Current Opinion in Otolaryngology & Head & Neck Surgery:
HEAD AND NECK RECONSTRUCTION: Edited by Michael Hinni
Hinni, Michael L.
Mayo Clinic College of Medicine, Residency Program Director, Otolaryngology-Head and Surgery Mayo Clinic Arizona, Arizona, USA
Correspondence to Michael L. Hinni, MD, Consultant, Mayo Clinic, Associate Professor, Mayo Clinic College of Medicine, Residency Program Director, Otolaryngology-Head and Surgery Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054, USA. Tel: +1 480 342 2928; fax: +1 480 342 2626; e-mail: email@example.com
It is my distinct pleasure to serve as guest editor for this issue of Current Opinion. Many exciting developments are evolving in head and neck surgery in general and around the topic of head and neck reconstruction more specifically. The following edition reviews the recent medical literature and highlights new or evolving technologies and improvements in head and neck reconstruction.
In the early 1990s, chemoradiotherapy-based strategies were reported to be equivalent to surgery (total laryngectomy) regarding advanced staged laryngeal cancer. The nonsurgical strategy helped inspire a pendulum swing away from primary surgery, not only for laryngeal cancers but for mucosal head and neck squamous cell carcinoma of other sites, particularly the oropharynx. By 2003 following the publishing of the RTOG 9111 trial nonsurgical chemoradiotherapy became standard care in many parts of the Americas and Europe inspiring increasing numbers of nonsurgical clinical trials. Much has transpired in the management of head and neck cancer in more recent years with the pendulum perhaps beginning to swing back toward primary surgery (with or without reconstruction) for mucosal squamous cell carcinoma for previously untreated disease. There are numerous factors at play that may be influencing this shift. One is the dissemination of transoral surgery for primary head and neck cancers, which has migrated primarily from Europe to other parts of the world over this period. Using transoral laser microsurgery or more recently transoral robotic surgery, the morbidity following primary surgery for pharyngeal and laryngeal carcinomas has been diminished. At the same time, dramatic improvements in outcomes, including overall survival are being realized due to the rise of HPV-associated oropharyngeal malignancy. There is rising awareness that standard therapy as utilized for traditional HPV-negative mucosal squamous cell carcinoma produces significant and unnecessary morbidity when applied to the HPV-positive patient population. Head and neck oncologists around the globe recognize the need to ‘de-escalate’ the treatments for HPV-positive disease. As yet, there is no consensus on how to best accomplish this, with multiple nonsurgical clinical trials in practice, and even a few surgical-based trials in various stages of development.
Adding to this shift in recent years is the global economic crisis, which has governments and private payers alike looking for ways to reduce the cost of healthcare delivery. The roll out of the Affordable Care Act in the USA in particular signals a renewed emphasis on this cost containment. Multiple articles have been published in the recent past evaluating cost. It seems that in some medical systems around the world transoral surgery may present economic advantages over nonsurgical strategies. This also foments not only a rising interest in minimally invasive surgery but also in head and neck reconstruction when necessary. New reconstructive techniques offer cost savings as well, relative to standard care.
In the past 2 years, there has been a trend toward the more efficient application of reconstructive practices, reduced operative times, and reduced morbidity. Supraclavicular pedicled flap has been around for decades, but its use fell into almost nonexistence following the rise of microvascular-free tissue transfers. Given the cost realized with operating room time and hospital stay, many microvascular reconstructive surgeons are moving away from free tissue transfers and using pedicled flaps when the benefits are equivalent or superior. The peer reviewed article by Drs T. Nagel and R. Hayden (pp. 305–310) speaks to the use of the supraclavicular flap among others to reconstruct laryngopharyngectomy defects. In most cancer centers around the world, these defects are managed with free tissue transfers and in some centers exclusively with free tissue transfers. Given the equivalent functional outcomes and the obvious cost savings, the use of the supraclavicular flap is perhaps emblematic of an evolving shift in surgical care for head and neck defects. I anticipate this shift to continue.
In the same spirit regarding oral cavity defects, Drs Rigby and Taylor (pp. 311–317) discuss recent developments in oral cavity reconstruction. In a thorough review, these two also focus on cost and describe the use of acellular dermal matrix for reconstruction of smaller oral cavity defects. Larger defects, for example those requiring removal of 50% or greater of the tongue, still do functionally better with surgical reconstruction. Dr H. J. Welkoborsky's article (pp. 318–327) on the reconstructive options for larger defects of the pharynx concurs. This review provides a basic framework for flap selection. There is growing consensus in the recent literature that the anterior lateral thigh (ALT) flap may be viewed worldwide as the ‘workhorse’ free flap for soft tissue defects in the head and neck when a free flap is chosen. The relative ease of harvest and low donor site morbidity make this reconstruction particularly attractive. However in the non-Asian population its thickness and excess bulk can be problematic for some defects. For thinner defects requiring free tissue transfers, the radial forearm free flap remains a critical component of the reconstructive surgical armamentarium.
Further in the past couple of years there is a growing awareness of the value and potential cost savings of medical modeling prior to head and neck surgical reconstruction. Borrowed from industrial engineering and time-consuming by a number of days, three-dimensional modeling assists the reconstructive surgeon by providing educational opportunities, simulation and invaluable visual/tactile information before the patient is treated. The article by Drs Zenga and Nussenbaum (pp. 335–343) provides a concise but thorough lesson detailing the complexity and limitations of various modeling techniques. The time delay is problematic for traumatic defects but most complex defects, particularly those involving the mandible can be modeled. Dr E. Moore's article beautifully describes the practical benefits of three-dimensional modeling with examples. Often the contouring of the flap can be initiated prior to pedicle transaction and flap transfer, thus reducing ischemia time. Evolving evidence suggests this is an advantage over the freehand technique in terms of OR time, precision, and cost. These two articles provide evidence for the benefits of these evolving techniques that I expect to become more prevalent in the future.
In conclusion, I am excited to welcome the reader to this edition of Current Opinion. The following group of articles describes recent paradigm shifts not only in the care of the cancer patient but also in the use of specific reconstructive techniques. In light of the changing financial and economic environment in healthcare delivery, a back to basics simplification of reconstruction is occurring simultaneously with the increased use of new biological implants, a more thoughtful application of free flaps, and new advanced computerized three-dimensional planning to improve the outcomes and value of more complex reconstructions when necessary.
Conflicts of interest
There are no conflicts of interest.