David S Soutar – Evolution of Functional Reconstruction in Head and Neck Cancer Surgery

Written by David Soutar

The major problem for Head and Neck Surgery in the first half of the 20th century was operative mortality. With the introduction of antibiotics, blood transfusion and endotracheal anaesthesia, surgical survival improved and more radical procedures became possible. By the 1950s, Hayes Martin was able to demonstrate the effectiveness and safety of radical surgery to the primary tumour and lymph nodes simultaneously – the “commando operation”. There was no reconstruction at this time and the excisional defect healed by a combination of contracture and collapse.

The lack of available local tissue in the head and neck for reconstruction was problematic and importing tissue from a distance such as an abdominal tube pedicle (Gillies), required multi-staged procedures taking many weeks or months to complete. The advent of the Deltopectoral Flap (Bakamjian) and the Forehead Flap (McGregor) in the 1960s allowed immediate tissue replacement at excision but division and insetting of the flap was required at a second stage – usually 3-4 weeks. Single stage reconstruction was still elusive.

This was about to change with the development of microsurgery and Free Tissue Transfer and the report of a free Groin Flap used for intraoral reconstruction in 1971 (Kaplan). The lack of donor sites and variable results further hampered progress, as did the introduction of the Pectoralis Myocutaneous Flap (Ariyan 1979) – a reliable single stage soft tissue flap which soon became the “workhorse” in Head and Neck reconstruction. 1979 also saw reports of the DCIA Flap (Taylor) combining soft tissue and bone for mandible reconstruction. The introduction of the Radial Forearm Flap, The Chinese Flap, for intraoral reconstruction (Soutar, 1983) subsequently demonstrated the reliability, safety and versatility of immediate microsurgical reconstruction in Head and Neck Oncology. The 1980s onwards saw an explosion of Flaps and donor sites described for free tissue transfer offering differing tissues such as skin, fat, fascia, muscle, nerve, and bone, singly or in combination and specialised tissues such as bowel or mucosa e.g. jejunum. Reconstructive surgery was now better placed to replace like with like tissue and with more accurate design and shaping, restore anatomy and function.

Excisional techniques also underwent change as the defects necessary to facilitate facial contracture and collapse to allow healing were no longer required. Hemi-Mandibulectomy or Hemi-Maxillectomy gave way to tailored bone resections with accurate bone and soft tissue reconstruction and restoration of functional anatomy. Such techniques allowed for the insertion of osseointegrated implants, significantly improving dental rehabilitation and function and fixation of facial prostheses.

Cancer survival remained stable despite these changes in surgical treatment and attention turned to rehabilitation and quality of life. The extent of excisional surgery directly relates to the functional deficit. This can be reduced by more accurate excision, preserving tissue not involved by tumour, but maintaining a tumour free margin. Functional rehabilitation can be improved with accurate reconstruction, replacing like for like tissue and restoring functional anatomy.