Reconstruction
When tissue is removed as part of your cancer treatment, you may require reconstruction with replacement of tissue. The reconstructive surgery will also often be completed by Dr. Kang
When considering the best reconstructive option, issues of safety (protecting vital structures), form (restoring or improving appearance) and function (optimizing breathing, chewing and swallowing) will be a priority. In general, the simplest reconstruction that achieves all of these goals is the best reconstruction.
Some basic reconstructive methods include:
Healing by secondary intention
Healing by secondary intention is when the wound created by removing the cancer is allowed to heal and scar on its own.
A few examples of when healing by secondary intention might be used are as follows:
•Robot or laser-assisted transoral resection of oropharynx, tonsil, base of tongue or larynx tumors.
•Resection of minor salivary gland cancer of the hard palate (roof of the mouth) that does not require removal of bone.
•After removal of a skin cancer in very select areas of the face (such as the area between the corner of your eye and nose), letting the defect granulate on its own can result in an improved appearance.
Primary closure
The wound that is created by removal of the cancer is closed by bringing the edges together with stitches, staples, tape or special skin glue. These are the most common wound closure techniques when an incision is made in the skin without removing any skin. The end result is a thin scar located where the surgical incision was made.
Aftercare of a wound that is sealed by primary closure is quite simple. Dr. Kang may ask you to avoid getting it wet for 2-3 days to prevent infection. Then, keep it out of the sun and/or apply sunscreen when you go outside to prevent discoloration of the scar. Over-the-counter scar creams can be used to help to improve the appearance of the scar.
Primary closure might be used when:
•A surgical wound or incision is made to remove tissue somewhere in the neck or face, without removing skin.
•There is an excision of small areas of skin along with removing deeper tissue in the face or neck.
•There are small cancers of the oral cavity—such as on the tongue, inner aspect of the cheek or floor of mouth—that will not result in tongue tethering.
Skin graft
The wound that is created by removal of the cancer is covered with a thin layer of skin taken from another part of the body. A skin graft is a method of covering a wound with a very thin layer of skin that is removed from another part of the head or neck or another part of the body. The skin graft does not have its own blood supply, and it survives by the growth of blood vessels into the graft from the wound. This occurs over the course of approximately one week, during which time a bolster dressing is usually sutured over the skin graft to keep it tight against the wound.
There are a few different types of skin graft that might be used:
Split thickness skin graft
A split thickness skin graft involves cutting a very thin sheet of skin, usually from your thigh. Once the skin graft is placed, your surgeon might place a bolster over the graft to secure it.
Full thickness skin graft
A full thickness skin graft involves cutting a piece of skin from a healthy area using a scalpel. the wound created can often be closed by primarily.
Skin substitute
Instead of taking a skin graft, Dr. Kang sometimes will use artificial, or synthetic, skin substitutes.
Local flaps
A local flap involves rotating or moving skin from an area close to a surgical defect to close the surgical wound. These flaps are generally a better color match of the skin compared to skin grafts, regional flaps or free flaps. A disadvantage of using a local flap, based on a random blood supply of blood vessels under the skin, is that the size of the flap is quite limited, and there is always a risk that part of the flap might not survive.
Local flaps are typically used after skin cancer removals or removal of small superficial tumors on the face or neck.
Regional flaps
A regional flap is tissue transferred from a part of the body in or near the head and neck region and rotated into the surgical defect.
Regional flaps used in head and neck surgery include:
• Pectoralis major muscle
• Submental artery island
• Supraclavicular artery island flap
• Temporalis flap
• Sternocleidomastoid flap
• Scalping Flap
• Trapezius flap
• Latissimus dorsi flap
• Paramedian forehead flap
• Palatal Island Flap
Free flap surgery
A free flap, also called free tissue transfer or microvascular reconstruction, involves removing a piece of tissue from one part of the body along with an artery and vein and transplanting it to another part of the body. The artery and vein of the flap are sewn to an artery and vein near the wound to give the flap a new blood supply. However, expertise in performing microvascular surgery is required and is usually obtained through advanced fellowship training.
Free tissue can be taken from just about anywhere in the body as long as there is a good artery and vein feeding the flap. Some of the more common types of free flaps and examples of their use in head and neck reconstruction include:
Rectus Abdominus
Gracilis
Latissimus dorsi
Radial forearm
Anterolateral thigh
Temporoparietal fascia
Lateral arm
Fibula
Scapula
Iliac crest
The free flap is chosen depending on the type of tissue is required, such as thick skin, or thicker muscle or bone. Dr. Kang has trained extensively if microvascular free tissue transfer for reconstruction of complex oral, head and neck defects. He will discuss with you extensively, on what type of reconstruction will give you the most optimal functional and aesthetic outcome.
FIBULA FREE FLAP
What is a fibula free flap?
A fibula free flap in one way of filling a bone defect in either the upper, or the lower jaw. It is a common way of replacing bone that has been removed for cancer treatment or non-cancer that involves removal of bone.
What does surgery involve?
Dr. Kang will remove one of the two bones from the lower part of your leg (the fibula). The fibula bone runs on the outside of the leg from the knee joint to the ankle joint. It is a small, thin bone and can be entirely removed without affecting your ability to bear weight in the majority of patients. The fibular bone is removed (the flap) along with two blood vessels, one of which supplies new blood to the flap (the artery) and one of which drains old blood away from the flap (the vein). Once the bone is removed, it is transferred to the head and neck area and secured into position with plates and screws. The blood vessels supplying and draining the flap are then joined to blood vessels in your neck under a microscope. These bloods vessels keep the flap alive while it heals into its new place. Depending on the defect being reconstructed, the surgeon will often include an area of skin and/or muscle attached to the fibula.
What will my leg be like afterwards?
Your leg will be placed in a bandage for a week following surgery. A special boot will be worn most of the time to help maintain correct ankle position and to assist in walking. The boot should be worn for approximately 1 month after surgery whenever you leave home, although you may try wearing supportive shoes while at home. It often takes several weeks for the swelling in your feet to resolve enough before you can wear your normal shoe size. You may also try wearing a shoe with the laces loose to accommodate your swollen foot.
Occasionally, it is necessary to remove a piece of skin along with the fibula bone. If the piece of skin that is removed is large, it will need to be replaced with a skin graft from the upper outer thigh area.
What can I expect after the operation?
The area of your leg where the bone has been removed is likely to be sore. Regular pain medicine will be arranged for you. A small tube may also be placed through the skin into the underlying wound to drain any blood the may collect. This “drain” is usually removed after a few days while you are still in the hospital.
Will I have a scar?
All incisions made though the skin leave a scar but the majority of these fade with time. The scar on the outside of your leg runs from just below the knee joint to just above the ankle joint. If a skin graft is necessary, you will also have a “patch” of skin from your upper thigh healing on the fibula surgical site above the ankle.
What are possible problems?
There are potential complications with any operation; most of them are rare. However, it is important that you are aware of them and have the opportunity to discuss them with your surgeon.
•Bleeding: since a “drain” is inserted into the wound, excess bleeding is unusual.
•Infection – you will be given antibiotics during surgery and for several days after surgery. As a result, infection is usually not a problem. Previous radiation therapy or uncontrolled diabetes may raise your risk of infection.
•Numbness: sometimes you may notice a small patch of skin on the lower part or your leg or foot that is numb or tingly after the operation. This numbness may take several months to disappear and in the minority of patients may be permanent.
•Flap failure: in 5% of cases, one of the blood vessels supplying or draining the flap can develop a blood clot within it. This means that the flap does not get any fresh blood or, if the drainage vein clots, then the flap becomes very congested with old blood. It is an occurrence that usually happens with the first two days and means that you will have to return to the operating room to have the clot removed. Removing the clot is not always successful and on these occasions the flap “fails” and an alternative method of reconstruction is sought. In general, about 50% of flaps which are returned to the operating room are eventually saved.
Will my walking be affected?
In the long term, removing the fibular bone should produce minimal to no problems in your walking. You will be on bed rest for a day or two after surgery. Soon after this, you should be sitting up in a chair. With the help of a physical therapist, you will start to walk around the 3rd day. By the end of the second week, you should be walking near normally and climbing stairs. Occasionally, you may need help (a cane or walker) for a further week or so. You will have a padded boot for extra support. We recommend using the boot for 1 month after surgery any time you leave home.
How long will I be in the hospital?
The minimum stay for this operation is usually 5-10 days, although other circumstances may require you to stay longer. 5-10 days is needed to allow some healing of the leg and to give the physical therapist time to get you walking on it again.
RADIAL FOREARM FREE FLAP
What is a radial forearm free flap?
A radial forearm free flap is one way of filling a defect, which is left when cancer has been removed. It is one of the most common ways of replacing tissue in the head and neck, particularly after mouth or facial cancers have been removed. It can be used to replace large portions of the mouth and has the advantage that when it heals, it does not shrink so that changes in speech and swallowing will be minimized.
What does the surgery involve?
Dr. Kang will take a piece of skin from the inside surface of your forearm near the wrist. The skin and fat layer in this region is removed (the flap) along with blood vessels, one of which supplies blood to the flap (the artery) and one of which drains blood from it (the vein). Once the flap of skin is raised, it is transferred to the head and sewn into the hole created by the removal of your cancer. The blood vessels are attached to vessels in the neck to keep the flap alive while it heals into its new place.
Once the flap is removed from your forearm, the defect created is covered with a new graft of skin. This graft of skin can be taken from one of several places, including the upper outer thigh or the upper inner arm.
What will my arm be like afterwards?
Your forearm will be placed in a splint for a few days. The bandage is removed after around 5 days and replaced with a lighter dressing. The blood vessels lifted with the flap run from the inside of the wrist as far as the inside of the elbow. There will be no sutures that are required to be removed as they will all be buried under the skin aesthetically. The skin removed from the arm is replaced by a patch of skin taken from the upper thigh or from the upper arm.
The nerve which supplies feeling to the skin over the base and side of the thumb is sometimes bruised when the flap is raised. This area may end up tingly or numb for several months following the surgery. Occasionally, it can be permanent. Rarely a bruised nerve can give rise to feelings of pain. You may also notice that your grip does not feel as strong as it was before the operation and sometimes it will feel colder than it used to in the winter months.
What are the possible problems?
In 5% of cases, one of the blood vessels supplying or draining the flap can develop a blood clot. This means that the flap does not get any fresh blood or, if the drainage vein clots, the flap becomes very congested with old blood. If this occurs, it usually happens within the first two days and means that you will have to return to the operating room to have the clot removed. Removing a clot is not always successful and on these occasion the flap “fails” and an alternative method of reconstruction is sought. When a flap is returned to the operating room, they are able to be saved about 60% of the time.
Virtual Surgical Planning
Dr. Kang using Medical Modeling, one of the world leaders in personalized surgery with Virtual Surgical Planning (VSP), where a combination of medical imaging, surgical simulation, and additive manufacturing (3D printing) come together to give Dr. Kang a detailed surgical plan with custom engineered instrumentation to ensure surgical success.
What is VSP?
This is the utilization of medical imaging data to accurately plan a surgery in a computer environment, and then transferring that plan to the patient using customized instruments. This type of pre operative planning is now becoming the standard of care for reconstructive craniomaxillofacial surgical procedures.
Maxillofacial Trauma
There are many possible causes of facial trauma including motor vehicle collisions, falls, sports injuries, interpersonal violence, and work related injuries. Traumatic facial injuries can range from a simple cut to complex fractures of the facial bones with injury to special structures such as the eyes, nerves, and salivary glands.
Soft Tissue Injuries
Lacerations and soft tissue injuries are meticulously closed with the highest concern for aesthetic outcomes. Postoperative care for lacerations are just as important to decrease posts inflammatory hyperpigmentation, and to minimize scars. Soft tissue avulsions results in the loss of tissue and Dr. Kang is well versed in local and regional flaps for reconstruction of these complex defects, as well as using more advanced methods of free tissue transfer for reconstruction of these difficult wounds.
Facial Fractures
Fractures of the facial bones are treated in a similar fashion to fractures of the arm or leg, using internal fixation of these fractures. Titanium plates and screws are placed to restore the bones in their original position to optimize facial appearance. All fractures of the skull and face can be restored by Dr. Kang, including the frontal bone and frontal sinus, orbital fractures, cheek bone fractures, nasal fractures, and fractures of the upper and lower jaws. The incisions used are typically placed in places that are hidden or difficult to see, to minimize unsightly scarring. Dr. Kang will discuss with you what surgical approaches and fixation methods will yield the optimal outcomes for you on a case by case basis.