|Year : 2019 | Volume
| Issue : 1 | Page : 3-5
Head and neck surgery: An evolution
Vijay V Haribhakti
Department of Oncology, Sir H N Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
|Date of Web Publication||26-Jul-2019|
Vijay V Haribhakti
Department of Oncology, Sir H N Reliance Foundation Hospital and Research Centre, Raja Ram Mohan Roy Road, Prarthana Samaj, Girgaum, Mumbai - 400 004, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Haribhakti VV. Head and neck surgery: An evolution. J Head Neck Physicians Surg 2019;7:3-5
When I first decided to pursue a career in head and neck oncology well over a quarter century back, little had I realized the enormity of the decision, or “seen” the important bi-lanes within this huge terrain, or comprehended the need to remain a seeker of knowledge and clarity almost “in perpetuity.”
It is perhaps this very overpowering feeling that compelled me to put down some of my “top of the mind” thoughts into a book, which is focused on outcomes which matter immensely to the patient and the practitioner alike.
This book has been titled “Restoration, Reconstruction, and Rehabilitation in Head and Neck Cancer,” and is intended to reach out to all practitioners, trainees as well as students engaged in the challenge of managing head and neck cancer.
My fundamental background in general surgery and training in surgical oncology almost naturally led the way to head and neck oncology, which I took to “instantaneously.” However, what happened almost simultaneously was a fascination with reconstruction and indeed, restoration of function, esthetics, and productivity. Hence, this book offers a combined perspective, which at a personal level, I believe in passionately. Even if a head and neck surgeon chooses not to pursue or perform reconstruction, a fundamental awareness about the nuances of incision planning and creation of an “optimal defect” are absolutely germane. This book is thus addressed to both, the “excision team” and the “reconstructive team,” and moves beyond both to rehabilitation and evaluation of outcomes which truly define the ultimate result for a given patient.
Beyond any reasonable doubt, one of the most important disciplines to inculcate in ourselves is planning. Whether for resection or reconstruction, fundamental planning is germane.
Incisions and approaches, so crucial to an adequate resection and an optimal outcome, are discussed at great length.
Neck incisions have been considered, underscoring the possibilities with horizontal crease incisions as opposed to vertical and trifurcate incisions, which are not recommended in the current context.
A brief mention about the current approaches to and nomenclature of neck dissections is included to express the present state of the art.
Important factors that govern the adequacy of primary excision, such as mucosal, soft-tissue, and bone margins are included.
In the domain of reconstruction, the importance of complete teamwork and collaborative thinking is stressed.
In addition, essential principles of after-care are discussed to enhance outcomes, minimize complications and re-exploration, and ensure uneventful postoperative recovery. Despite the long and complex surgical procedures frequently needed, it should be possible to minimize hospitalization and get patients ready for adjuvant therapy when indicated.
Clearly one of the most important ingredients of sound planning is excellent imaging, which lends accuracy and reliability to excision planning, evaluation, and follow-up. All the important modalities and their nuances must be comprehended effectively by attending clinicians to do justice at each point of time, by choosing and using the best modality at the appropriate time.
One of the most important needs of any practitioner, student, or trainee in head and neck oncology is an understanding of the physiologic basis of the most fundamental functions of food intake, mastication, speech, and deglutition.
Disruption of these basic functions underlies almost all the morbidity that is encountered in the management of head and neck cancers.
After a recapitulation of normal physiology, illustrated with some highly original schematic drawings to enunciate the phases of deglutition, there is a discussion of alterations that occur following disease and treatment, and the resulting impacts on the patient.
A clear understanding of these processes alone enables the surgeon to devise restorative strategies and the therapist to devise maneuvers to correct altered physiology and help address common morbidities associated with treatment.
The next most important concern is esthetics, given the highly noticeable anatomy of the face and neck.
The concept of esthetic subunits and their importance in the visual impact of facial deformities is discussed. This, along with the fundamentals of incision planning, should give important inputs for planning, which is so essential in every case.
Incisions planned along borders of esthetic subunits heal very well without conspicuous scarring.
Facial symmetry is crucial, and all departures from normal symmetry are very conspicuous.
Facial expression is equally important, and loss of expression, especially if one-sided, is highly visible.
During the reconstruction of various portions of the face, it is important to achieve volume correction in all areas resected. This is crucial to understand the concept of compartmental reconstruction, which contributes significantly to optimal outcomes by the systematic restoration of contour.
Given the already present and progressively escalating use of microvascular reconstruction, it was thought imperative to outline the strategies that lead to consistently high success rates. Exhaustive preoperative evaluation to assess potential risk factors is crucial and includes obtaining a detailed history (comorbidities, smoking, uncontrolled diabetes, extreme old age with severe atherosclerosis, systemic conditions causing hypercoagulability and previous free flap loss), detailed physical examination and careful selection of the best alternative in a given case.
A very detailed plan is made to ensure tension-free anastomosis and absence of kinks and pressure points over anastomosed vessels.
The use of antiplatelet agents is considered helpful in selected circumstances, and a careful postoperative vigil is maintained in all cases. If microvascular thrombosis is suspected, immediate re-exploration is the only way out, as timing is crucial and the patient must be re-explored before the “no reflow” phenomenon sets in, indicating microcirculatory failure.
One of the most cruel yet consistent realities in head and neck cancer is the phenomenon of recurrent disease, rendering it crucial to discuss strategies in such cases.
In general, a short disease-free interval following apparently adequate treatment portends adversely. The details of previous treatment, whether surgery alone or in combination with radiation and chemotherapy, significantly influence the local milieu and the anticipated difficulties in planning appropriate salvage efforts.
All factors must be carefully weighed prior to embarking on an ambitious salvage attempt, and the patient and family counseled at length about the anticipated risks and complications.
In relation to reconstructive techniques, a perspective of all commonly used flaps is presented.
Following an initial discussion of the basics of vascularized tissue transfer, all the commonly employed flaps for head and neck reconstruction are described in a simple, “how-I-do-it” style.
Many important local flaps are described, illustrating their use with relevant patient examples. The salient details of planning and technique of elevation are included, rendering it possible for the reader to pick up important tips for use in clinical situations.
Among the regional flaps, all available alternatives that have been used by the author are described, serving to simplify and demystify all flaps in common use.
For the free flap alternatives described, again all descriptions are rendered in a practical manner to enable all readers to incorporate these important workhorse flaps into regular clinical use.
In summary, it is intended to provide a practical guide to all head and neck surgeons as well as reconstructive surgeons keen to learn the fundamental techniques necessary to master the challenges of head and neck reconstruction.
The approach to various anatomical subsites is presented in individualized accounts, covering the lips, cheek and gums, tongue and floor mouth, mandible, pharynx, mid-face and finally, an individualized approach to unique situations.
All subsite descriptions are organized with an initial section on the fundamental physiologic anatomy, spread patterns and approaches to resection, followed by reconstructive alternatives for increasingly complex requirements, in a defect-based fashion.
The current and possible future role of robotics is addressed with a discussion of the principal advances achieved by robotic technology in the reconstructive context, namely:
- Transoral robotic reconstructive surgery for complex head and neck reconstruction without dividing the lip or mandible
- Robotic microvascular, microneural, and microlymphatic anastomoses, with “supra-human” levels of precision and
- Minimal access harvest of both the latissimus dorsi and rectus abdominis muscles, minimizing donor-site morbidity, and enhancing cosmetic outcomes.
Hugely important issues of morbidities and complications following radiation and chemotherapy are systematically presented. An approach to prevention as well as treatment of these everyday issues and pain is discussed at length.
These issues are an immutable part of the current treatment efforts and must be understood by all in the head and neck team to minimize suffering and provide quality of life, which remains our most important goal.
A special section captures the essence of prosthetic rehabilitation.
All important considerations for the maxillary obturator prosthesis are covered at length, giving the reader a number of technical guidelines to achieve excellent results.
The basics of soft palatal obturators and comparison with surgical reconstruction are addressed.
Trismus, a very common condition in the Indian population, is a very significant problem that needs effective solutions, which are presented in an easily implementable form.
For all patients undergoing radiotherapy, the basics of oncologic dentistry and dental prophylaxis are clearly outlined.
Finally, anaplastology and the creation of external facial, ocular, and auricular prosthesis is touched upon.
In conclusion, the importance of cooperation between the surgical and prosthetic teams is stressed.
In conclusion, quality of life, which is clearly the essential goal for the entire head and neck team, is addressed. It focuses on patient-reported outcomes, which are most crucial and relevant, and provides a context for measuring outcomes realistically.
It is hoped that this book becomes a friend to go to, for every aspiring and practicing member of the head and neck team.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.