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Recent advances and controversies in head and neck

reconstructive surgery

Moni Abraham Kuriakose, Mohit Sharma, Subramania Iyer

Head and Neck Institute / Division of Reconstructive Surgery, Amrita Institute of medical Sciences, Kochi - 682026, India

Address for correspondence: Dr. Moni Abraham Kuriakose, Professor and Chairman, Head and Neck Institute, Amrita Institute of Medical
Sciences, Kochi - 682 026, India. E-mail: akuriakose@aims.amrita.edu

ABSTRACT

Advances in head and neck reconstruction has made signiÞcant improvement in the quality of life and
resectability of head and neck cancer. ReÞnements in microsurgical free tissue transfer leave made

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restoration of form and complex functions of head and region a reality. Standardized reconstructive
algorithms for common head and neck defects have been developed with predictable results. Some of

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the major advances in the Þeld include- sensate free tissue transfer, osseo integrated implant and dental

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rehabilitation, motorized tissue transfer and vascularized growth center transfer for pediatric mandible
reconstruction. However there exist several controversies in head and neck reconstructive surgery. Some

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are old; resolved partially in the light of recent clinical evidences and others are new, developed as a result
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of newly introduced reconstructive techniques. These include, primary versus secondary reconstruction,
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pedicled versus free ßaps, primary closure versus free tissue transfer for partial glossectomy defects,
reconstruction of posterior mandible and reconstruction of orbital exenteration defects. Rapid advances
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in the Þeld of tissue engineering and stem cell research is expected to make radical change in the Þeld
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of reconstructive surgery. This manuscript review progress in head and neck reconstructive surgery
during the last decade, current controversies and outline a road map for the future.
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KEY WORDS
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Free tissue transfer, head and neck, reconstruction, tissue engineering

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INTRODUCTION and function and are fast approaching the ultimate

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reconstructive goal of `replacing like with like’. However,

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ead and neck cancer is one of the leading causes there exist several controversies and limitations.
of cancer-related death and disfigurement,
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particularly in the Indian subcontinent. Although ALGORITHM-BASED SELECTION OF

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there has been quite significant progress in the
management of head and neck cancer such as the
introduction of organ-sparing strategies using concurrent
chemo-radiotherapy and biological modulation of cancer
with epidermal growth factor pathway interruption, none
of the strategies has come close to the contribution made
by reconstructive surgery.[1] It has made a profound impact
not only in improving the quality of life of patients but
also in improving the resectability of advanced head and
neck cancers. To a large extent current reconstructive
techniques can offer predictable results to restore form
DONOR SITES FOR HEAD AND NECK
RECONSTRUCTION
Reports of studies based on large series during the past
decade have helped to establish a general consensus
on the choice of reconstructive options and the
development of an algorithm-based practice of head and
neck reconstructive surgery.[2] The following description
outlines the head and neck reconstructive algorithm
practised by the authors’ team at the Amrita Institute
of Medical Sciences. For the purpose of discussion, the

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Kuriakose, et al.

common head and neck defects can be categorized as 1.
Mid-face, 2. Tongue and floor of mouth, 3. Mandible and
4. Laryngo-pharynx.
MID-FACE RECONSTRUCTION
To assist in the planning and execution of the mid-face
region, the defects are classified into four classes and
three subgroups as described by Brown [3] in this issue. The
priority for reconstruction and the technique are different in
each of these groups, which are summarized in Table 1.
Class 1: maxillary alveolectomy defect without maxillary
sinus involvement
Class 2: maxillectomy defect involving sinus with intact
tongue can be repaired by direct closure or left to heal by
secondary intention, especially when the ablation is carried
out using laser. Hemi or subtotal glossectomy defect needs
reconstruction, which is best carried out using free tissue
transfer.[4,5] The choice of flap depends on the reconstructive
need. If the defect is restricted to the tongue, without
involvement of the floor of the mouth a lateral arm flap
suits best. However, if the floor of the mouth is involved, a
pliable radial forearm free flap is the better choice of flap.
In larger defects differentially thinned antero-lateral thigh
flap can also be considered. There is no general consensus
on the choice of flap in total glossectomy defect. A total
glossectomy with laryngectomy defect can be reconstructed
with pedicled pectoralis major myocutaneous flap. Choice
of flap in total glossectomy defect with preserved larynx

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orbital floor is controversial and is discussed later.

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Class 3: maxillectomy defect including the orbital floor,
but the orbital contents are preserved

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MANDIBLE RECONSTRUCTION
Class 4: maxillectomy with orbital exenteration

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Subgroup-a: defect does not cross midline
.c Pu wn The algorithm in the management of mandibular defect
Subgroup-b: defect crosses midline is now well defined and is outlined in Figure 2. The
Subgroup-c: bilateral defects reconstructive needs and choice of flap depends on the
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site of defect and the dentate status of the patient.[6]

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An additional Class 5 needs to be incorporated into this A lateral defect distal to the premolar teeth, especially
classification to describe defects extending to the cranial in edentulous patients can be reconstructed using
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cavity. pedicled flaps. However, lateral defects in dentate

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patients and anterior mandibular defects require

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skeletal reconstruction. The choice of flap depends

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TONGUE AND FLOOR OF MOUTH

on the site of the defect and the associated soft tissue
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The algorithm in tongue reconstruction is shown in Figure requirements. Table 2 summarizes the choice of flaps in
this scenario.
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1. A partial glossectomy defect involving less than one-third

of the tongue, especially when not involving the tip of the
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LARYNGO-PHARYNX RECONSTRUCTION
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Table 1: Classification of mid-face defects and

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reconstructive options
Primary closure, if it can be obtained, is the ideal
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Class Sub Order of reconstructive Reconstructive

group priority options
1 a-c Dental rehabilitation Obturator
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2 a Dental rehabilitation Obturator

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DCIA ßap
2 b-c Nasal support Fibula osseo-cutaneous
Dental rehabilitation ßap or DCIA ßap
3 a Orbital support Fibula osseo-cutaneous
Dental rehabilitation ßap
3 b-c Orbital support Fibula osseo-cutaneous
Nasal support ßap
Dental rehabilitation
4 a-c Base for orbital Rectus free ßap
prosthesis
reconstruction
Orbital prosthesis
5 a-c Separation of cranial Rectus free ßap
and oral cavity reconstruction
DCIA: Deep circumßex ileac artery Figure 1: Algorithm in tongue reconstruction

Indian J Plast Surg 2007 Vol 40 Supplement S4

4 CMYK
 Head and neck reconstruction

Primary versus secondary reconstruction in head

Mandibular Defects
and neck cancer surgery
The argument for secondary reconstruction was primarily
centred on the concern that reconstructed tissue can
delay detection of recurrence. In addition, during the
era of pedicled flaps and multi-stage reconstruction,
there was concern of delay in implementing the essential
postoperative radiotherapy required for optimal control
of the disease. Previously the multi-stage reconstruction
often extended beyond the optimal period of initiation of
adjuvant radiotherapy which is six weeks after completion
Figure 2: Algorithm in mandibular reconstruction of surgery.

reconstruction of pharyngectomy defects. This permits With the availability of reliable, single-stage reconstructive
restoration of pharyngeal conduit and better voice procedures and the often-practiced two-team approach, head

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rehabilitation with tracheo-oesophageal voice prosthesis. and neck reconstruction can be performed expeditiously
This is however not possible or desirable in certain and with predictable outcome. Improved quality of life with

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scenarios. This includes salvage laryngo-pharyngectomy primary reconstruction is now considered an overriding

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following chemo-radiotherapy and extended and total argument for primary reconstruction. Availability of high-

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pharyngectomy. Choice of flaps in pharyngectomy defects
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is discussed in detail elsewhere in this issue, which is facilitates detection of local recurrence and counters the
summarized in Table 3. argument to delay reconstruction.
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Secondary reconstruction has almost become obsolete

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CONTROVERSIES IN HEAD AND NECK

RECONSTRUCTION with a few exceptions. In circumstances when there is
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lack of microvascular surgical expertise or due to inherent

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There exist several controversies in head and neck patient factors, it may still be necessary to employ
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reconstructive surgery. Some are old, resolved partially in alternative methods of reconstruction and/or delay
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the light of recent clinical evidences and others are new, definitive reconstruction.
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developed as a result of newly introduced reconstructive

techniques. These are discussed below: Pedicled versus free flaps in head and neck
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1. Primary versus secondary reconstruction reconstruction

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2. Pedicled versus free flaps In reconstruction of head and neck defects after cancer
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3. Primary closure versus free tissue transfer for partial resections, the traditional concept of the `reconstructive
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glossectomy defects ladder’ has now been replaced with the concept of
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4. Reconstruction of posterior mandible ‘reconstructive elevator’ or ‘reconstructive escalator’. In

5. Reconstruction of orbital exenteration defect this concept, there is no need to strictly follow the
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Table 3: Choice of flap in laryngo-pharyngeal defects

Table 2: Choice of flap for mandibular reconstruction
Extent of defect Reconstructive option
Choice of flap Partial pharyngectomy with Primary closure
Reconstructive Site of defect retained mucosa of 3 cm or more
need Anterior Lateral Combined Retained pharyngeal mucosa of Pectoralis major ßap with skin
Bone++ less than 3 cm width or in most paddle
Soft tissue -/+ Fibula DCIA Fibula cases of salvage laryngectomy
Bone++ after chemo-radiotherapy
Soft tissue -/+ Fibula DCIA Fibula Circumferential pharyngeal Jejunum or anterolateral thigh
Bone++ defect, inferior extent above free ßap
Soft tissue -/+ Radial forearm Rectus pect Fibula + pect the manubrium
Þbula + Radial major major Circumferential pharyngeal Gastric transposition
forearm defect, inferior extent below
DCIA: Deep circumßex ileac artery the manubrium

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CMYK5
Kuriakose, et al.
reconstructive ladder of considering the simpler procedures
first and then escalating to complex procedures; but rather
to choose the most appropriate technique as the initial
procedure. Choice of reconstructive options depends
on various factors such as site of the defect, type of
tissue required, functional and cosmetic implications of
the defect, associated co-morbidity and availability of
resources. In most head and neck defects there is often
an ‘ideal reconstruction’ option. This however needs to
be selected based on the factors related to the anatomical
and functional defect and also based on the patient factors
and available expertise.
The concept of primary reconstruction of head and neck
cancer surgery defects began with the advent of delto-
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pectoral, forehead and pectoralis major myocutaneous
flaps. For years, pectoralis major myocutaneous flap has
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been the workhorse for reconstruction of a variety of defects
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in the head and neck region. Latissimus dorsi, trapezius,
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platysma myocutaneous flaps are the other less utilized
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pedicled flaps. However, all these flaps have limitations.
Firstly, they have a limited reach because of which there
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are more chances of distal flap failure and wound gape due
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to tension by the downward pull of the flaps. Secondly, the
type of tissue in the flap, its bulk and pliability does not
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always suit the defect to be reconstructed. Thirdly, it may
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not be possible to contour the flap to the defect in different
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planes than that of the pedicled flap.
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All these drawbacks can be overcome by the use of
free tissue transfer. Though the reliability and utility
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of free tissue transfer is established in head and neck
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reconstruction, the technique is not frequently adopted
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because of various reasons. Surgical expertise, the time
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factor and questionable benefit in advanced cases with
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poor prognosis were some of the arguments against the
wide use of free tissue transfer. But today, with widespread
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practice of the technique, availability of structured training
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in microvascular surgery, safe anaesthesia and two-team
approach these factors can readily be overcome in many
tertiary care centres. Free flaps are also associated with
some drawbacks like the need for vigorous monitoring and
re-exploration if required. Donor site morbidity limits its
use in patients with co-morbidity. Extremes of age of the
patient, however, are found not to be a contraindication
for free tissue transfer.
Certain locations in the head and neck region cannot be
effectively reconstructed without free tissue transfer. These
include anterior and antero-lateral mandibular defects and
Indian J Plast Surg 2007 Vol 40 Supplement
6 CMYK
major skull base defects. The cost-effectiveness of free
flaps has also been reported as no worse than the pedicled
flaps. However, for certain defects such as patch defects of
the pharynx and posterior mandibular defect, pectoralis
major myocutaneous flap is the preferred reconstructive
option because of its reliability and ease of technique. For
the reconstruction of smaller cutaneous defects, local flaps
are better because of better colour and texture match.
So, today the surgeon has a variety of reconstructive
options to choose from. Hence, the choice should be based
on the nature of the defect, its functional implications,
patient factors and availability of resources.
Primary closure versus free tissue transfer for
partial glossectomy defects
The main functions of tongue are speech and swallowing.
In speech, tongue is involved in the articulation of the
consonants and hence the intelligibility of speech. Tongue
mobility is a key factor affecting speech intelligibility.[7]
Tongue is also involved in mixing the food and chewing
and pushing the food backward for swallowing. So, the
aims of the reconstructive surgery should be to restore
these functions. As the tissue we use for reconstruction
is adynamic, functional reconstruction of such a vital and
dynamic structure at present is an elusive goal. However,
the reconstructive technique should attempt to take
advantage of the mobility of the residual tongue as well
as that of the floor of mouth, in addition to restoring
the volume of the tissue lost. The most appropriate
reconstructive choice depends on the size of the tongue
resection and site of the defect. As more tongue is lost,
normal function is less likely to be restored; and a bulkier
flap is required to reconstruct the defect adequately.
Defects involving the floor of mouth or tip of tongue
require a thin and pliable flap.
Partial glossectomy defects following resections for
cancer of the anterior two-thirds of the tongue vary in
size and site. These defects may extend to the floor of
the mouth and partly to the base of the tongue. Defects,
which are less than one-third of the oral tongue, medio-
laterally and antero-posteriorly, if closed primarily or
left to heal by secondary intention produce no major
limitation of tongue movement or loss of significant
bulk. Hence, speech and swallowing are not significantly
affected.
Those defects that exceed more than two-thirds of
tongue require flap reconstruction for optimal result.
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This is particularly true if the defect extends to the floor
of mouth.
The issue of reconstruction is controversial in partial
glossectomy defects that are between one-third and
two-thirds of the tongue. Many surgeons adopt primary
closure of these defects with good functional results.[8]
Some studies show better results with reconstruction.[5]
However, the small number of patients in these studies
and the fact that all types of flaps have been included
in the reconstruction do not make the results reliable.
Pedicled flaps that have been utilized include nasolabial,
platysma, submental or pectoralis major flaps whereas
the free flaps reported to be useful include lateral arm
and radial forearm flaps and of late anterolateral thigh
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flaps.
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However, studies that compare functional results between
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these methods are limited. Studies with small numbers
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have compared results between pectoralis major and
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radial forearm flap and the results are reported to be
better with the latter.[9,10]
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Reconstruction of posterior mandible
Options for posterior mandibular reconstruction, distal
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to the molar teeth segment, are no reconstruction,
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soft-tissue reconstruction and osseous reconstruction.
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Proponents for no reconstruction or reconstruction with
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soft-tissue flap argue that in dentate patients the teeth
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will guide the mandible into normal alignment and there
will not be any significant functional deficit. In edentulous
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patients, deviation of jaw is not a concern as there is
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no occlusion to be maintained. Argument for osseous
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reconstruction is that, it maintains symmetry of mandible
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at rest and on opening the mouth. Moreover, over time,
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unopposed action of the contralateral mandible can cause
significant deviation of the mandible. This is important in
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dentate patients where occlusal relationship is essential
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for optimal functional outcome. Our policy is to offer
osseous reconstruction in all patients other than elderly
patients with edentulous mandible and those who have
preexisting restriction of mouth opening as in submucous
fibrosis.
Reconstruction of orbital exenteration defect
Controversy regarding the reconstruction of orbital
exenteration defect is whether to excise the eyelids and
obliterate the cavity and offer an orbital prosthesis or
to maintain the eyelids and orbital cavity and offer an
S7
Head and neck reconstruction
ocular prosthesis. The advantage of the former is that the
result is more predictable, although the aesthetic result of
orbital prosthesis is far inferior to ocular prosthesis. The
advantage of the latter is better aesthetic result, however
with several potential problems. For an ocular prosthesis,
it is essential to have an orbital floor and a cavity lined
with skin. In addition the function of the orbicularis
occuli and levator muscles should be maintained. The
latter reconstruction although more challenging and less
predictable, offers a better aesthetic result than provided
by an orbital prosthesis.
RECENT ADVANCES IN HEAD AND NECK
RECONSTRUCTION
There were several notable advances in head and
neck reconstruction in the recent past. Some of the
developments, which have changed clinical practice or
will do so in the near future, are outlined below:
1. Sensate free tissue transfer
2. Osseo integrated implant and dental rehabilitation
3. Motorized tissue transfer
4. Vascularized growth centre transfer for paediatric
mandible reconstruction
Sensate free tissue transfer
Oral mucosal sensory feedback plays a critical role in
many stomatognathic functions such as mastication, oral
hygiene, phonation and swallowing and can influence the
patient’s quality of life. This goal of sensory feedback can
be achieved by use of sensate free tissue reconstruction.
It requires transfer of a composite functional unit with its
own vascular supply (angiosome)[11] and innervated by a
sensory nerve (neurosome).[12] Taylor et al.,[13] in detailed
cadaveric studies, demonstrated various neurovascular
territories of the body. They made the observation that
cutaneous nerves often run along with blood vessels in an
overlapping distribution of angiosomes and neurosomes.
This work suggests that many of the currently used axial
or fasciocutaneous flaps can be potentially modified
as neurovascular flaps. Several authors have reported
successful sensate free flap transfer of oral cavity defects
with successful restoration of sensation.
Radial forearm free flap with lateral antebrachial cutaneous
nerve is the commonly used sensate flap in the head and
neck region.[14-16] What is not convincingly reported as
yet, is either improvement in function or quality of life of
patients with sensate flap reconstruction.
Indian J Plast Surg 2007 Vol 40 Supplement
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Kuriakose, et al.
Vascularized growth centre transfer in paediatric
mandible
Mandibular reconstruction in a growing child is a
challenging problem, requiring transfer of bone with
growth potential to avoid progressive facial deformity.
Today there are various options available to us for
addressing this complex issue.[17]
Epiphysis and hemi-joint transfer for reconstruction of the
temporomandibular joint and ramus-condyle unit, using
the proximal epiphyseal plate and proximal one-third of
the diaphyseal shaft of the fibula has been successfully
performed in cases of hemifacial microsomia.[18] Pruzansky
Type II and III patients have reported to have a good range
of painless movement at the temporomandibular joint and
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growth at the neo ramus-condyle unit.
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Microvascular temporomandibular joint (TMJ) and
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mandibular ramus reconstruction can be performed in
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patients with absence of the vertical mandibular ramus
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using metatarsophalangeal (MTP) joint transplantation.
This technique appears to be a promising alternative in the
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treatment of children with Pruzansky Type III hemifacial
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microsomia. Various teams have used costochondral grafts
for reconstruction of the mandibular condyle and ramus.[19]
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The latter technique has gained increasing popularity
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in the reconstruction of the temporomandibular joint
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and condyle in patients with hemifacial microsomia and
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temporomandibular joint ankylosis during the growth
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period. Long-term follow-up has shown some patients have
excessive growth of the graft, while others have suboptimal
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or no growth pointing to the fact that the growth pattern
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of the costochondral graft is unpredictable.[20]
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For oncological reconstruction, the defect will
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include both bone as well as associated soft tissue.
In addition, the majority of these patients have to
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undergo postoperative radiotherapy. This precludes
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the use of free costochondral graft. An alternative
technique would be the use of vascularied rib along
with serratus anterior muscle based on the thoracodoral
vascular pedicle.[21] This has the potential advantage of
vascularised growth centre transfer and soft tissue for
reconstruction [Figures 3 a-d].
Dynamic muscle transfer
In head and neck reconstruction functional muscle transfer
is an established concept for facial reanimation surgery.
This concept is increasingly being used for oncological
reconstruction, particularly in reconstruction of major
Indian J Plast Surg 2007 Vol 40 Supplement
8 CMYK
glossectomy defects.
The priorities to be considered while reconstructing total
or near total glossectomy patients are airway protection,
swallowing and articulation. The transfer of static tissue
acts mainly by providing bulk for glosso-palatal contact.
It also helps in swallowing and speech to some extent.[22]
The use of dynamic muscle transfer for total tongue
reconstruction can actively suspend the larynx and
allows for better speech and swallowing by providing
coordinated tongue movements.[23,24]
This reconstructive technique has recently been refined by
us using innervated gracilis along with a gastro omental
flap. The logic behind choosing this combination is that
the innervated gracilis muscle provides active tongue
movements for coordinated swallowing and better speech
and allows elevation of the larynx during swallowing which
helps in preventing aspiration. The gracilis muscle closely
matches the normal tongue in its cross-sectional diameter.
The muscle can be trimmed to a requisite length and can
be accommodated easily in the limited space provided
within the mandibular arch.
It is well documented that the gastric mucosa has good
radiation tolerance capacity.[25] That the stomach mucosa
has inherent secretory capability in response to local stimuli
is another important factor in decision-making for the
use of the gastro omental flap. The stomach is used in an
inside-out fashion, so that it can act as an alternative source
of secretion. As virtually all patients undergoing subtotal
glossectomy require adjuvant postoperative radiotherapy
and have the risk of developing xerostomia, the secretion
from the gastric lining is an added advantage. The omentum
is sandwiched between the stomach and floor of mouth
to provide the bulk needed for adequate glosso palatal
contact. Moreover, with the use of this combination of
tissues, the colour and appearance of the neo tongue very
closely match the original tongue [Figures 4a, b].
Osseointegrated implants and dental
rehabilitation
The primary function of jawbones is to provide support
for teeth. Therefore reconstruction of the jawbone will
not be complete without appropriate dental rehabilitation.
Dental restoration with the assistance of a prosthodontist
is essential for total functional reconstruction. Dental
rehabilitation can be carried out either using removable
prosthesis or fixed prosthesis. The surgical bed should be
optimized for dental restoration. This includes:
S8
 Head and neck reconstruction

Figure 3a: Child with recurrence of Þbrous histiocytoma affecting the mandible Figure 3d: Same child 2 years post-operatively showing symmetrical growth
and infratemporal fossa of the face

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Omentum
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Tongue remnant
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Gracilis
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Figure 3b: CT scan of the same child Figure 4a: Graphic representation of combined gastroomental and dynamic
gracilis ßaps for total tongue reconstruction
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Figure 4b: Reconstructed tongue maintaining its volume and lubricated surface
Figure 3c: Composite free latiismus dorsi- serratus anterior with rib incorporating six months after radiation therapy
costal cartilage

! Availability of occlusal space of 10 to 15 mm ! Neo-mandible lined with mucosa rather than skin,
! Aligning the neo-mandible to the opposing natural which is firmly attached to the underlying bone
teeth ! Providing adequate bone and soft-tissue support for

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CMYK9
Kuriakose, et al.
the teeth bordering the defect
Currently available reconstructive techniques need to
be modified to meet these requirements. The bone flap
should be aligned to the lower border of the mandible.
Care should be taken to provide optimal inter-alveolar
space (10 to 15 mm), particularly at the molar teeth
segment. A `bite-block’ can be prepared preoperatively, to
ensure occlusal space, as well as alignment with opposing
teeth. Skin is a poor substitute for mucosa. Moreover, the
skin over the osteo-cutaenous flaps is mobile affecting
stability of the denture. This can be avoided by de
epithelization of skin paddle or avoiding skin paddle
altogether and have muscle or fascia as oral lining. Lack
of skin facilitates contracture of the oral lining on to the
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bone and permits mucosilization of the flap. Care should
be taken to maintain adequate bone and soft-tissue
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support at the time of primary mandibulectomy.
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In a large number of patients conventional denture
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cannot be fabricated because of the morphology of the
neo-mandible and lack of support from adjacent natural
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dentition. Dental restoration in these patients can be
undertaken using osteointegrated implants.[26] This is
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a two-stage procedure in which titanium implants of
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appropriate dimension are inserted into the bone and
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allowed to integrate with the bone which takes about
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three months. After that period, the implant needs to be
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exposed and an abutment is attached to the implant. A
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fixed prosthesis can be fabricated on these abutments. The
number and position of abutments needs to be carefully
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planned with the prosthodontist.
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These implants can be placed either at the time of primary
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surgery or as a secondary procedure.[27] The proponents
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of primary implantation argue that it avoids additional
surgery, expedites the rehabilitation of the patients and
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more importantly allows predictable osteointegration as
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the implants are placed prior to start of radiotherapy, which
is required in most of these patients. The implant placement
also is technically easier as there is wide exposure of oral
cavity during the primary surgical procedure. The main
disadvantage of the primary implantation is that in the
event of flap failure, albeit low, there will be failure of
implants too. In addition implant placement also increases
the operating time of an already lengthy procedure.
The advantage of secondary placement of the implants is
that the implant placement can be performed as an office
procedure, after ensuring success of bone flap. Moreover,
Indian J Plast Surg 2007 Vol 40 Supplement
10 CMYK
the implants can be placed with accurate alignment with
the opposing teeth using template. The main disadvantage
of secondary implant placement is that the implant is
inserted in an already irradiated bone with about 20%
lower integration rate.[27]
Our practice is to perform implantation for those patients
who undergo resection for benign diseases as primary
procedure and as a secondary procedure in malignant
diseases.
Future developments in head and neck recon-
struction
Exciting developments in tissue engineering hold promise
for the future, either as an `off the shelf ’ reconstruction
option or by incorporating the technique into the
conventional techniques to improve their efficiency or
lower the donor site morbidity. This technology is likely
to change the way we reconstruct tissue defects in the
future.[28] Although tissue engineering is considered
as experimental at present, based on Phase III clinical
trials two products are currently available for clinical
use. These are recombinant Bone Morphogenic Protein
(rhBMP-2) for spine fusion (INFUSE, Medtronic Sofamor
Danek, Memphis, Tennessee) and a cell-based therapy of
autologous chondrocyte implantation for articular disc
replacement (Carticel, Genzyme Biosurgery, Cambridge,
MA).
Tissue engineering involves regeneration of new tissue
through the use of biological mediators or scaffold.
Success of tissue engineering depends on the effective
participation of three components-scaffold, signalling
molecules and cells. Either all or some of these components
are introduced for the regeneration of tissue. The scaffolds
used at present are either natural tissue such as collagen,
acellular dermis or demineralized bone matrix; polymers
such as polyglycolic acid or metal (Titanium). The scaffold
should have mechanical properties to provide tissue
morphology and have chemical properties to serve as bio-
molecule carriers. Signalling molecules to be incorporated
into the system will provide signalling to activate tissue
regeneration. This can be either in the form of biologically
active molecules (e.g., rhBMP), gene therapy to deliver
genes coding for the biologically active molecule or as
tissue-specific cells (e.g., chondrocyte, keratinocyte).
Tissue engineering has progressed farthest in bone
regeneration. RhBMP-2 and rh-BMP-7 are in use for spine
fusion and for long bone non-unions. In the head and neck
S10

region this is being used in alveolar regeneration and
in sinus floor augmentation procedures.[29] This concept
was recently applied for regeneration of a 6cm segmental
bony defect of the mandible.[30,31] Bone marrow stromal
cells loaded in a demineralized bone matrix scaffold have
been successfully used for calvarial bone defects.
Autologous chondrocyte cultured ex vivo and loaded in
polyglycolic acid scaffold has been used for regeneration
of cartilage. This has been successfully used for auricular
cartilage reconstruction in animals.[32]
Another area where tissue engineering is showing
promise is in tracheal regeneration. Animal studies where
composite chondrocyte was delivered in polyglycolic
ns om
acid scaffold and later seeded with epithelial cells have
shown to regenerate composite cartilage-transitional cell
tio fr
epithelial sub-unit of trachea.[33]
). lica ad
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CONCLUSION .c Pu wn
Rapid progress in head and neck reconstructive surgery
ow w do
has helped in developing reliable and effective strategies
kn kno ee
to restore form and function. The advent of tissue
engineering is showing promise for the future to lower
ed d fr
donor site morbidity and improve the aesthetic and
m e or
functional result.
w. M f
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(w ed ilab
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Source of Support: Nil, Conflict of Interest: None declared.

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