Head and Neck Cancer / Free-Flap Reconstruction | Planning around tumour treatment

Each operation removes the tumour, then repairs the defect. Flaps are often most appropriate for complex defects. A free flap is living tissue transferred with its blood vessels reattached microsurgically. Surgeons can tailor it thin and pliable or bulky and padded; skin, oral lining, muscle, cartilage and bone can all be reconstructed. The defect's size, depth, tissue planes, surrounding tissue quality, location near the eye or mouth, and prior radiotherapy or surgery affect decisions. Larger composite or through-and-through defects usually require free tissue transfer, while smaller defects may allow primary closure or local flaps. Prognosis also matters: in poor prognosis, quicker rehabilitation may be preferred. Multidisciplinary care is essential.

After tumour removal, the defect may expose vital structures and affect swallowing, speech or breathing, so immediate reconstruction is often important to restore the mouth seal, anatomy and function. Microvascular free tissue transfer is a standard option because it can match tissue to the defect. Reconstruction may be immediate or delayed: flaps after cancer removal can usually be done immediately or within a few days when margins are confirmed clear. Patients must be fit for a long operation, and medical conditions may be optimized first; free flaps are not usually done as emergencies. The choice depends on cancer stage, prognosis and recovery goals and overall health status.

Each operation removes the tumour and reconstructs the defect. Free flaps are tailored to the defect: thin and pliable or bulky and padded. Skin, oral lining, muscle, cartilage and bone can all be reconstructed. Larger composite or through-and-through defects require free tissue transfer. Reconstructing inside dimensions close to the original defect size matters; too little tissue can lead to wound breakdown, fistulas, stenosis or trismus from contracture, while a larger flap can be debulked. If postoperative radiation is anticipated, flap volume and surface area are usually overcorrected by at least 10% to preserve contour. Adequate recipient vessels and potential complications such as fistulae must also be considered.

Head and neck reconstruction is challenging because the tumour site, disease stage, patient condition and need to restore function and appearance all matter. Free tissue transfer is the gold standard after ablative treatment. In areas such as the floor of the mouth, obtaining clear margins can require removing nearby bone, while reconstruction must keep the area mobile to preserve near-normal swallowing and speech. A free flap brings its own blood supply and can be tailored thin or bulky to match the defect. The aim is cancer control first, then the best possible function and appearance. Reconstruction also helps recreate a watertight seal between the mouth and neck when neck surgery is performed.

Radiation causes fibrosis that increases with dose and time since treatment, and prior neck surgery can scar or injure vessels, so dissection may be more tedious and sometimes needs a microscope. Clinical studies do not show irradiated vessels are unusable, so they are not an absolute contraindication, but their use is technically more demanding. Carotid rupture has been reported during dissection after radiation. If common vessels are unavailable, surgeons may consider other regional vessels, contralateral neck vessels, or vein grafts, though vein grafts have been associated with more thrombosis. Imaging of the neck may help when prior irradiation, neck dissection or free-flap surgery has occurred, and neck skin quality may need assessment in irradiated patients.

The team may include a head and neck or ENT surgeon, oral and maxillofacial surgeon, plastic and reconstructive surgeon, clinical oncologist, radiologist, pathologist, clinical nurse specialist, dietitian, speech and swallowing therapist, dentist and social support staff. Microvascular free tissue transfer is often the gold standard for reconstruction after ablative treatment, and combined operations can be in the patient's best interests. The defect may involve skin, lining, muscle, cartilage or bone, so reconstruction can be tailored to restore function and appearance. The head and neck surgeon coordinates care among services, while the reconstructive surgeon performs complex reconstruction. Rehabilitation addresses speech, swallowing, nutrition and emotional support, and some patients also need radiotherapy or chemotherapy.

Free-flap reconstruction rebuilds defects after cancer removal, and nutrition is supported throughout the perioperative period. Patients with intraoral reconstruction are not fed orally at first; a nasogastric tube is commonly used, and tube feeding may continue for 7 to 10 days to allow healing. Swallowing capacity should be evaluated before oral feeding begins, and some patients may never resume oral feeding. Bulky upper aerodigestive tract tumors can make nasogastric passage impossible, so a percutaneous stomach or jejunal tube may be used. Temporary tube feeding or supplementation may also be needed during adjuvant radiation because radiation can temporarily prevent swallowing for some patients. Depending on the procedure performed and anticipated complications, nutrition management is individualized.

Malnutrition is common in head and neck cancer, especially throat cancers, because tumor cachexia, painful swallowing, swallowing weakness, poor appetite, early fullness, prior chemotherapy or radiation, and higher metabolism can reduce intake and weight. Malnutrition occurs in 35% to 60% of patients, particularly oropharyngeal and hypopharyngeal cancers. A 20% preoperative weight loss has been linked with mortality up to 30%. When weight loss is unclear, serum albumin can indicate nutritional status. Poorly nourished patients face higher surgical and radiotherapy complication risk, so cardiopulmonary status and nutrition are optimized before surgery when possible. Severe malnutrition may require preoperative nutritional therapy; decisions balance cancer progression risk.

Microvascular free tissue transfer is often the gold standard after head and neck cancer removal because it can match tissue to the defect and restore function. However, not every patient or centre can support a long microsurgical operation; it needs trained staff, equipment and close monitoring. For smaller skin defects, direct closure or skin grafts may suffice; larger defects may need skin flaps. In advanced cancer with limited life expectancy, some surgeons consider plate or combined plate and soft-tissue reconstruction because surgery is shorter and recovery faster, but plate-related complications are common and results are rarely ideal. After partial maxillectomy in poor prognosis, an obturator may be completed sooner than bone reconstruction.