Conclusion

Although the authors have highlighted the impact of free tissue transfer on three reconstructive problems in the head and neck, it is evident that the management of many other defects has been greatly effected. Reinnervated free muscle flaps have been shown to restore mimetic activity to the paralyzed face.55,56 Sen-sate flaps have provided valuable information to the patient to avert the effects of relining the upper aerodigestive tract with anesthetic tissue.57,58 Vascularized bone-containing flaps have been applied to the midface region to reconstruct the palate in a manner similar to that which has been achieved in the mandible.59 The use of free tissue transfer has pushed the envelope of partial laryngectomy surgery to the next level.

However, despite these advances, which have occurred over the past decade, the goal of these efforts has been to use the entire body as the source of tissue to most closely match the characteristics of the missing part in the head and neck. With the first successful laryngeal transplantation having been achieved in a human subject by Marshal Strome and his colleagues, the ability to match missing parts with comparable tissues from a different donor has now been realized. At Mount Sinai, we have been working on the reconstruction of long segment tracheal defects with a tracheal transplant. It is evident that the ability to transplant organs in the head and neck successfully is now possible. The return of function when dynamic activity and sensory feedback are important factors in functional recovery of such organs as the larynx and the tongue remains a major issue, as do issues related to immunosuppression. However, it is clear that head and neck reconstruction will take a new direction in the new millennium.

REFERENCES

Genden and Urken—CHAPTER 13

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13. Baek SM, Lawson W, Biller HF. Reconstruction of hypophar-ynx and cervical esophagus with pectoralis major island myocutaneous flap. Ann Plast Surg 1981;7:18-24

14. Heimlich HJ. Reversed gastric tube (RGT) esophagoplasty for failure of colon, jejunum and prosthetic interpositions. Ann Surg 1975;182:154-160

15. Mes G. A new method of esophagoplasty. J Int Coll Surg 1948;11:270

16. Leonard J, Maran AG. Reconstruction of the cervical esophagus using esophagus via gastric anastomosis. Laryngoscope 1970;80:849

17. Hiebert C, Cummings GO. Successful replacement of the cervical esophagus by transplantation and revascularization of a free graft of gastric antrum. Ann Surg 1961;154:103-106

18. Harii K, Ebihara S, Ono I, Saito H, Terui S, Takato T. Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 1985;75: 463-476

19. Harii K, Iwaya T, Kawaguchi N. Combination myocutaneous flap and microvascular free flap. Plast Reconstr Surg 1981;68:700-711

20. Hayden R. Reconstruction of the hypopharynx and the cervical esophagus. In: Cummings C, Harker LA, et al., eds. Otolaryn-gology-Head and Neck Surgery. St. Louis: CV Mosby; 1993

21. Li KK, Salibian AH, Allison GR, et al. Pharyngoesophageal reconstruction with the ulnar forearm flap. Arch Otolaryngol Head Neck Surg 1998;124:1146-1151

22. McDonough JJ, Gluckman JL. Microvascular reconstruction of the pharyngoesophagus with free jejunal graft. Microsurgery 1988;9:116-127

23. Takato T, Harii K, Ebihara S, Ono I, Yoshizumi T, Nakatsuka T. Oral and pharyngeal reconstruction using the free forearm flap. Arch Otolaryngol Head Neck Surg 1987;113:873-879

24. Blocker TS, Stout RA. Mandibular reconstruction during World War II: a review of the literature. Plast Reconstr Surg 1949; 4:153-156

25. Parel SM, Drane JB, Williams EO. Mandibular replacements: a review of the literature. J Am Dent Assoc 1977;94:120-129

26. Conley J. A technique for immediate bone grafting in the treatment of benign and malignant tumors of the mandible and the review of 17 consecutive cases. Cancer 1953;6:568-577

27. Snyder C, Bateman JM, Davis CW, et al. Mandibulofacial restoration with live osteocutaneous flaps. Plast Reconstr Surg 1970;45:14-19

28. Conley J. The use of composite flaps containing bone for major repairs in the head and the neck. Plast Reconstr Surg 1972;49:522-526

29. Barnes DR, Ossoff RH, Pecaro B, Sisson GA. Immediate reconstruction of mandibular defects with a composite stern-ocleidomastoid musculoclavicular graft. Arch Otolaryngol 1981;107:711-714

30. Gullane PJ, Holmes H. Mandibular reconstruction. New concepts. Arch Otolaryngol Head Neck Surg 1986;112:714-719

31. Klotch DW, Prein J. Mandibular reconstruction using AO plates. Am J Surg 1987;154:384-388

32. Gullane PJ. Primary mandibular reconstruction: analysis of 64 cases and evaluation of interface radiation dosimetry on bridging plates. Laryngoscope 1991;101(pt 2):1-24

33. Ostrup LT, Fredrickson JM. Reconstruction of mandibular defects after radiation, using a free, living bone graft transferred by microvascular anastomose. An experimental study. Plast Reconstr Surg 1975;55:563-572

34. McKee DM. Microvascular bone transplantation. Clin Plast Surg 1978;5:283-292

35. Daniel RK. Free rib transfer by microvascular anastomoses [letter]. Plast Reconstr Surg 1977;59:737-738

36. Ariyan S. The viability of rib grafts transplanted with the periosteal blood supply. Plast Reconstr Surg 1980;65:140-151

37. Baker SR, Sullivan MJ. Osteocutaneous free scapular flap for one-stage mandibular reconstruction. Arch Otolaryngol Head Neck Surg 1988;114:267-277

38. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71-79

39. Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978;1:346-371

40. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530-545

41. Moscoso JF, Keller J, Genden E, et al. Vascularized bone flaps in oromandibular reconstruction. A comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants. Arch Otolaryngol Head Neck Surg 1994;120: 36-43

42. Urken ML, Buchbinder D, Weinberg H, et al. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients [see comments]. Laryngoscope 1991;101:935-950

43. Lawson W, Baek S, Loscalzo L, et al. Experience with immediate and delayed mandibular reconstruction. Laryngoscope 1988;92:5-10

44. Duncan MJ, Manktelow RT, Zuker RM, Rosen IB. Mandibular reconstruction in the radiated patient: the role of osteocutaneous free tissue transfers. Plast Reconstr Surg 1985;76:829-840

45. Urken ML. Composite free flaps in oromandibular reconstruction. Review of the literature. Arch Otolaryngol Head Neck Surg 1991;117:724-732

46. Urken ML, Buchbinder D, Weinberg H, Vickery C, Lawson W, Biller HF. The internal oblique-iliac crest free flap in composite defects of the oral cavity involving bone, skin, and mucosa. Laryngoscope 1991;101:257-270

47. Moscoso JF, Urken ML. The iliac crest composite flap for oromandibular reconstruction. Otolaryngol Clin North Am 1994; 27:1097-1117

48. Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 1998;124:46-55

49. Wilson KM, Rizk NM, Armstrong SL, Gluckman JL. Effects of hemimandibulectomy on quality of life. Laryngoscope 1998; 108:1574-1577

50. Basteiro J, Aki FE, Ferreira MC, et al. Free flap reconstruction of tumors involving the cranial base. Microsurgery 1994;15:9-13

51. Urken ML, Turk JB, Weinberg H, Vickery C, Biller HF. The rectus abdominis free flap in head and neck reconstruction [comment]. Arch (OtolaryngolHead Neck Surg 1991;117:1031

52. Izquierdo R, Leonetti JP, Origitano TC, al-Mefty O, Anderson DE, Reichman OH. Refinements using free-tissue transfer for complex cranial base reconstruction. Plast Reconstr Surg 1993;92:567-574; discussion 575

53. Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base reconstruction. Plast Reconstr Surg 1996;98:1159-1166; discussion 1167-1168

54. Clayman GL, DeMonte F, Jaffe DM, et al. Outcome and complications of extended cranial-base resection requiring microvascular free-tissue transfer. Arch Otolaryngol Head Neck Surg 1995;121: 1253-1257

55. Rubin L. Reanimation of the Paralyzed Face. St. Louis: CV Mosby; 1977

56. Aviv JE, Urken ML. Management of the paralyzed face with microneurovascular free muscle transfer. Arch Otolaryngol Head Neck Surg 1992;118:909-912

57. Urken ML. The restoration or preservation of sensation in the oral cavity following ablative surgery. Arch Otolaryngol Head Neck Surg 1995;121:607-612

58. Urken ML, Weinberg H, Vickery C, Biller HF. The neurofas-ciocutaneous radial forearm flap in head and neck reconstruction: a preliminary report. Laryngoscope 1990;100(pt 1): 161-173

59. Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 1994;120: 633-640

60. Deschler DG, Doherty ET, Reed CG, Anthony JP, Singer MI. Tracheoesophageal voice following tubed free radial forearm flap reconstruction of the neopharynx. Ann Otol Rhinol Laryngol 1994;103:929-936

61. Blackwell KE, Buchbinder D, Urken ML. Lateral mandibular reconstruction using soft-tissue free flaps and plates. Arch Otolaryngol Head Neck Surg 1996;122:672-678

The goals of head and neck reconstruction have been to ensure primary wound healing and to maximize functional restoration while minimizing patient morbidity. During the past two decades, the use of modern microvascular free-tissue transfer has revolutionized the reconstruction of large defects in the head and neck. By enabling reliable one-stage reconstruction, microvascular free-tissue transfer has expanded the limits to which extirpative techniques can reasonably be applied in the head and neck.1 Although, in expert hands, the success of these free flaps is greater than 95% with low morbidity,2-13 questions regarding their suitability in older patients,14-18 as well as their cost-effectiveness19'20 and superiority over conventional techniques,21-28 continue to be raised.

At the Department of Otolaryngology, University of Pittsburgh School of Medicine, we have amassed extensive experience with the use of microvascular free-flap reconstructions of deficits in the head and neck. Our published experience of more than 300 free flaps was one of the largest in the English literature with a greater than 90% success rate and described the factors responsible for the success of free flaps in our institution.2 Some of the keys to the consistent success of free flaps in our experience have been appropriate patient selection, choosing the most appropriate flap for each defect, meticulous preoper-ative and postoperative management, and a close working relationship between the oncologic and reconstructive surgical teams. Although we do not use free flaps in all cases, microvascular free-tissue transfer, when used appropriately, represents the most reliable, cost-effective, and functional state-of-the-art technique for reconstruction of defects in the head and neck.

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