Reconstruction after cancer surgery | Prof. Dr. Alper Tunga Derin

General education only; not a substitute for examination or diagnosis.

What reconstruction after cancer surgery covers

In head and neck cancer surgery, removing the tumour with a margin of healthy tissue can leave a tissue gap (defect) in the tongue, floor of the mouth, jawbone, palate, throat or facial skin. Reconstruction is the combination of surgical and prosthetic treatments that repair this gap and protect essential functions such as swallowing, speech and breathing. It is not a cosmetic procedure; appearance is one of the goals considered together with function.

Swallowing: supporting safe swallowing by preserving enough bulk and movement in the tongue and throat.
Speech: keeping speech intelligible by preserving tongue mobility and the separation between the mouth and nose.
Airway: keeping the breathing passage open and safe after surgery.
Protecting vital structures: covering structures such as the major neck vessels and skull base with healthy, well-vascularised tissue, especially in areas that will receive radiotherapy.
Appearance: preserving the jawline, midface and facial symmetry as far as possible.

Symptoms

The need for reconstruction usually arises from the extent of the planned operation rather than from a symptom, and it is planned together with the tumour surgery. After treatment, however, the following problems may point to a need for further rehabilitation or repair:

Coughing while eating or drinking, or liquids coming out through the nose.
Reduced speech clarity or a nasal-sounding voice (hypernasality).
Limited mouth opening (trismus), difficulty chewing or being unable to wear a denture.
Facial asymmetry or collapse of the jawline.
A non-healing wound in the mouth, exposed bone, or discharge from the mouth or neck (fistula); after radiotherapy these can be signs of jawbone damage (osteoradionecrosis).

When to see a doctor

Situations that need emergency care

Breathlessness or a blocked tracheostomy tube needs an immediate call to emergency services or the nearest emergency department.
Rapidly increasing neck swelling, or bleeding from the mouth or wound.
While in hospital, any sudden change in flap colour (paleness, darkening) or coolness should be reported to the team at once.
High fever, a wound opening up, foul-smelling discharge, or food or liquid leaking from the neck wound.

Situations that need a planned appointment

Swallowing, speech or chewing problems that do not improve over several weeks.
A palatal prosthesis (obturator) that does not fit or causes sores or pain.
Delayed wound healing or difficulty walking at the donor site (arm or leg).
For anyone who has had radiotherapy, discussing with the team before any tooth extraction or jaw surgery.

Every patient's defect and needs are different. A definite diagnosis and treatment decision are made after examination.

How it is diagnosed

In reconstruction, the diagnostic stage is really a planning stage, and it starts while the cancer treatment is being planned.

Imaging: CT and MRI show how much tissue will be removed and whether bone is involved; for jaw reconstruction, computer-assisted 3D planning based on CT may be used.
Donor-site assessment: hand circulation is tested before a forearm flap, and the leg vessels may be imaged before a fibula (calf bone) flap.
General health: heart and lung status, diabetes, smoking and nutrition all affect wound and flap healing.
Whether there has been previous radiotherapy or neck surgery, which affects the suitability of neck vessels and tissue healing.
Dental and prosthetic assessment and a speech and swallowing assessment; before upper jaw surgery, impressions may be taken in advance for an obturator.

Treatment options

The repair method is chosen according to the size and site of the defect, whether bone is involved and the person's general health. The options are thought of as a “reconstructive ladder” from simple to complex; the aim is not always the most complex method but the most suitable one for that defect.

Simple repair and local flaps

Primary closure: small defects are closed directly with stitches.
Skin grafts: a thin layer of skin taken from another area, often the thigh, is placed on the defect.
Local flaps: tissue right next to the defect is advanced or rotated while keeping its blood supply.

Regional pedicled flaps

Tissue such as a pectoralis major (chest muscle) or supraclavicular flap is moved to the neck or mouth while still attached to its own blood supply; it does not need microsurgery and is valuable when vessel options are limited.

Microvascular free flaps

Tissue is taken together with its own artery and vein and connected to neck vessels under a microscope.
Radial forearm flap: thin, pliable tissue often used for tongue and floor-of-mouth repair.
Anterolateral thigh (ALT) flap: can be used for defects that need more bulk.
Fibula flap: contains bone; it is commonly chosen to rebuild the lower jaw (mandible) and can provide a base suitable for dental implants.

Prosthetic and dental rehabilitation

When part of the upper jaw (maxilla) is removed, the palatal opening can be closed with a special prosthesis called an obturator; in some patients flap repair is preferred. A systematic review reported that both approaches can be effective, with some measures favouring surgical reconstruction.
Lost teeth can be replaced in suitable patients with implants and prostheses placed in the same operation or later.

Speech and swallowing therapy, physiotherapy and nutritional support are integral parts of surgical reconstruction.

Before and after surgery

Reconstruction is usually done in the same operation in which the tumour is removed; in some cases it is delayed. An anaesthetic assessment is done beforehand, and blood thinners are adjusted only on the advice of the treating physician. Stopping smoking is important because smoking impairs blood flow to the flap.

Flap monitoring: the first days are the most critical; flap colour, temperature, capillary refill and, when used, the Doppler signal are checked at frequent intervals. A problem with flap circulation is uncommon but serious and may need urgent return to theatre.
A temporary tracheostomy may be needed to secure the airway, and a feeding tube through the nose or abdomen until swallowing is safe.
Donor-site care: a graft and splint on the forearm, or gradual walking and physiotherapy for the leg, may be needed; the team explains drain and stitch care.
The hospital stay and full recovery depend on the extent of surgery; recovery often takes weeks to months.
Postoperative radiotherapy usually starts once the wounds have healed. Radiotherapy can cause shrinkage, stiffening and loss of volume in the flap, and healing is slower in previously irradiated tissue.

Follow-up

Follow-up runs alongside cancer check-ups and is carried out by a multidisciplinary team. Depending on the centre, this team may include head and neck surgery, plastic and reconstructive surgery, oral and maxillofacial surgery, prosthodontics, speech and swallowing therapy, dietetics, physiotherapy and oncology.

The flap and donor site are checked, and wound healing, sensory changes and restricted movement are monitored.
Speech and swallowing therapy and nutritional support continue until a safe return to oral feeding and beyond.
An obturator is adjusted or remade as the tissues heal and change shape.
In patients who have had radiotherapy, regular dental check-ups are important to prevent and detect jawbone problems early.

Frequently asked questions

No. The main aim is to preserve functions such as swallowing, speech and breathing after cancer surgery and to cover vital structures. Preserving appearance is also a goal, but it is considered together with function.

The donor site is chosen to keep loss of function to a minimum. There may be a scar, reduced sensation and temporarily limited movement; after a fibula flap, walking may need physiotherapy for a while. Possible effects are discussed in detail before surgery.

Yes. Healing is slower in irradiated tissue and the risk of problems such as fistula may be higher, so transfer of healthy, well-vascularised tissue may be preferred. Postoperative radiotherapy can cause the flap to shrink and stiffen over time.

Both methods can be effective. Advantages of an obturator include a shorter operation and direct inspection of the surgical cavity at check-ups, while flap repair avoids the need to insert and remove a prosthesis. Defect size, dental status, general health and personal preference are weighed together.

This depends on the extent of the operation and on healing. Oral feeding is started gradually after a speech and swallowing therapist confirms that swallowing is safe; a feeding tube may be used until then.

Sources

The general information on this page is based on the guideline and institutional sources below. Individual diagnosis and treatment decisions require an examination.

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