Head & Neck Reconstruction

Advances in digital imaging and computer science have given us an incredible range of tools in planning complex surgeries. While the success of any procedure will always depend on the skill and artistry of the surgeon, Virtual Surgical Planning® allows for more sophisticated solutions, more predictable post-operative outcomes, and can reduce recovery times for patients undergoing major reconstructive surgery.

Craniofacial surgeons perform major structural surgeries that involve both the bones and soft tissue (skin and muscle) in the head and neck area. These are complex, three-dimensional structures, and using patient- and wound-specific computerized data to accurately plan surgeries now allows us to provide sophisticated surgical solutions that would have been considered too difficult or even impossible just a few years ago.

In cases where Virtual Surgical Planning will be beneficial, we obtain high-resolution three-dimensional CT scans in order to create a detailed, patient-specific view of the affected structures. This gives the surgeon precise measurements and other detailed information about the various structures that lie beneath the skin. Improvements in computer software, meanwhile, allow surgeons to manipulate these images in three dimensions, so that we know exactly what we will encounter before each surgery.

This process allows us to create a detailed plan for even the most complex surgeries before we have made the first incision. Better planning means fewer surprises, fewer complications, and allows us to use minimally invasive and other advanced techniques that produce a better, more predictable cosmetic result.

More Predictable Surgical Results

Virtual Surgical Planning® has opened new vistas in craniofacial surgery, in part because it allows us to fabricate patient-specific instruments and implants, including specially-designed plates to stabilize repairs to underlying bony structures.

These patient-specific instruments act as guides during the operation, and they allow us to achieve results accurate to a fraction of a millimeter…something that would have been unthinkable until we began using this technology.

Applications of Virtual Surgical Planning

Here in New Orleans, we have used Virtual Surgical Planning® in order to improve functional and cosmetic outcomes in surgeries related to:

Mandible reconstruction secondary to cancer, osteoradionecrosis, or benign tumors

• Orthognathic surgeries

• Maxillary and mandibular osteotomies

• Malunion of facial fractures

• Cranial vault remodeling

• Distraction osteogenesis

One of the most common reconstructive procedures of the head and neck performed by our group is the reconstruction of the mandible (the lower jaw). This is done for several reasons, either due to partial removal of the bone for active cancer, removal of large benign tumors, bony destruction from radiation therapy (osteoradionecrosis), or trauma.

Here in New Orleans, we are able to replace diseased bone and soft tissue with healthy tissue from remote parts of the body. The process is complicated, but safe, cost-effective, and restores healthy tissue in those areas where it is needed. We call this meticulous procedure “free flap” microsurgery. The process involves the transfer of healthy skin and bone — with all of its nourishing vascularity — from one site where it is not needed to another where it can aid in healing. In reconstructing the jaw, the “donor” site is typically the fibula, a non-weight-bearing bone in the lower leg. For aesthetic purposes, we often borrow a second flap of skin from the outer or inner thigh, which allows for an inconspicuous scar. 

These are technically challenging cases, but with the use of Virtual Surgical Planning® and refined microsurgical techniques the outcomes can be excellent, with successful aesthetic restoration of the lower part of the face, and functional use of the mouth, lips, and jaw.

Radiation therapy is an important part of the post-ablative treatment for cancer in certain patients. It has helped hundreds of thousands of men and women beat cancer. For those few who suffer from osteoradionecrosis, however, there are additional challenges.

Osteoradionecrosis is a particularly difficult and unfortunate complication of the radiation therapy used to treat cancers of the head and neck. Radiation is an effective means of killing rapidly-dividing cancer cells. However, it can also kill healthy cells and can damage the vascular structures that support healthy bone that may result in a chronic and progressive process, the symptoms of which a patient might not experience for many years after their treatments have been completed.

A common consequence is bone death in the mandible, or lower jaw, which does not have the vascularity that is present in the upper jaw and other bones of the face. That vascularity supplies blood, which carries healing factors necessary for healthy bone to repair itself. So when radiation affects the soft tissue of the lower jaw, the bone may have trouble responding to the damage. As the bone dies over time, patients will experience pain, infections, difficulty with eating and oral hygiene, and in more advanced cases the surrounding soft tissue may become compromised as the condition progresses.

There is hope for relief, however.

Our practice offers a composite reconstruction of the jaw using Virtual Surgical Planning® and the state-of-the-art microsurgical techniques described above. Indeed, our group has co-authored several papers on our pioneering work on behalf of patients who suffer from osteoradionecrosis.

In certain patients—typically those that are suffering from benign tumors or destructive cysts of the mandible—we are able to perform reconstructive microsurgical procedures under ideal conditions without the complicating factors of radiation damage, previous infections, or significant traumatic damage to the local soft tissue. In these patients, our group has successfully developed very sophisticated surgical techniques that allow us to accurately recreate a functional jaw without any surgical incisions on the visible skin. The potential benefits of this approach with regard to recovery time and the final aesthetic results are far superior to more traditional techniques.

In addition to being able to perform mandible reconstruction without visible scars, we have the ability to reconstruct the sensory nerves to the lower lip that are usually compromised in patients with these conditions. This is done using frozen nerve grafts and ultimately allows the patient to maintain functional sensation after healing.

Likewise, we are also able to perform simultaneous dental rehabilitation at the time of mandible reconstruction using osseointegrated dental implants. When a portion of the jaw is removed, the teeth are removed with it. Dental implants are the best way to restore functional dentition for both chewing and aesthetic purposes. During the Virtual Surgical Planning® session when we plan out the steps of the reconstructive procedure we are also able to decide where the implants should be placed into the transferred bone of the fibula so that it can all be done in a single procedure. This is known as the “jaw-in-a-day” technique.

When these three surgical techniques are combined, it represents the most advanced and comprehensive procedure for mandible reconstruction being performed today. It also provides patients with life-changing results that were inconceivable even a decade ago.