Head and Neck Reconstructive Surgery
Core concepts
Head and neck reconstruction after ablative surgery is driven by defect anatomy and functional goals: oral competence, speech, swallowing, airway, and contour. Master the classification of mandibular and maxillary defects (e.g., segmental vs marginal mandibulectomy; maxillectomy classes), and match reconstruction to them-free fibula for segmental mandible, scapular/DCIA alternatives, obturator vs free flap for maxillectomy. Know pharyngoesophageal reconstruction options (tubed fasciocutaneous free flap, jejunum, gastric pull-up) and the trade-offs in fistula rate and speech. Understand recipient vessel selection in the neck after prior surgery/radiation and the role of vein grafts. Know when to use regional pedicled flaps (pectoralis major, submental, supraclavicular) versus free tissue transfer.
Traps
Questions frequently hinge on bone vs soft tissue needs and on radiation history. A previously irradiated neck raises fistula and wound-healing risk and may push toward free tissue with healthy recipient vessels outside the field. Another trap is confusing marginal vs segmental mandibulectomy indications-marginal preserves continuity and often needs no bone flap. Distinguish maxillectomy obturator (good for poor-performance patients, allows inspection) from free flap (better for large, irradiated, or dentate patients).
Worked example / rule of thumb
Segmental mandibulectomy crossing the midline or >6 cm: free vascularized bone (fibula) with reconstructive plate backup. Rule of thumb: bone defect → bone flap; through-and-through soft tissue → pliable fasciocutaneous flap; irradiated bed → bring healthy vascularized tissue.