The Journal of Laryngology & Otology (2016), 130 (Suppl. S2), S191–S197.

GUIDELINE
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doi:10.1017/S0022215116000621

Reconstructive considerations in head and neck

surgical oncology: United Kingdom National
Multidisciplinary Guidelines

M RAGBIR1, J S BROWN2, H MEHANNA3

1
Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, 2Department of Oral and
Maxillofacial Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool University, Liverpool, and
3
School of Cancer Sciences, Institute of Head and Neck Studies and Education, University of Birmingham,
University Hospital Birmingham, Heart of England NHS Foundation Trust, Birmingham, UK

Abstract
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer
patients in the UK. The reconstructive needs following ablative surgery for head and neck cancer are unique and
require close attention to both form and function. The vast experience accrued with microvascular reconstructive
surgery has meant a significant expansion in the options available. This paper discusses the options for
reconstruction available following ablative surgery for head and neck cancer and offers recommendations for
reconstruction in the various settings.

Recommendations
• Microsurgical free flap reconstruction should be the primary reconstructive option for most defects of the head
and neck that need tissue transfer. (R)
• Free flaps should be offered as first choice of reconstruction for all patients needing circumferential
pharyngoesophageal reconstruction. (R)
• Free flap reconstruction should be offered for patients with class III or higher defects of the maxilla. (R)
• Composite free tissue transfer should be offered as first choice to all patients needing mandibular
reconstruction. (R)
• Patients undergoing salvage total laryngectomy should be offered vascularised flap reconstruction to reduce
pharyngocutaneous fistula rates. (R)

Introduction stage reconstruction utilising vascularised tissues with

The problems of reconstructive surgery for the head a high success rate and good overall results.
and neck are variable and can be very complex.1,2 Priorities of reconstruction include restoring oral
These guidelines have been divided into the manage- cavity lining, maintaining oral competence, maintain-
ment of the loss of skin, the maxilla, the mandible, ing function of speech and swallowing and providing
including the associated soft tissues, the oropharynx an acceptable aesthetic result. Choice of reconstructive
and the laryngopharynx. There is very little level 1 evi- options depends on patient comorbidities, factors
dence relating to the reconstruction of head and neck relating to the surgical defect, any future possible treat-
defects. Mandibular reconstruction techniques are ments including radiotherapy and donor site morbidity.
fairly standard but some controversy remains regarding No appropriately powered randomised controlled trials
the midface and maxilla because of the complexity of exist to determine flap selection in most instances and
the defects and the possibility of using a dental or this is usually determined by the expertise of the
facial prosthesis. individual surgeon. Patient factors include prior treat-
Most reconstructions are performed primarily follow- ments, especially surgery and radiotherapy and the
ing tumour extirpation, but secondary reconstructions patient’s overall health including medical and social
are also undertaken to treat problems such as fistulae history. Multiple tissue types often require to be
or osteoradionecrosis. Modern techniques aim for one reconstructed.
S192 M RAGBIR, J S BROWN, H MEHANNA

Oral cavity soft tissues The fibular flap allows harvest of a long piece of bone
Oral soft tissues include tongue, floor of mouth, buccal which is of adequate height for osseo-integration and
mucosa and the retro-molar trigone extending to the can be osteotomised several times for contouring.6,7
tonsillar area. It is rare that only one of these areas is This is now made easier with the availability of software
involved. Reconstructive access is usually determined to plan the osteotomies at the mandible and on the fibula
by the extent of surgical resection and may involve a prior to transfer. It is relatively easy to harvest as an
lip-split and mandibular osteotomy, although a per- osseus or osteoseptocutaneous flap, with or without
oral approach is usually possible. muscle. This versatility means it is the workhorse for
Microsurgical techniques provide the mainstay of mandibular reconstruction in most centres. One draw-
oral soft tissue reconstructions as they allow import- back of the flap is its relative lack of height.
ation of large volumes of healthy tissue from sites The DCIA flap provides for a high bony segment
distant to prior surgical or radiotherapy fields. Flaps and the natural curve of the ilium lends itself to
commonly used include the radial forearm flap (RFF) lateral mandibular defects where an osteotomy may
and the anterolateral thigh (ALT) flap. Less commonly not be necessary. The donor site defect can be problem-
the latissimus dorsi, rectus abdominus and flaps based atic and its skin paddle is usually reserved for external
on the scapular and/or para-scapular axis are utilised. use although muscle can be incorporated for oral
More recently, the medial sural artery perforator flap reconstruction.
(MSAP) and the superficial circumflex iliac artery per- The scapular flap allows for harvest of a relatively
forator flap are being used. The first two represent the small amount of bone. The main advantage of this
workhorse flaps in this field and will be discussed flap is the large volume of skin and muscle (latissimus
separately. dorsi) which can be used. The bone is a good height,
The RFF allows for importation of a large, thin, but two-team flap harvesting is generally not possible.
pliable flap with excellent reliability and simplicity of Radial forearm flap is rarely used for bone recon-
harvest.3 Multiple skin paddles can be designed and struction as only a small volume of bone of low
the flap can be raised as a cutaneous, fasciocutaneous, height can be harvested. There is a risk of subsequent
fascial, adipofascial, osseo-fascial or osseo-cutaneous fracture of the radius.
flap (see below). The principal disadvantage of this A new classification of the mandibular defect has
flap is the poor donor site aesthetics when skin grafting been described based on the four corners of the mandible
is required. which are both angles and both canines (Figure 1):8
The ALT flap allows for importation of very large
tissue volumes and is versatile.4 Fascio-cutaneous and • Class I (70 mm)/Ic (84 mm): Subcondylar region
fascial flaps can be raised, along with muscle and to the ipsilateral canine and class Ic includes the
fascia lata if required. The flap has a long pedicle, condyle. Most of the flaps described above will
but can be technically challenging to raise. It is a rela- work well as the length of this defect is around
tively thick flap which can be thinned. If multiple per- 7–8 cms and so all bone donor sites are adequate.
forating vessels are available, then the flap can be In the lateral defect the height of the reconstruction
raised with two skin paddles. Donor site morbidity is is less problematic.
minimal and use of the ALT is increasing in most • Class II (85 mm)/IIc (126 mm): Hemimandibu-
reconstructive centres. lectomy from subcondylar region including ipsi-
If microsurgery is considered, inadvisable local or lateral canine and class IIc includes condyle. The
regional flaps are still used. Within the oral cavity iliac crest can work well as the shape of the ipsilat-
local mucosal flaps can be useful to help close small eral hip may reduce osteotomy preparation and a
defects. Regional flaps such as pectoralis major and scapula may not be sufficiently long for a class
deltopectoral can be effective in importing tissue, but IIc when soft tissue is seldom an issue.
are not generally considered as a first choice. • Class III (100 mm): Includes both canines, but
neither angle. The choice of flap depends more
on the plan of rehabilitation and height of chin
Mandible support. The fibula flap can be double-barrelled
Reconstruction of the mandible must address the site to increase height, but scapula and radius are
and size of the bony defect, associated soft tissue loss often difficult to implant successfully for complete
and the desirability of dental rehabilitation. Free oral rehabilitation.
tissue transfer is the mainstay of mandibular recon- • Class IV (152 mm)/IVc (168 mm): This is an
struction as it allows importation of bone which can extensive mandibulectomy including at least one
be tailored to fit the desired shape, is well vascularised angle and both canines. The fibula flap is
and is amenable to osseo-integration. Several flaps are usually the best option for faithful reconstruction,
commonly used with high success rates, including the but the mandible is often best made smaller for
fibula flap, deep circumflex iliac artery (DCIA) flap, such major resections especially if there is loss
scapular flap and RFF.5 of maxillary teeth.
RECONSTRUCTIVE CONSIDERATIONS IN HEAD AND NECK SURGICAL ONCOLOGY: UK GUIDELINES S193

FIG. 1
Classification of mandibular defects.

Dental rehabilitation is a key part of mandibular defects of an orbitomaxillary (class V) or nasomaxil-

reconstruction and pre-operative liaison with an appro- lary (class VI) nature. This refers not only to the verti-
priate team including consideration of osseo-integrated cal component but also to the extent of the dental or
implants is mandatory. alveolar part of the resection relevant to the prostho-
dontist in deciding on appropriate obturation. Other
Maxilla and midface classifications suggested include those by Okay et al.,
The level of evidence is very weak in all areas of recon- but there is no distinction between classes III and IV.
struction, but more particularly in the maxilla and All cases involving the loss or ablation of the maxilla
midface because of the differing complexity of the and/or midface should be discussed in a multidiscip-
defects, and the potential for skull base involvement. linary setting. The choice of reconstruction or prosthe-
Throughout this section, it is necessary to refer to the tics requires discussion among the ablative and
classification suggested in Fig. 2.9 The choice of a reconstructive teams, the prosthodontist, maxillofacial
prosthetic option or reconstruction depends on the technician, the patient and the family. There are clear
nature of the defect. In class I and II defects an obtur- advantages in simplifying the surgery and using pros-
ator is a reasonable option, but this becomes less thetic options, but this choice becomes more difficult
favourable as the orbital adnexae are involved (class to deliver and for the patient to cope as the defect
III), orbital exenteration (class IV) and the midface becomes larger and more complex.
S194 M RAGBIR, J S BROWN, H MEHANNA

FIG. 2
Classification of the maxillary and midface defects. Classes I–VI relate to the vertical component of the defect including orbitomaxillary (class
V) and nasomaxillary (class VI) when often the palate and dental alveolus are intact. Classes a–d relate to the increasing size of the palatal and
dento-alveolar part of the defect indicating increasing difficulty in obtaining good results with obturation.

Class I: This includes resections of the alveolar bone if an implant-retained prosthesis is planned, but the
not resulting in an oroantral fistula and these can either scapula tip flap using latissimus dorsi muscle is also a
be left to granulate or treated with a local flap. Also good option with a more reliable pedicle. The fibula is
included are defects involving the junction of the also described for this defect but considerable skill in
hard and soft palate usually obturated or reconstructed the adaptation of this flap for the defect is required with
with a soft tissue flap, and minor maxillectomies which variable results. The rectus abdominus with non-vascu-
may occur following the removal of small inverted pap- larised bone is also an option but is associated with a
illomas which generally do not require rehabilitation. high ectropion rate and there is a risk of bone loss if radio-
Class II: This is the standard hemimaxillectomy not therapy is required. The vastus lateralis based on the des-
involving the orbital floor or adnexae. Obturation is cending branch of the lateral circumflex femoral artery is
often very successful for this form of defect as the orbit another option.
does not require support and if the defect is not too Obturation alone will result in facial collapse, poor
large there is less of a problem for the patient in terms support of the orbit and a high risk of vertical orbital
of retention and stability of the prosthesis. In more exten- dystopia and ectropion. In children, the scapula tip
sive cases (classes IIc–d), it is possible to gain very good will probably be the best option as the iliac crest has
retention with an implant-retained prosthesis, although a cartilaginous cover and the vessels are much smaller.
reconstruction with the fibula flap has also shown good Class IV: Reasonable results can be achieved with a
outcomes. A vascularised bone with greater height, soft tissue flap alone such as rectus abdominus or
such as the DCIA flap which includes the iliac crest and vastus lateralis but this will result in poor definition
internal oblique muscle, will give better support to the of the orbital defect and some facial collapse. The
peri-nasal area. The scapula flap can be supplied by the choice is similar to class III in that the iliac crest with
circumflex scapular artery which supplies the lateral internal oblique offers better implant options but the
scapula (scapula flap) through peri-osteal perforators scapula tip flap is also a good option.
along its length or the angular branch of the thoracodorsal Class V: In the orbitomaxillary defect, the main aim
artery which supplies the scapula tip. The advantage of is not to obturate the orbital space with too much soft
the scapula tip option is that the pedicle is considerably tissue so as to allow space for an orbital prosthesis.
longer than the circumflex scapula artery option which The temporalis or temporoparietal flap are ideal, but
is a great advantage in the maxilla and midface as the in more extensive defects it is worth considering the
recipient vessels are more distant. radial or ALT in a thinner patient.
Class III: In these cases, there is loss of the orbital Class VI: If there is loss of the facial skin between the
support and often a part of the nasal bones may also orbits and nasal bones, then free tissue transfer is prob-
require reconstruction. There is good consensus in the lit- ably essential. The composite RFF can be ideal if har-
erature that the restoration of orbital support with vascu- vested with fascia to line the nasal side of the radial
larised tissue (pedicled or free flap) is essential to strut and the skin to restore the face. The composite
ensure healing of the bone graft and reduce the soft radial can be augmented with a glabella or forehead
tissue problems such as epiphora and ectropion. The flap. A classical rhinectomy can be rehabilitated with a
iliac crest with internal oblique provides the best solution prosthesis and of course the surgeon can check the
RECONSTRUCTIVE CONSIDERATIONS IN HEAD AND NECK SURGICAL ONCOLOGY: UK GUIDELINES S195

margins of resection and resect more tissue if required. TABLE I

There are very successful full rhinectomy reconstructions METHODS OF SOFT PALATE RECONSTRUCTION
performed which can give a permanent biological solution
No Obturation
if preferred. In this defect attention must be paid to the res- reconstruction
toration of the nasal bones with vascularised tissue to
prevent complications during and following radiotherapy. Local flaps Superiorly based pharyngeal
Palatoplasty and lateral pharyngeal
Palatal island mucoperiosteal
Oropharyngeal reconstruction Palatal island and pharyngeal
The oropharynx can be divided into the walls of the Masseter and buccal mucosa transposition
Masseter, buccal mucosa and pharyngeal
oropharynx (lateral and posterior), the base of the Temporalis
tongue and the soft palate. The oropharynx is a muscu- Superior constrictor advancement
lar tube connecting the larynx and hypopharynx to the Velopharyngoplasty or masseter and buccal
advancement
oral cavity. The role of reconstruction is to try and Pedicled flaps Temporal osteocutaneous island
maintain the function of the residual tissue. From a Galeo-peri-cranial
functional point of view the most difficult area is the Free flaps Radial forearm
Radial forearm and additional local
posterior tongue which allows normal movement of Folded radial forearm
the epiglottis and maintains swallowing and speech. Lateral arm
The use of transoral robotic and laser resections Jejunum
Anterolateral thigh
without reconstruction may give better functional
results than reconstructing this muscular tube with
non-sensate skin such as the radial forearm flap.
often better to excise the remnant and undertake a
Reconstruction of the soft palate total circumferential reconstruction.
The most commonly described method of soft palate
Total circumferential pharyngolaryngectomy defects
reconstruction involves the use of the RFF often in
combination with a local flap such as the superiorly Lower anastamosis above clavicles. Where the lower
based pharyngeal flap or the superior constrictor anastamosis of a total circumferential pharyngolaryn-
advancement flap. Some suggest the use of a folded gectomy reconstruction would lie above the clavicle,
RFF which is de-epithelialised in order to be sutured several options exist:12 jejunal free flap (JFF), gastro-
to the de-epithelialised posterior pharyngeal wall, but omental free flap (GFF), tubed radial forearm free
a superiorly based pharyngeal flap can be utllised to flap (RFFF) and tubed anterolateral thigh free flap
provide the nasal lining with good results.10,11 The (ALTF). All of the above options carry the risk of
free flap is used in the horizontal part of the defect free flap failure, anastamotic leaks, anastamotic stric-
only if it is possible to close the posterior tongue to tures, donor site morbidity, failure of voice rehabilita-
narrow the pharynx and maintain its function. tion, swallowing problems and a small peri-operative
mortality rate.
Reconstruction of the pharyngeal walls and
tonsillar regions Previously untreated cases. In previously untreated
Placing free tissue transfers will disrupt the muscular cases, ALTs, tubed over a salivary bypass tube,
tube and probably decrease function. For this reason, appear to provide the lowest complication rates –
transoral robotic and laser resections are preferred to with minimal donor site morbidity, lower leak rates
address these tumours where possible. and lower stenosis rates. Good swallowing and voice
rehabilitation have also been reported. Alternatives
Reconstruction of the posterior tongue include the JFF13 and the RFF. Swallowing problems
Most surgeons do not claim to be able to restore func- due to hyper-peristalsis and a ‘wet’ sounding voice
tion in this region if more than half of the posterior are common with JFF, which also carries a morbidity
tongue requires resection (Table I). rate due to abdominal complications (≈5 per cent).
Radial forearm flap carries lower donor morbidity
Pharyngo-laryngectomy reconstruction rates, but higher stenosis and leak rates than JFF.
Tubing of the RFF over a salivary bypass tube
Partial pharyngeal defects appears to decrease fistula rates.14
Partial pharyngeal defects with more than 3.5 cm of
remaining pharyngeal mucosal width may be closed Post-chemoradiotherapy (salvage) cases. In general,
primarily. Defects with less than 3.5 cm of pharyngeal reconstructive free flap surgery in the salvage setting
mucosal width remaining may be reconstructed using a carries higher risks of complications due to the deleteri-
pedicled flap – usually a pectoralis major myocuta- ous effects of chemoradiotherapy on tissue vascularity
neous flap. Free flaps, such as radial forearm free and wound healing. In such cases, limited case series
flaps, may also be used. If the pharyngeal mucosal suggest that use of GFFs may have an advantage due
remnant is very narrow (<1 cm in width), then it is to the availability of the omentum. This can be
S196 M RAGBIR, J S BROWN, H MEHANNA

wrapped around the anastamotic site to decrease the pos- Key points
sibility of leakage and also improve the overlying skin Mandible and oral cavity
quality. Additional vascularised tissue can be included
• The radial forearm and the anterolateral thigh free
with the ALT as a chimaeric flap to resurface the neck
flaps are the preferred options for oral soft tissue
in cases where there is poor quality skin or contracted
reconstruction. Newer flaps such as the medial
skin that would not safely close post-operatively.
sural artery perforator flaps are increasing in
Any of the other options mentioned previously, for
popularity
example JFF, RFF, may also be used in salvage surgery.
• The fibula free flap is now considered
Lower anastamosis below clavicles. If the resection the workhorse for mandibular reconstruction fol-
extends to below the level of the clavicles, then a lowing ablative surgery. Planning software
gastric pull through or colonic transposition flap may makes osteotomies easier
be used. Both these techniques carry significant mor- • The deep circumflex iliac artery with internal
bidity and mortality due to the need to enter three vis- oblique provides a superior form for the mandible
ceral cavities. Gastric pull through carries a mortality and facilitates deeper implant placement and
rate of 5–15 per cent, morbidity of 30–55 per cent should be considered if implant-retained oral
and reported fistula rates of 3–23 per cent. Colonic rehabilitation is planned
transposition carries similar risks, and appears to be • The scapula provides a good option for extensive
less commonly used. It can however provide a higher soft tissue resections including the mandible and
reach than gastric pull through, and is therefore useful an alternative if atheroma precludes use of the
for tumours that extend up high into the oropharynx. fibula. The donor site is also the best tolerated

Vascularised tissue after salvage Midface and maxilla

laryngectomy • Multidisciplinary decision-making should include
Pharyngocutaneous fistulae (PCF) are known to the patient, surgeon and dental prosthodontist
occur in nearly one-third of patients who undergo • Prosthetic options reduce the morbidity of treat-
salvage total laryngectomy after chemoradiation. ment and can give excellent results but recon-
Pharyngocutaneous fistulae have severe impact on dur- structive options should be considered as the
ation of admission and costs, quality of life and can defect becomes larger and more complex
even cause severe complications such as bleeding,
infection and death. Recent meta-analyses suggest Oropharynx
that there is a clear advantage in using vascularised • Using local tissue only to restore the constrictor
tissue from outside the radiation field in the laryngect- tube is essential. Free tissue transfer is best
omy defect, either as a buttress or to augment the cir- reserved for the reconstruction of the soft palate
cumference of the pharynx.15,16 This intervention • Functional results for posterior tongue reconstruc-
reduces the risk of PCF by one-third to a half. tion are disappointing
• The greater role played by transoral surgery will
Recommendations reduce the need for reconstruction in this area
• Microsurgical free flap reconstruction should
be the primary reconstructive option for most Pharyngolarynx
defects of the head and neck that need tissue • Partial pharyngeal defects may be closed primarily
transfer (R) or using a pedicled myocutaneous, usually a pec-
• Free flaps should be offered as first choice of toralis major flap or with a free flap
reconstruction for all patients needing • Total circumferential defects where the lower ana-
circumferential pharyngoesophageal stamosis is above the clavicle can be reconstructed
reconstruction (R) with several free flaps. In previously untreated
patients, anterolateral thigh free flaps, tubed over
• Free flap reconstruction should be offered for a salivary bypass tube, appear to carry lowest
patients with class III or higher defects of the complication rates. In post-radiotherapy patients,
maxilla (R) limited evidence suggests that gastromental free
• Composite free tissue transfer should be flaps may have some advantages
offered as first choice to all patients needing • Tubing over and use of a salivary bypass tube
mandibular reconstruction (R) appears to decrease complication rates with
• Patients undergoing salvage total laryngectomy anterolateral thigh and radial forearm free flaps
should be offered vascularised flap • Total circumferential defects where the lower
reconstruction to reduce pharyngocutaneous anastamosis is below the clavicle may be recon-
fistula rates (R) structed by gastric pull through or colonic
transposition
RECONSTRUCTIVE CONSIDERATIONS IN HEAD AND NECK SURGICAL ONCOLOGY: UK GUIDELINES S197
Salvage laryngectomy resection and composite microvascular reconstruction. Lancet
• Use of vascularised tissue to buttress or augment the Oncol 2016;17:e23–30
9 Brown JS, Shaw RJ. Reconstruction of the maxilla and
pharynx in patients undergoing salvage total laryn- midface: introducing a new classification. Lancet Oncol 2010;
gectomy reduces pharyngocutaneous fistula rates 11:1001–8
10 Brown JS, Zuydam AC, Jones DC, Rogers SN, Vaughan ED.
Functional outcome in soft palate reconstruction using a radial
forearm free flap in conjunction with a superiorly based pharyn-
Acknowledgment geal flap. Head Neck 1997;19:524–34
The authors acknowledge the contributions of Stephen 11 Kim EK, Evangelista M, Evans GR. Use of free tissue transfers in
Morley to the previous edition of this manuscript. head and neck reconstruction. J Craniofac Surg 2008;19:1577–82
12 Patel RS, Goldstein DP, Brown D, Irish J, Gullane PJ, Gilbert
RW. Circumferential pharyngeal reconstruction: history, critical
analysis of techniques, and current therapeutic recommenda-
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