The Future of Head and Neck Reconstruction

Micah K. Harris, MD, Joshua D. Smith, MD, Kevin Contrera, MD, Shaum Sridharan MD, Steven Chinn, MD, and Matthew E. Spector, MD, on behalf of the Head and Neck Surgery & Oncology Committee

April is recognized as Head & Neck Cancer Awareness Month, an initiative to encourage adults who are at high risk for head and neck cancer to take advantage of the nationwide and international free screenings. A key message of the campaign is that early diagnosis is key to successful treatment of these types of cancers.

Free flap reconstruction for head and neck anomalies has drastically evolved since its introduction in the 1950s. Historically focused on defect obliteration, modern free flap reconstruction prioritizes restoration of form and function. An expansile repertoire of tissue donor sites are now available to the reconstructive surgeon, such as fibular, anterolateral thigh, subscapular system, lateral arm, and medial sural artery perforator flaps. As patients continue to live longer with cancer, optimizing postoperative quality of life (QOL) has become highly relevant. A recent review by Gosselin et al. highlighted a sharp increase in articles focused on QOL after free flaps since 2010.¹ Empowered by this patient-centric data, microvascular surgeons have an exciting opportunity to optimize patient outcomes by pursuing customized reconstruction.

A precision reconstruction method for free flaps prioritizes the “right flap for the right patient.” Within this framework, unique patient factors should be considered, such as BMI and adipose tissue distribution, which can influence flap volume and contour. The patient’s lifestyle and priorities should be considered, including their occupation, hobbies, social circumstances, and aesthetic concerns. Along these lines, novel flap approaches continue to emerge. For example, a “high fibula” osseous flap can be harvested to preserve the flexor hallucis longus, and a second fasciocutaneous flap (e.g., parascapular flap) with a flow-through anastomosis may be added for composite defects.² As reconstructive techniques continue to be re-evaluated through the lens of QOL, the value of patient-reported outcome measures will become paramount.

Reprint permission granted by University of Pittsburgh Head and Neck.The efficiency of free flap surgeries has dramatically improved as well. Surgeries that used to take a day can now be done in a matter of hours. Virtual surgical planning and computer-aided 3D design permits significant improvements in intraoperative efficiency for bony mandibular and midface defects.³ Integrated two-team surgical approach to microvascular reconstruction significantly shortens operative time, in which one surgeon performs ablation while a co-surgeon simultaneously raises the flap, followed by inset and anastomosis.⁴ The “jaw in a day” technique leverages 3D-printed patient implants to permit dental rehabilitation during mandible reconstruction in a single stage, eliminating the need for a second surgery.⁵ These improvements in surgical efficiency are critical, as they minimize the time under general anesthesia, reduce perioperative risk factors, and cheapens operative and perioperative costs.

The next frontier of innovation in free flap reconstruction will prioritize custom, patient-specific reconstruction that accounts for the unique anatomic, functional, aesthetic needs of each patient. As we continue to evolve as a field, thoughtful donor site selection with careful consideration of QOL and patient-reported outcomes will ensure a holistic, patient-centric approach to “precision reconstruction.

Check here for more Academy resources on Head & Neck Cancer Awareness Month.

References

1. Gosselin LE, Villemure-Poliquin N, Audet N. Quality of Life After Head and Neck Cancer Surgery and Free Flap Reconstruction: A Systematic Review. J Otolaryngol Head Neck Surg. 2024;53:19160216241248666. https://doi.org/10.1177/19160216241248666
2. Staricha KL, Smith JD, Raad RA, Sridharan S, Contrera KJ, Chinn SB, Spector ME. Next generation of head and neck free flap reconstruction: the future of innovation and refinement. Curr Opin Otolaryngol Head Neck Surg. 2025;33(5):324-30. https://doi.org/10.1097/MOO.0000000000001077
3. Marchiano E, Stevens JR, Liao E, Rosko AJ, Powell AR, Chinn SB, Stucken CL, Spector ME. Three-dimensional modeling of the scapular tip for anterolateral and lateral mandibular defects. Oral Oncol. 2020;107:104718. https://doi.org/10.1016/j.oraloncology.2020.104718
4. Yalamanchi P, Peddireddy NS, McMichael B, Keilin C, Casper KA, Malloy KM, Moyer JS, Prince MEP, Rosko AJ, Stucken CL, Spector ME, Chinn SB. Team-Based Surgical Approach to Head and Neck Microvascular Free Flap Reconstruction. JAMA Otolaryngol Head Neck Surg. 2023;149(11):1021-6. https://doi.org/10.1001/jamaoto.2023.3028
5. Ong A, Williams F, Tokarz E, Shokri T, Hammer D, Ducic Y. Jaw in a Day: Immediate Dental Rehabilitation during Fibula Reconstruction of the Mandible. Facial Plast Surg. 2021;37(6):722-7. https://doi.org/10.1055/s-0041-1732478