Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting major reconstruction of the head and neck, defect-oriented approach to free tissue transfer. Joining me is Dr. Austin Lam. He's an assistant professor in the Division of Head and Neck Oncology and Microvascular Reconstructive Surgery in the Department of Otolaryngology, Head and Neck Surgery at the University of Florida College of Medicine.

Dr. Lam, thank you so much for joining us today. I'd like you to start by setting the table for us. What makes head and neck cancer so challenging and unique? What are some of the after effects of these types of treatments? How does it affect the daily lives of patients, their families. As long as we're talking about microvascular reconstruction, let's talk about why we would need that in the first place.

Dr. Austin Lam: Absolutely. Thank you so much for having me. So, head and neck cancer is a bit unique in that it occurs within the head and neck, and the head and neck is really the way that we communicate with the world. So, cancers in the head and neck, defects in the head and neck, they affect our ability to communicate, to speak, to swallow, to breathe. Basically, all the things that we do in our day to day lives that make us humans, these cancers affect them.

Melanie Cole, MS: Well, as you said, Dr. Lam, cancers of the head and neck region can really have devastating effects on appearance, function of the patient, and are among some of the most disabling and socially isolating defects, really affecting the quality of life. Tell us a little bit about how endoscopic instrumentation coupled with improved imaging, intraoperative imaging, and localization techniques have really changed the landscape of what you do.

Dr. Austin Lam: So, in my practice, I do some endoscopic work. More specifically, I do a fair bit of robotic work. So, cancers of the oropharynx and hypopharynx, that's the back of the throat just behind the voice box. Previously, we would have to do what we call lip-split mandibulotomy, where we would have to actually cut a lip, cut the mandible in half, and really open the face up in order to access those areas. With the robot, we're able to access those areas just going through the mouth without having to add the morbidity of cutting through the face in order to access those. Most of the surgeries that I do are open approaches surgeries that we can't get to with the endoscopes. But some of my colleagues, especially in Rhinology and Laryngology, do a lot of surgery with the endoscopes that would have previously only been able to be accessed with open approaches.

Melanie Cole, MS: It's really quite an exciting field you're in. Give us an overview of what the defect-oriented approach to free tissue transfer involves in the context of head and neck reconstruction. Give us a little overview of that.

Dr. Austin Lam: Absolutely. So, a defect oriented approach is really a mindset. It's a thoughtful approach to determining how best to reconstruct a defect. Many years ago, surgeons would use only local or regional flaps to do a reconstruction and they were limited in their choices really with just basically putting pieces of muscle to fill a hole. Today, we think about the form and the function of the areas that we're reconstructing. And we have a really a wide variety of free tissue transfer options to best fill a defect and provide a patient with the best form, the best functional outcome that we can.

Melanie Cole, MS: Well, then how do you choose between those different options? Give us some considerations you employ when you're assessing those reconstructive options.

Dr. Austin Lam: A lot of things we think about are, one, do we need soft tissue or do we need bone? That's kind of one of our first big determinations in what to use. There are several free flap options that we have available to us where we can bring up bone from either the fibula or the scapula. Those are really our main ones, and then we think about how much tissue we need. There are some flaps where we can provide just little bit of skin, that is very pliable. We can turn it into tubes, and there are other free flap options that we have that really can help to provide us with a lot of bulk to help to maybe bring the tongue all the way up to the palate so that the patient has better speech and swallow outcomes. Or if we need to fill the floor of mouth, we have these very pliable tissue options like the radial forearm free flap where we can help to allow the tongue to be nice and mobile.

Melanie Cole, MS: I'd like you to speak to other providers, Dr. Lam, with your technical expertise in this area. Speak a little bit about some of the tech considerations, advantages and drawbacks commonly employed free tissue options you were just describing.

Dr. Austin Lam: So, I'd say some of the more commonly employed free flaps that we use, probably the most common one is the radial forearm free flap. That's a soft tissue only, a very thin pliable flap from the forearm. It has a very reliable blood supply on the radial artery. It's nice and pliable so you can bring it up and you can fold it into a very small area. But the drawback is that it's not a very large flap. So if you need to fill a defect where you need a lot of volume, it's not going to give you that volume. Another drawback is the donor site morbidity, because there's not a lot of additional tissue from the forearm in order to close the secondary defect that you create when you're raising the flap. We often have to take a skin graft from the thigh, and that takes quite a while to heal. There can also be exposed tendon from using that free flap.

On the other hand, we have the anterolateral thigh flap, which comes from the upper thigh of a patient. It can be thinned out nicely with a perforator dissection, so we can actually dissect this very small, tiny vessels that supply the skin to make it nice and thin. But on the other hand, we can make it really bulky, and it has very, very little donor site morbidity because there's plenty of tissue in those patients' thighs in order to close that secondary defect.

Other common flaps we have the scapular system flaps, where we can bring up bone with the flap, and we can make a chimeric flap with other tissue in the area, like the latissimus latissimus muscle we can bring up with that flap, and the skin from the back, which provides us with really a lot of options. However, the scapula bone is not near as dense or large as a fibula, which is another bony flap that we use. So, it's not very good for dental implants if you want to give patients teeth after their free flap. It doesn't really provide good dental restoration options, but it has very little donor site morbidity in contrast to the fibula free flap, which provides really good dense bone that you can put teeth into. But like the forearm free flap, you have to do a skin graft. And with many of our patients who are not in fantastic health, their lower extremities often don't heal very well. So, we have to take that into consideration as well.

Melanie Cole, MS: Expanding on that and patient selection for this, potential complications, Dr. Lam, of the free tissue reconstruction. When you come across those complications, please tell the listeners what those are and how you mitigate them and manage them as they crop up.

Dr. Austin Lam: Complications after these surgeries are not uncommon. And I always tell my patients when I'm counseling them preoperatively to expect speed bumps along the way. These are big surgeries, often taking eight to 10 hours, and there are many, many things that have to go right after the surgery for everything to go perfectly. Just one little thing to go wrong for there to be a speed bump. So, I tell them to expect those speed bumps.

Typically, we're getting much better with our techniques and most of these complications are quite small, but they can be significant. The one that we think about most is a salivary fistula or a leak coming from the oral cavity, the pharynx through the skin. This is something that we look for, and we watch very closely after the surgeries with our physical exams, and often can be solved with just some wound care, but sometimes it does require an additional surgery in order for us to fix them.

Another complication that we always think about after these surgeries is flap failure. So when we bring the tissue up from whatever part of the body we're bringing it from and we're bringing it to the head and neck, we connect the blood vessels that supply that flap with nutrients to blood vessels in the neck, and those blood vessels are at risk after that initial anastomosis of clotting. So, we often will implant implantable dopplers. And we'll watch that flap very closely every couple hours for the first few days in order to detect early signs of flap failure. If that does occur, hopefully, we're able to detect it early and we're able to bring that patient back to the operating room quickly in order to fix it.

Melanie Cole, MS: Wow. This is a fascinating topic, Dr. Lam, and your expertise is excellent for us to listen to. Thank you so much. As we get ready to wrap up, how important is collaboration with other specialists? What role does multidisciplinary care play in your practice for these complex patients?

Dr. Austin Lam: For these patients, multidisciplinary care is really everything. In order for them to recover after these surgeries, they almost all require a lot of work with speech-language pathologists, with physical therapists, with occupational therapists. Depending on where the tumor is, we very frequently will collaborate with neurosurgeons or other otolaryngologic specialists like laryngologists, rhinologists, and skull base surgeons or otologists. Because, as I stated earlier, tumors in this area often affect many other facets of their day to day life that could be managed by an otologist or laryngologists. And so, working with them is really critical to their recovery.

Melanie Cole, MS: Do you have any final thoughts you'd like to leave other providers with for head and neck reconstruction?

Dr. Austin Lam: Yeah. I'd say always look for those tumors that have a low index of suspicion and refer them early, because treating these cancers and reconstructing them early is always easier than when the tumor gets out of control.

Melanie Cole, MS: Thank you so much, Dr. Lam, for joining us today. To learn more about this and other health care topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.