Reconstruction of soft tissue defects in the oral cavity and oropharynx.

Abstract

During the decade following its description by Ariyan and Baek et al in 1979, the pectoralis major myocutaneous flap was widely considered to be the “workhorse” flap for reconstruction of major soft tissue defects of the oral cavity and oropharynx. This flap’s reliability and the good to excellent outcome with its use inhibited exploration of other more versatile techniques of reconstruction. Although the first microscope-assisted transfer of a free flap was reported in 1973, and microvascular head and neck reconstruction was described in 1976, initially there was limited enthusiasm in the United States to apply free flaps for head and neck reconstruction. This reluctance arose from several perceived potential shortcomings of microvascular tissue transfer. Such concerns included questions regarding the reliability of a technique that was dependent on smallvessel vascular anastomoses for a successful outcome and the potential for an adverse impact on the costs and complications of therapy. The pectoralis major myocutaneous flap was the preferred method for reconstruction of significant soft tissue defects at our institution until the late 1980s, when initial efforts were undertaken to investigate the potential utility of free flaps for head and neck reconstruction. Initially, free flaps were only chosen for reconstruction of selected patients for whom our previous reconstructive efforts using regional flaps had been disappointing (eg, patients with segmental defects of the anterior mandibular arch). During the past decade, our favorable experience with microvascular free tissue transfer has resulted in an evolution of our reconstructive philosophy, so that free flaps are now the preferred method of soft tissue reconstruction when primary mucosal repair or skin grafting would be insufficient in patients who undergo surgical therapy for cancers of the oral cavity and oropharynx. This includes patients with soft tissue resection of many T2 and most T3/T4 tumors, as well as some patients who undergo lateral composite mandibulectomy, in whom a soft tissue free flap is used in conjunction with a bridging mandibular reconstruction plate. We will review our experience with soft tissue free-flap reconstruction of the oral cavity and oropharynx and compare it with the results of regionalflap and free-flap reconstruction reported in the literature to determine whether our current reliance on free flaps is justified. PRO