with antibiotics to delineate infected versus neoplastically involved tissue, promoting a more efficient resection and likely improved pain, hygiene, and healing.
A patient's past medical history directly impacts the medical fitness of a patient for the anticipated extirpative and reconstructive procedure. Adequate cardio-pulmonary function and reserve must be present to tolerate the often prolonged anesthesia time and intravascular fluid shifts associated with many types of reconstructive procedures (11). Such comorbid disease can significantly lower the limits of resectability. Preoperative evaluation and clearance by a hospitalist, cardiologist and/or pulmonologist can often help to maximize cardiopulmonary preoperative function. Mental impairment can jeopardize reconstructive success and recovery, as well as limit overall rehabilitative potential. Diabetes, advanced age, vascular disease (i.e., atherosclerosis, hypertension, arteritis), poor nutritional status, hypothyr-oidism, previous radiation therapy, and chronic steroid usage seriously hinders healing and can guide the reconstructive surgeon to either more conservative or more aggressive reconstructive options (12). A history of cerebrovascular incidents can indicate significant carotid vascular disease. This not only increases the risk of neurologic morbidity and mandates adjustment of anesthetic management, but can also potentially compromise available arterial vessels for microvascular anastamosis. Significant sleep apnea influences perioperative airway management and can be seriously worsened post-operatively by large, bulky, and swollen reconstructions. The long-term treatment of this disorder must be re-evaluated after surgery, and often requires a prolonged tracheotomy. A history of hematologic diatheses (i.e., von Willebrand's disease, hemophilia, lupus anticoagulant abnormality, thrombocytopenia, polycythemia vera, sickle cell disease, or protein C deficiency) contraindicate extensive surgery and/or microvascular free-tissue transfer if poorly or un-treatable perioperatively (13). Paraneoplastic hypercoagulability syndromes can also cause influence anastamotic patency. In addition, the patient is advised to immediately cease activities that could cause perioperative bleeding difficulties such as smoking (vasoconstriction can compromise local skin flaps), and drinking, and taking medications (aspirin, ibuprofen, vitamin E, etc.) (14). A history of regular alcohol usage requires aggressive perioperative withdrawal prophylaxis and nutritional supplementation.
In patients requiring regional pedicled or distant free flaps for reconstruction, a donor-site specific history and exam is necessary. Detailed inquiry of a patient's handedness, footedness, occupation, and recreational activities also reveals information that can dictate the side or site of a flap harvest. The presence of a thoracotomy scar, a pacemaker, or indwelling central line may require use of the contralateral pectoralis major flap or a modified surgical approach to the ipsilateral flap harvest. Previous abdominal and pelvic surgery can obviate the use of some potential free flap vascular pedicles (i.e., rectus abdominis, iliac crest). Claudication or rest pain are indicative of significant peripheral vascular disease and warrant aggressive workup of extremity vascular pedicle adequacy. History of previous surgery or trauma to the donor-site prompts in-depth evaluation of the donor-site anatomy. This includes workup of both arterial and venous supplies as well as boney integrity.
Exam of the potential donor site for scars, asymmetries, or bony deformities can often prompt a patient's memory to an old injury or surgery. Objective evaluation of the mobility, strength, and function of the extremity should confirm the patient's history. Non-healing sores, cold fingers and toes, loss of sensation, and significant distal extremity swelling are also indicators of inadequate vascularity and frequently contraindicate the involved extremity from usage as a donor site. Unfortunately, most of these conditions are bilateral and usually require the use of a completely different, and often less ideal, donor site for reconstruction. Palpation of distal pulses (i.e., radial, ulnar, dorsalis pedis, and posterior tibial arteries), subjective Allen's tests, and ankle-arm indices can be reassuring, but adequacy determinations should be supplemented by formal vascular assessments in equivocal cases (15,16). Body habitus, especially morbid obesity, may influence perioperative recovery and healing and may require alteration in reconstructive technique or donor site (17).
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