Surgical Planning Incisions

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Reconstructive planning occurs from initial presentation and undergoes an evolving process until a final plan with possible contingencies is developed. This plan can even change intraoperatively due to unexpected oncologic findings, anatomic abnormalities, and anesthetic instability. Surgical incision planning extends beyond just the purview of the oncologic surgeon. Adequate access and visualization of the surgical field, especially for posteriorly based neoplasms, is paramount for resection. Fortunately, frequently multiple transcutaneous or transoral approaches exist that can achieve the same exposure necessary for cancer resection. The chosen surgical approach must also provide adequate access for the planned reconstruction. Visualization is necessary for safe and adequate inset suturing of the planned reconstruction flap into the surgical defect. A needle holder frequently requires more maneuverable exposure than a monopolar (Bovie) cautery, knife, scissor, or laser. In addition to recipient-site edema, initial flap bulk can be larger than the extirpated native tissue volume. Suturing gaps can lead to salivary leakage, wound infection, and potential flap or large vessel compromise. Myofascial pedicled flaps require a surgical approach that allows non-constricting passage of an often thick, muscular, vascular pedicle. These needs may require potential incision extension or new incisions.

Incision placement also depends on the quality of the native tissue. Not infrequently, surgical candidates requiring complex reconstructions have had previous cervico-facial incisions, traumatic incisions, skin-flap elevation, prolonged steroid usage, radiation therapy, and now more commonly, chemotherapy. All of these factors play a role in subsequent skin-flap viability, requiring worst-case scenario planning. Old incisions are the best initial choice, as the native vascularity is already compromised. Sub-platysmal or thicker skin-flap elevations are desirable, but are often limited by oncologic considerations. Further incisions must respect these lines of compromised vascularity, avoiding elevated areas of skin flap even partially isolated from their vascular supply. Chin incision trifurcations, and carotid endarter-ectomy scars are classic examples of this. Such an error, at best, will result in skin-flap loss and poor cosmesis, and it can yield large vessel, hardware, alloplast, allograft, and/or boney exposure risks. Exposure of a microvascular pedicle can result in the loss of the entire reconstruction. If detected intraoperatively, providing a well vascularized muscular or fascial bed underneath the compromised skin-flap area may result in preserving cutaneous coverage in the best case and provide a good bed for skin grafting in the worst case. Alternatively, the devascularized area should be resected and become part of the reconstructive defect. Full-thickness reconstructions from mucosa to skin add significant complexity and difficulty to the procedure. Poor incision planning and/or delayed detection usually requires a larger, secondary and/or more complicated reconstruction than anticipated. This is in addition to the morbidity of another operation with its concomitant risk to the previous reconstruction.

Further skill in incision planning involves anticipation of future potential extirpative and loco-regional flap needs, which can be quite difficult, but should be attempted in all cases. Generally, vascularity for potential local rotation and advancement flaps can be preserved, but after multiple previous surgeries and adjuvant therapy, their viability and usefulness remains in question. Preservation of potential standard regional flap pedicles is important (i.e., superior trapezius flap, deltopectoral flap, pectoralis major flap).

An improved aesthetic result can be achieved with incision placement in natural skin creases, aesthetic unit junctions, relaxed skin tension lines, old scars, or hair-bearing areas. Such considerations should be secondary to those stated above.

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