It should be emphasized that our algorithm has been designed as a guide to the reconstructive surgeon with limited experience in head and neck reconstruction. Although the approach has allowed us to achieve good surgical and functional results and was followed in 93% of cases, we acknowledge that surgeons in other high-volume units may prefer to adopt a more bespoke approach to flap selection according to the defect in question and the availability of recipient vessels in the neck. Furthermore, there are occasions when the optimal flap is unavailable and alternative donor sites should be sought. For example, in our series a patient with a mucosa-only defect involving 1 mucosal zone but no RFFF donor site available underwent a lateral arm flap instead.
The algorithm presented does not attempt to guide the reconstructive surgeon on the size and shape of flap harvest. The nuances of designing the skin island depend on evaluation of the resulting defect and, therefore, decisions should be made on a case-by-case basis. Although a partial glossectomy simply requires a RFFF designed to fit the defect, the approach to designing the skin island for more extensive tongue defects have been discussed extensively elsewhere.14,15,32,33 Our algorithm simply affirms the opinion that the optimal flap for a tongue defect involving more than one third of the tongue bulk is best reconstructed with an ALT and, thus, guides the initial flap selection.14,34,35
In our experience, flap selection can be made according to the depth and mucosal extent of the defect irrespective of the exact location within the oral cavity. We have, however, extended this concept further to develop a classification system that describes the exact location, mucosal extent, and resection depth (Fig. 2). The adoption of the classification system will aid in communication among reconstructive surgeons, data collection, and future outcomes-based research. It should, however, be emphasized that it is simply the number of mucosal zones and lamina excised that will dictate flap selection.
Finally, the approach to isolated hard palate defects is different and so cannot be included in the unifying algorithm applicable to the rest of the oral cavity. Many postcancer resection palatal defects extend into maxillectomy-type defects and so would not be addressed using our algorithm. On the occasions that the defect is isolated to the hard palate, most would be treated with obturation alone. In the cases where an obturator fails to prevent oronasal leakage and hypernasality, or is poorly tolerated by the patient, microvascular reconstruction is an option for defects not amenable to local tissue transfer techniques. Both the RFFF21,22,36 or the scapula tip flap37,38 are good options. The RFFF provides a long pedicle that can reach the branches of the external carotid artery but does not restore bony integrity. It also necessitates either raising local palatal mucosal flaps or folding skin or fascia of the RFFF to restore the nasal lining.21 We, therefore, prefer the scapula tip flap where possible (Fig. 11). When using the scapula tip for an isolated hard palate defect, our approach is to raise the bone flap with the subscapularis and infraspinatus muscles and use the muscle layers to line the oral and nasal mucosal defects. As these subsequently remucosalize, mucosal integrity is restored. It should be noted that previous reports on the use of the scapula tip flap primarily focus upon defects that extend into the maxilla.37,38
The algorithm presented is aimed at providing a simple system to classify oral cavity defects and to guide the reconstructive procedure rather than focusing upon the anatomical location of the defect. This is based upon the knowledge that, in 93% of the cases, the application of the algorithm guided the reconstruction of the breadth of oral cavity defects. This approach can be used by reconstructive microsurgeons with varying levels of experience and has been demonstrated to generate excellent surgical and functional outcomes.
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