RECONSTRUCTIVE SURGERY: BONY FREE FLAPS This infrmatin aims t help yu understand the peratin, what is invlved and sme cmmn cmplicatins that may ccur. It may help answer sme f yur questins and help yu think f ther questins that yu may want t ask yur cancer care team; it is nt intended t replace advice r discussin between yu and yur cancer care team. AN OVERVIEW TO RECONSTRUCTIVE SURGERY USING BONY FREE FLAPS Surgery fr head and neck cancer can lead t sme majr changes in the appearance f yur head and neck, and in functins such as eating, talking and breathing. RECONSTRUCTIVE SURGERY: may be needed t rebuild the area if a large area f tissue r bne was remved during surgery. will be planned by cnsidering: hw t get the tissue t heal quickly, t avid a lng stay in hspital hw best t prtect vital rgans, such as majr bld vessels what is safe hw yu will lk fllwing the surgery hw best t imprve functins such as speaking, breathing, chewing and swallwing. There are different ways f rebuilding the tissue including: Skin grafts a layer f skin laid n the wund Lcal flaps mving tissue with a bld supply frm next t the wund Reginal flaps mving tissue n a stalk (bld vessels) frm smewhere near the head and neck, like the chest Free flaps mving tissue frm smewhere else in the bdy with its wn bld vessels. This includes bne and sft tissue free flaps. 1
BONY FREE FLAPS: are ften used after surgery t remve cancers frm the upper and lwer jaw, they are called bny because they invlve taking bne frm smewhere else in the bdy. ften include sft tissue like skin and muscle, t frm a seal ver the bne. This is called a cmpsite free flap. use tissue frm anther part f the bdy such as the lwer leg, hip, back r frearm. The area where the flap is taken frm is called the dnr site. Are different t bne grafts because they have their wn bld supply called the pedicle (an artery and a vein frm its riginal lcatin) which is mved with the bne t keep it alive invlves specialised surgery under the micrscpe (micrvascular anastmsis) s that the bld vessels f the flap are cnnected t the bld vessels in the neck. require a team f surgens with special expertise and takes many hurs t perfrm. A multidisciplinary team is ften invlved in planning and undertaking the peratin and helping yu recver after the peratin. TYPES OF BONY FREE FLAPS: There are many different types f bny free flaps. They use different types f tissue depending n what is needed fr the recnstructin. Sme f the cmmn flaps include: Fibula flap: Uses the bne frm the utside f the lwer leg called the fibula. Usually the skin ver the bne and sme f the surrunding muscle is included with the bne. The fibula bne is lng and thin. It can be safely used because there are tw bnes in the lwer leg. The ther bne, called the tibia, is very strng. The fibula is the mst cmmn flap used t recnstruct the lwer jaw after a mandibulectmy. Usually a skin graft is needed t cver the area where the flap was taken frm (dnr site). A plaster is ften put n the leg until the skin graft takes. Remval f the fibula shuld nt affect the functin f yur leg, thugh yu may have sme difficulty raising yur big te. The scar is quite nticeable if yu wear shrts. Iliac crest r deep circumflex iliac artery (DCIA) flap: Uses bne frm the pelvis called the iliac crest. Usually this is either cmbined with muscle frm the abdmen (internal blique muscle) r skin ver the bne. The iliac crest is brad and thick. It can be safely used because the pelvic bnes are very large and strng. The iliac crest 2
is cmmnly used t recnstruct the lwer jaw after a mandibulectmy r the upper jaw after a maxillectmy. The dnr site is clsed directly s n skin graft is needed but a synthetic mesh may be used t replace the internal blique muscle t prevent hernias. Remval f the iliac crest shuld nt affect the functin f yur hip, but it may be painful t walk fr a few weeks. The scar is well hidden by clthes but there may be a nticeable hllwing in the area where the bne was taken if yu wear a bikini. Scapula flap: Uses bne frm the wing-bne (scapula) n yur back. Usually this is cmbined with muscle r skin frm the same area. The scapula is brad but quite thin, cmpared t the iliac crest. It can be safely used because it avids areas that are imprtant fr shulder mvement. The scapula is less cmmnly used than the fibula but can be used t recnstruct the lwer jaw after a mandibulectmy r the upper jaw after a maxillectmy. The dnr site is clsed directly s n skin graft is needed and the scar is well hidden by clthes. Remval f part f the scapula will restrict yur shulder mvement fr a mnth r tw after the surgery but this shuld return t nrmal in the lng term. The scapula is a gd ptin in patients wh have peripheral vascular disease r difficulty walking because it avids the leg and hip regins. Radius flap: Uses bne frm the frearm called the radius. Usually this is cmbined with skin frm the frearm called the radial frearm flap, which is ne f the mst cmmn sft tissue free flaps. The radius is a very imprtant bne and s nly a small prtin can be taken fr use elsewhere and smetimes a plate is put n the remaining bne t prevent it breaking. The radius can be used t replace smaller prtins f the upper and lwer jaw bnes and ther areas f the face. The dnr site is usually clsed with a skin graft. Remval f part f radius shuld nt affect the functin f yur frearm r hand. The scar is quite nticeable if yu wear a shrt sleeve shirt. 3
WHY IS A BONY FLAP NEEDED? There are a several reasns why a bny free flap is used. These include: The hle (defect) is t large t clse reliably with a bne graft r prsthetic material The tissue will nt functin well withut a flap, such as: Restring yur ability t speak and chew when the jaw bne is remved Maintaining the psitin f the eye when part f the eye scket is remved Prviding bne that implants can be placed int t supprt a denture Yur appearance will be affected withut a flap, such as when the bne that prvides the cntur f yur face has been remved. The tissue is unlikely t heal withut a flap, such as when yu have had previus raditherapy r many peratins Recnstructive surgery may be perfrmed at the same time as the primary surgery, r at a later date. Yur dctr will discuss these ptins with yu. HOW TO PREPARE FOR THE OPERATION Befre the peratin: Yu will need t fast (have nthing t eat r drink) fr 6 hurs befre yur peratin (unless advised differently by yur surgen r anaesthetist) because the recnstructive surgery is perfrmed under a general anaesthetic (yu will be asleep and will nt remember what happens during the peratin). Yur surgen will explain the details f yur peratin. Be sure t bring up any questins r cncerns, and share yur needs and wishes with yur cancer care team (see bx). Pssible questins that yu may want t ask yur cancer care team What are the side effects f taking tissue frm anther part f the bdy (dnr site)? If I have a flap taken frm smewhere else, hw will it lk in its new lcatin? Can the flap replace the nrmal functin f the tissue it is replacing? What will the dnr site lk like? I d manual labur, will the flap affect my ability t wrk? I enjy sme sprts, will the flap affect my ability t place sprt? Are there any things I will find mre difficult t d as a result f the flap? Is there an alternative dnr site that will have less side effects fr me? Will I be able t feel the skin f the flap? Hw ften d these flaps succeed r fail? Additinal questins are listed at the end f this factsheet. 4
If yu are having a flap taken frm yur arm, make sure that a drip (intravenus cannula) is NOT placed in the same arm Let yur surgen knw if yu have had: Prblems with the bld vessels in yur arms r legs such as blcked arteries r clts in the legs (deep venus thrmbsis - DVT) Previus surgery in the area where the flap will be taken frm (dnr site) Let yur surgen knw if: Yur wrk invlves manual labur that culd be affected by the flap Yu enjy sprts that culd be affected by the flap Yur career depends n hw yu lk r speak Yu shuld speak t yur dctr abut hw t manage aspects f yur lifestyle, such as smking, drinking alchl and chrnic cnditins (e.g. diabetes and besity) that may increase the risk f cmplicatins. If yu take bld thinning medicatin fr a heart cnditin r bld clts (such as Warfarin, Plavix, Aspirin r Pradaxa), make sure yur surgen is aware. Sme f these medicatins need t be stpped mre than a week befre the peratin. Smetimes a shrt-acting bld thinner (such as Clexane) is used befre and after the surgery. Talk t yur cancer care team abut any likely side effects t expect fllwing the peratin, such as speech, swallwing, breathing and appearance. Yu may find it useful t talk t a dietitian, speech pathlgist r specialist head and neck nurse abut these issues. Visit the Beynd Five website fr further infrmatin n the health prfessinals wh may be part f yur cancer care team 5
WHAT TO EXPECT DURING THE OPERATION Recnstructive surgery may be dne at the same time as the primary surgery fr the remval f yur cancer. Smetimes it is dne mnths r years after the riginal cancer surgery. Visit the Beynd Five website fr further infrmatin abut the specific surgery yu are having fr yur particular cancer and fr questins t ask yur dctr. Bny free flap surgery invlves: Finding suitable bld vessels in the neck t jin t the flap. Preparing the bne flap frm a suitable part f the bdy; this may include a piece f skin and smetimes muscle, alng with the bne and its bld vessels. The chice f the dnr site depends n the defect needed t be repaired. The bne flap is transferred t the defect in the head r neck regin needing repair and the dnr site is clsed using stitches r smetimes a skin graft. The bld vessels f the bne flap are cnnected t vessels in the neck using micrvascular surgical techniques (very small sutures and a micrscpe). The surgery may take several hurs; during this time in the perating theatre yu will be kept warm and prtected frm getting pressure sres. If the recnstructive surgery invlves areas such as the muth, lwer jaw bne, neck r thrat, a trachestmy (r pening) may be made in the windpipe assist with breathing after the surgery. WHAT TO EXPECT AFTER THE OPERATION After the peratin, nce yu are fully awake, yu will be mved t a bed in the hspital r intensive care unit. Yur treatment team will carefully lk after and check the flap by: carefully checking the clur and warmth f the flap. Using a Dppler (special ultrasund) t listed t the bld flwing thrugh the flap Occasinally pricking r scratching the flap t check that it bleeds. Dn t wrry this will nt hurt because the flap des nt have any feeling. Keeping yur head in a neutral (straight psitin) while yu sleep t prevent the bld vessels frm kinking 6
The flap is checked every hur fr a few days s that if a clt develps and there is nt enugh bld flw, this can be fixed immediately befre the flap fails (dies). Yur anaesthetist and surgical team will give yu medicine t help cntrl any pain and nausea after the peratin. Yu may have surgical drains frm the site f the peratin t allw bld r fluid t escape and prevent swelling. These will be remved befre yu g hme. Yur anaesthetist and surgical team will give yu medicine t help cntrl any pain and nausea after the peratin. Yu may als have a buttn t push that delivers strng pain killers (patient cntrlled analgesia, r PCA), r yu may have t ask the nurse fr extra pain medicatin. Yu may have a drip in yur arm t prvide fluid and a feeding tube t help yu receive nutritin. The drips and tubes will be remved when they are n lnger needed and befre yu g hme. Yu may have a breathing tube in yur lwer neck t assist yu breathing. This is called a trachestmy and is usually temprary. This will make it difficult t talk, and yu may need t write things dwn that yu want t say t peple. It is useful t have a pen and paper, mini white bard r ipad/tablet in hspital t write dwn anything yu want t say. Trachestmy tubes need t be suctined regularly t stp them clgging with phlegm and mucus. This will make yu cugh and it can feel uncmfrtable t start with. Visit the Beynd Five website fr further infrmatin n Trachestmy. It can be very difficult t sleep in the first tw days after surgery because f everything ging n. Yu might feel tired, fatigued, upset and get a bit irritated with peple trying t help yu. This is nrmal but it helps t prepare yurself s yu dn t get t frustrated. Mst patients stay in hspital fr arund 1 2 weeks. 7
POSSIBLE RISKS OF RECONSTRUCTIVE SURGERY USING BONY FREE FLAPS All peratins carry sme risks such as bld clts, wund infectins, bleeding, chest infectin, adverse reactins t anaesthetic, and ther cmplicatins. These risks will be explained by yur cancer specialist and anaesthetist. Yur dctr will explain details f the peratin, general risks and side effects f the peratin, they may recmmend: stpping bld thinners (e.g. aspirin) befre surgery t reduce the risk f bleeding a bld thinner (called heparin) may be injected befre and after surgery t reduce the risk f bld clts antibitics t reduce t risk f wund infectin early mbilisatin t reduce the risk f bld clts and chest infectin special stckings t reduce the risk f bld clts. Free flap recnstructins are big peratins but they have becme very cmmn after majr head and neck surgery. Many hspitals d hundreds f these peratins safely every year. There are sme specific risks t be aware f: Clts in the flap (flap failure): The mst serius cmplicatin f free flap surgery is blckage f the bld vessels that prvide bld t the flap t keep it alive. If this happens r is suspected, yu will need t return t the perating theatre t unblck the bld vessels. Despite the best effrts, apprximately 5% f the sft tissue flaps cannt be saved (salvaged). Infectin. The muth and thrat cntains lts f bacteria, which may cause an infectin in the wund after the surgery. The surgen will prescribe antibitics t prevent this ccurring, but if an infectin still ccurs, it might require pening part f the wund t allw any pus t drain ut. Abnrmal pening r fistula: The flap may pull away frm the tissue it was stitched t. This makes a hle which may result in fluid (such as saliva) leaking int the wund causing an infectin. This can be a very serius cmplicatin and might require pening a wund t allw it t drain r anther peratin t fix the seal. 8
Plate cmplicatins: Bny free flaps require metal plates t hld them in place. Usually these plates remain frever but if they get infected, becme visible r break they will need t be remved. Dnr site cmplicatins: Each bne flap has its wn specific risks related t imprtant structures that are nearby. Sme examples are Nerve damage: The nerve that raises the ft wraps arund the fibula bne. If this is injured it will cause a ft drp Fracture: If t much bne is remved frm the radius the bne can cme weak and break. Inadequate bld supply: There are three bld vessels that supply the ft. One f these is remved with the fibula bne. If the ther tw are blcked, then the bld supply t the ft will be cmprmised. Pain: The nerve that gives feeling t the side f the thigh (lateral femral cutaneus nerve) has t be mved during an iliac crest flap. Smetimes this can cause pain the thigh. Wund cmplicatins: Smetimes it can take a lng time fr the dnr site wunds t heal. This is particularly cmmn in the lwer leg if a skin graft is required r if the bld supply is pr. 9
SIDE EFFECTS AND THEIR MANAGEMENT As with all peratins, there is a chance that recnstructive surgery using bny free flap may lead t a number f side effects. Yu may nt experience all f the side effects. Speak with yur dctr if yu have any questins r cncerns abut treatment side effects. Side effects cmmn fr bny free flap surgery may include: Nausea: General anaesthetic may cause nausea. This will settle dwn sn after the peratin and can be treated with medicatins. Sre thrat: Yur thrat may be sre initially because f the breathing tube placed during the peratin. Pain: Yur anaesthetist will give yu pain medicine during the peratin t keep yu cmfrtable when yu wake up, and yu may cntinue n pain medicines t ensure pain is under cntrl. Ensure yu take pain relief medicatins as prescribed by yur dctr and speak t yu cancer care team if the pain is nt under cntrl, gets wrse f if the medicatin causes any side effects. Yu may want t dwnlad further infrmatin abut pain management, which is available n the Beynd Five website. Recnstructive surgery is used t help healing, functin and yur appearance. Despite this sme peple underging recnstructive surgery may als experience: Changes in appearance: Yur appearance may change and it may be hard t accept. Seek supprt frm the cancer care team, and family and friends. Cntacting ther patients thrugh a supprt grup may als assist. Changes in eating and speaking: Cancer surgery may affect eating and speaking s it may be useful t have a tablet/prtable device r pen and paper t write dwn what yu want t say. The speech pathlgist and dietitian will prvide any assistance needed t help with yur speaking and eating during recvery. There are als side effects due t the surgery needed t remve yur particular cancer, if this is dne at the same time as the recnstructive surgery. Fr these side effects, refer t the infrmatin n the website abut the particular surgery yu are having fr yur cancer. 10
BEFORE GOING HOME Any particular instructins fr wund care r medicatins will be prvided t yu befre yu g hme. Yu may want t dwnlad further infrmatin abut wund care n the Beynd Five website. Yu may need dressings, especially if yu had a skin graft, fr several weeks after ging hme. This is ften dne by a cmmunity nurse. Yur dctr may prescribe pain medicatins t help relieve pain fllwing the peratin. Ensure yu take the pain relief medicatins as prescribed by yur dctr and speak t yur cancer care team if the pain is nt under cntrl, gets wrse r if the medicatin causes any side effects. Yu may want t dwnlad further infrmatin abut pain management, which is available n the Beynd Five website. Yu will be assessed by the team invlved in yur care befre yu g hme and fllw-up will be arranged with yur surgen and GP. Fllw-up may als be arranged with any ther allied health prfessinals that may assist yu with supprtive care Yur recvery at hme may vary and yu shuld allw time fr yur bdy t recver and heal. Regular fllw-up helps t assess yur prgress. Symptms t watch fr after discharge frm hspital Significant swelling: Yu will have sme swelling after yur surgery. This is nrmal and may last fr sme weeks r mnths in varying degrees. Hwever, cntact yur surgen, GP r the hspital, if the swelling becmes very nticeable and affects yur swallwing r breathing. Difficulty breathing r swallwing: Yu shuld be able t breath nrmally after yur surgery. If yu are having difficulty breathing r swallwing, immediately g t hspital emergency department r cntact yur surgen. Discharge frm the wund: If yur wund becmes red, ht and starts t discharge, these are signs f an infectin. Cntact yur surgen s ffice r yur GP, as yu may need sme antibitics. Fever: Cntact yur surgen f GP if yu develp a fever. 11
FOLLOW-UP CARE After yur peratin, yu will cntinue t have regular fllw-up visits with yur specialist dctr and cancer care team. Mst patients with head and neck cancer will be mnitred fr five years after surgery, smetimes mre. Any additinal recnstructin, csmetic prcedures r treatments that yu may need are planned after discharge. This enables time fr yu t recver frm the initial peratin, get results f the pathlgy that examined the tissue remved at the peratin, and make the arrangements fr any additinal treatment r next steps. Fr further infrmatin abut the peratin fr cancer and what t expect, yu can als refer t Understanding Surgery: a guide fr peple with cancer, their families and friends. QUESTIONS TO ASK YOUR DOCTOR What will happen if I decide nt t have the surgery? When will the cancer surgery be undertaken? Hw much will the surgery cst? Will my health insurance cver it? What are the pssible side effects f treatment? Hw can they be prevented r cntrlled? What scar am I likely t expect? Will I be able t lead a nrmal life? What fllw-up tests will I need after the peratin? Am I suitable fr any clinical trials? Wh are the health prfessinals that I will need t see as part f my fllw-up care? 12
Yu may want t write specific questins here t ask yur dctr r cancer care team Beynd Five disclaimer: Yu acknwledge and accept that the infrmatin in this factsheet is fr general infrmatin purpses nly. It is nt intended, nr shuld it be relied n, as medical r legal advice, r as a substitute fr cnsultatin with a physician r ther licensed healthcare prvider. Yu agree that if yu have individual healthcare-related questins yu shuld cntact yur dctr prmptly and shuld nt disregard prfessinal medical advice, r delay seeking it, because f infrmatin cntained here. Yu als agree that Beynd Five is nt liable fr any injury r damage t persns r prperty (hwsever caused, including by negligence) arising ut f r related t any use f Beynd Five s patient educatin materials, r fr any errrs r missins. Last updated: December 2016 13