Surgery to remove cancer from your mouth, throat, face, nose, sinuses, skin or voice box can sometimes badly disfigure you and/or affect your ability to chew, swallow or speak adequately. How you look is particularly affected if your cancer involves the skin of your face, your nose, lips, or your jawbone. The cosmetic deformity will be obvious, in that it will alter the shape of the nose, lips, or other structures of your face. Chewing and swallowing can be severely affected if cancer involves your tongue, floor of mouth or the pharynx.
Reconstruction after cancer surgery tries to restore both the appearance and the function of the involved area.

The simple answer is that it depends on where the defect is and how large the defect is after the operation. If your cancer is small and on the surface, than relatively simple surgical removal and closure is possible by sewing the edges of the incision together. Slightly larger defects can be reconstructed by using skin grafts from other parts of your body. Alternatively, adjacent skin or internal lining can often be shifted into position to fill the defect. If the tumor is larger and involves the eye-orbit, ears, nose, mouth or food pipe; more extensive surgical reconstruction by specialized techniques may be necessary. This is because reconstruction may require the transfer of muscle, bone, or skin flaps. In many cases, we can move around these tissues from your chest, shoulder or your back (regional pedicle flap). The most common regional flap used for head and neck reconstruction is from your chest muscle, with or without the overlying sin (Pectoralis Major Flap). If you need thin tissue we can also use the skin over your shoulder, the Supraclavicular flap.

However in other cases, the best function and looks are achieved by transplanting tissue from distant areas to close complex wounds of the nose, mouth or throat, particularly when the cancer surgery has removed bone from the jaw. When muscle and/or bone are taken from distant areas of your body, microsurgery is required to reconnect tiny blood vessels to provide blood flow to the transplanted tissue (microvascular free flap).

Microvascular head and neck reconstruction is a technique for rebuilding the face and neck using blood vessels, bone, muscle and skin from other parts of the body. The technique is one of the most advanced surgical options available for reconstructing surgical defects that are caused by the removal of head and neck tumors. Consider this as a transplant of your own body part to restore form and function of your head and neck region.

This technique involves carefully taking healthy tissue— where the tissue is not as important — with the blood supply from remote sites in the body. The tissue is then transferred to the defect caused due to cancer surgery. A microscope is used to suture the blood vessels of the flap to blood vessels in the neck, allowing the tissue to live as if it were back in its original location.

This depends on the kind of tissue we need and the area that need to be reconstructed. Generally speaking I take following tissue for reconstruction

Free bone transfer

Bony defects of the jawbone are among the most difficult reconstructions as precise alignment of bone is required. I most commonly use fibula that is one of the bones in the leg that does not take part in carrying your weight (Fibula free flap). In some patients the fibula is not available for transfer due to significant narrowing of blood vessels (peripheral vascular disease). In such cases I take tissue from your back (the Latissimus-Scapula free flap). This flap is particularly suitable for reconstructing the roof of your mouth and can also be used for reconstruction of bone under your cheek and eye socket.

Free skin and fat and or muscle transfer

In most cases requiring reconstruction of defect in your mouth without jawbone, I use tissue from your forearm - the Radial forearm free flap. It is also useful to reconstruct missing skin on your face, nose or neck. However if much thick tissue is required, I use tissue from the thigh (the Anterolateral thigh free flap). I also use either of these to reconstruct your pharynx (throat tube that leads to your food pipe).

Free muscle transfer

If only muscle is required, I harvest a muscle from the your back (latissimus) or your thigh (Anterolateral thigh flap). This is useful to reconstruction of the base of your skull bone.

Microvascular head and neck reconstruction is used to treat large defect following head and neck cancers. It is not possible to give an exact comprehensive list of conditions where I use free flaps for reconstruction as its application depends on the degree of cosmetic and functional defect present or anticipated. However, in general I use free flaps in following circumstances –

  • Surgery for mouth cancer that involves removal of
    • More than half of the tongue
    • The front part of your jaw bone
    • Large areas of the floor of mouth
    • Large areas of the roof of your mouth
    • Large areas of your cheek
  • Surgery that removes most or all of your pharynx (the part of throat that leads to your food pipe)
  • Surgery that removes a large part of your nose
  • Surgery that removes large part of skin from your face, your eye socket or your neck
  • Surgery on large tumours of the base of your brain that leads to fluid leak
  • Osteoradionecrosis of the mandible, which is a serious complication of radiation therapy to the head and neck
  • Oronasal fistula, which is a hole between the mouth and nose cavity
  • Non-healing wounds of the head and neck

In most cases, the reconstruction will be performed on the same day when you are having operation to remove the cancer. With very complex tumors we prefer a two-team approach, with one team responsible for removing the tumor, and the other dedicated to the reconstruction. This shortens the length of the operation, since the reconstructive team can harvest the tissue from a different part of the body while the oncologic team is removing the tumor.

Rarely with large and complicated cancers, we may delay the reconstructive surgery until the pathologist can examine the tumor to make sure it has been completely removed. Delayed reconstruction can also be done on if you have longstanding deformities, or if you have residual deformity after the initial reconstructive procedure.

In addition to investigations for your cancer, you may be required to undergo additional tastings, including: vascular imaging, cardiac and pulmonary testing. I will need to examine you to select the area from which we will take tissue to transplant.

After the procedure, you may be in the hospital for one to two weeks. After surgery patients typically spend a day or two in the intensive care unit (ICU), followed by an additional five to seven days in a regular hospital room before discharge. The transplanted flap will be checked at frequent interval to ensure it is healthy. In most cases, you will require some physiotherapy as part of rehabilitation.

Free flaps are transplant surgery and do have a small chance of not working due to problems with blood flow after the operation. Free flaps have good success rate of around 80% to 90%. The chance of success also depends on your general health and your habits e.g. smoking is known to reduce the success rate.

Cancer or operation on your salivary gland, skin of your face, your ear, and base of the brain or rarely in mouth can cause damage to the facial nerve. Occasionally accidental injury, infection or disease affecting the nerves can also damage this nerve that powers the muscles of your face. This leads to varying degrees of paralysis of the face that can affect your appearance and proper facial functioning.

I offer facial reanimation procedures that can improve how you look as well as how well you can use the muscles of your face, resulting in an improved appearance and quality of life. Several surgeries, spaced over time, may be needed to restore the maximum facial reanimation possible. This is likely to require the following procedures

Nerve Grafting

If the facial nerve damage is relatively recent, preferably within the last six months, you are likely to benefit from a nerve graft. During this procedure I usually take a nerve that provides sensation to your arm and use this to reconstruct the missing/damaged part of the facial nerve. Alternatively if a small segment of the main part of facial nerve is missing, I can use another sensory nerve from your neck.

Face Lift

To counter drooping of the face and or leaking from the corner of your mouth due to paralysis, we advocate procedures to lift the tissue of your face. I prefer to do this by using a special strong tissue from the side of your thigh (called Fascia Lata). Occasionally if it is just the cheek area that is sagging, I like to use a special designed product, called Endotyne that can be inserted through your lower eyelid. If you are severely bothered by drooping of the forehead and eyebrow skin that blocks your sight, you can benefit from forehead lift. In some patients, all of these areas need to be addressed and a full-face lift is required.

Procedures for the eyelid

Failure to close the eyelid after facial paralysis is a serious problem as it can potentially threaten your eyesight by drying the cornea. In addition to non-surgical management, I advocate operation to place special gold weight for the upper lid to help you close the eyelids. If leaking of tears due to slack lower lid bothers you, I can do a small surgery to tighten them up.

Due to the tremendous cosmetic and functional importance of your face and head and neck region, high quality reconstruction is desirable. As you can imagine, the quality of reconstruction will play a crucial role as you recover from the cancer, both personally as well as socially. By having experience and expertise in both resection and reconstruction, I am in a unique position to offer you the very best in both these specialties. As you can see from the exhaustive list of reconstructive options that I am skilled in, there is hardly any reconstruction in this area that I am unable to offer. You will not only benefit from the best quality surgery and care, but also by having all the required surgery by one doctor. In complex case where I need to work with another surgeon to keep the surgery time to minimum, you can be rest assured that the very best surgeon that I completely trust will work alongside me.

By choosing me as your surgeon, you will be choosing someone who has extensive experience in the highest quality reconstructive surgery that I have gained from my time at Karamanos Cancer center, USA. This is amongst the best head and neck cancer and reconstruction centers not only in USA but also around the world. I can ensure good quality operation with minimal risk of complications. The difference is in quality. You have one body and it deserves the very best.

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