Aesthetic Considerations Following Successful Free Flap Coverage of Head and Neck Defects

Microsurgical free flap reconstruction for head and neck defects has become widespread in many centers worldwide. The survival rate for these free flaps reaches 97%. However, complete and total reconstruction entails not only successful coverage of the defect, but also reintegration of the patient into society. This paper emphasized the importance of continuously considering improvement of facial aesthetics even after successful coverage of head and neck defects.

Eighteen patients who had previously undergone successful free flap coverage of cheek and lip defects following oral cavity cancer resection underwent further surgeries for aesthetic indications. Fourteen had previously received single free flap coverage (8 radial forearm, 5 fibula osteocutaneous, and 1 ALT) and 4 had double free flaps (fibula osteocutaneous and an ALT flap). Bone defects ranged from 6 to 13 cm, skin defects from 4 × 5 cm to 15 × 12 cm. Bulkiness of cheek flaps comprised the majority of patient complaints during follow-up (78%), while the rest complained of lip and cheek flap depression and contracture.

Fourteen patients complained of bulky flaps and underwent serial partial excisions of the cheek flaps in 1 to 3 stages, mostly under local anesthesia. Three of these patients had their cheek flaps (initially from 4 × 5 cm to 8 × 8 cm) totally excised at a third-stage procedure. The earliest staged flap excision was performed 6 months after treatment (with or without RT), and carried on at a minimum interval of 3 months. Cheek and lip contractures were handled in various procedures. Two underwent release of scar contractures with z-plasties. Another had a fat graft injection performed 2 years later to augment a cheek defect. Two patients with cheek contracture were managed by replacing the deformity with a free ALT flap, 8 months and 3 years after surgery, respectively. One of them, who also had an ipsilateral facial palsy as a sequela of radical ablative surgery, had his whole cheek aesthetic unit replaced by a free ALT flap with a tendon zygomatic sling. All patients reported an improvement and better satisfaction with the results.

Reconstruction of oral cavity defects should not end with just successful coverage and acceptable function. The ultimate goal should be total rehabilitation of the patient and reintegration into society. With this in mind, a re-evaluation of the patient's aesthetic complaints should be constantly undertaken in hopes of further improving patient self-esteem and confidence.