Reconstruction

The main reconstructive operations, mainly flaps and grafts and their subsequent likely postoperative progress are outlined below. The discussion is focussed on the donor sites as these are not emphasised elsewhere. Issues related to progress at recipient sites are discussed in the relevant pages, mainly pages about the treatment of oral, facial skin and salivary gland malignancies, cleft lip and palate, craniofacial anomalies, jaw disproportion, hard & soft tissue necrosis.

Grafts

Split skin grafts

Short term: the wound left by harvesting a split skin graft is one of the more frustrating ones in reconstructive surgery. The wound is raw with exposed nerve endings and requires a dressing, usually of Vaseline-impregnated gauze supported by cotton wool and a type of felt held in place by a wrap-around bandage.
Medium term: the wound takes 10 to 14 days to heal, gradually becoming less uncomfortable and itchy over this period. An increase in discomfort usually means a minor infection.
Long term: the area remains red and relatively visible for many months and will always look unusual. This is the reason why split skin grafts are usually taken from less regularly visible parts of the body.

Full thickness skin grafts

The great advantage of full thickness skin grafts is that the donor-site wound is closed by wide undermining and suturing.

Short term: the incision line often feels very tight with supporting sutures.
Medium term: over the next 5 to 10 days the wound heals, although it may gape a little in the middle (the area of maximum tension) when stitches are removed.
Long term: the wound heals as any incision (without the open secondary intention wound of the split skin graft, see above).

Buccal mucosa grafts

Short term: the suture line feels very tight and may limit mouth opening.
Medium term: the area feels tight and limited mouth opening may last for two weeks.
Long term: the area seems to heal without any long-term problems, as long as no interference with the parotid duct (the duct through which saliva is transported from the parotid salivary gland to the mouth) has happened.

Palatal mucosal grafts

These are like split skin grafts (see above) and leave a raw area which heals with a dressing.

Short term: can be painful and may bleed unless an analgesic dressing is held in place by a dressing plate (similar to an orthodontic plate) which clips onto molar teeth.
Medium term: the dressing plate is worn until the raw area has epithelialized (10 to 14 days usually).
Long term: no noticeable difference as the hard palate is essentially mucosal scar tissue.

Fascial grafts

Harvested subcutaneously, these graft wounds are only evident because of the skin incision used to gain access to them.

Short term: mild discomfort, stitches.
Medium term: far less tight than a full thickness skin graft (see above), so the only real issue is stitch line. Stitches are removed in 6 to10 days, depending on the site, or not at all if a resorbable suture is used.
Long term: nothing.

Free bone grafts

Hip

The pelvis is by far the commonest site for maxillofacial bone graft harvesting as it can offer small amounts of cancellous bone to large bi-cortical segments. The postoperative progress is therefore widely variable.

Short term: in most cases a drain will be in place and overnight stay in hospital is expected. It can ache quite a bit, necessitating analgesia. A local anaesthetic may be infused to reduce pain. Subcutaneous dissolving sutures are often used to eliminate the need for removal or cross hatching of scars.
Medium term: discomfort and a limp for 7 to 10 days is common but very much depends on the amount of bone harvested and whether or not the muscles of the buttock have been involved in the operation (more pain, more limping if they have – many approaches have been developed to avoid this). Numbness of the upper thigh may be noticed, this may be permanent but people gradually get used to it.
Long term: an ache that lasts months can develop and where the bone is part of a flap (see below) a bulging can occur in this area. The scar can stretch.

Tibia

This site is used mainly for alveolar bone grafts in cleft patients as it produces adequate amounts of cancellous bone but no cortical bone.

Short term: local discomfort and stitches are the only real issues, limp is minimal if present.
Medium: the scar can be prominent and itch. Exceptionally rarely a fracture at the site of operation has been reported.
Long term: the scar usually settles well and there are few, if any long-term problems.

Rib

Only really used now for condylar replacement in children.

Short term: rib graft harvesting can be quite painful and an indwelling catheter to allow infusion of local anaesthetic is often used to help with this and promote deep breathing to avoid chest infection.
Medium: the discomfort can take 7 days to settle down, sutures are often a subcutaneous, dissolving type to avoid removal and the scar is barely noticeable.
Long term: in children regeneration of the rib can occur, the scar is not visible and few long-term effects are found.

Cartilage grafts

The postoperative path is dependent on the donor site. Rib cartilage is similar to rib bone, although less painful. For ear and nose donor sites only the skin suture line is noticed.

Short term: minor discomfort, suture line may feel tight and irritate.
Medium term: heals quickly and once sutures dissolve or are removed, not much of a noticeable problem.
Long term: the cartilage does not tend to regenerate, so edges under a thin skin or mucosal layer may be noticed.

Nerve grafts

All nerve grafts leave a deficit from where they were taken. This is very much a balancing act. Will the hoped-for benefit (usually an important motor nerve function or a very important sensory nerve) be worth the definite loss of function (usually sensory in a less important area) be worth it? Wherever the nerve graft is taken from, the area will be numb to a greater or lesser extent permanently, although some minor improvements are described probably because of contributions by surrounding intact nerves

Flaps

Local flaps

A nasolabial flap – taken from the looser facial skin to the side of the nose.

Short term: discomfort rather than pain, but the line of stitches are visible and feel tight. Mouth opening can be restricted and the normal oral function feels decidedly odd.
Medium term: the next 3 weeks are difficult. The flap creates a connection between the mouth and face which is unnatural. This has to stay in place for 3 weeks as the flap picks up a new blood supply so eating, drinking and appearance are all substantially affected. The skin stitches are removed between 7 and 10 days, depending on the amount of tension used to close the initial defect. The flap is divided and inset at a second operation around three weeks after the first. This means some more stitches on the face but these are usually removed at 6 to 7 days. The sutures in the mouth are almost always dissolving sutures, but can take weeks to fully vanish.
Long term: these flaps, despite their inconvenience in the short and medium term, give a very good mouth-lining reconstruction and the facial skin incisions create a ‘reverse facelift’ effect making the skin tighter on the operated side.

A tongue flap - whether based on the front, back or side of the tongue, this flap is frustrating because it requires part of the tongue tissue to be stitched to another part of the mouth for three weeks.

Short term: Lots of stitches in the mouth, sometimes mouth opening is deliberately restricted by wiring or using elastic bands between the teeth. Difficulties in eating, drinking and swallowing are usual. These frustrations are more of an issue than pain from the operation.
Medium term: this goes on for 3 weeks and while it is something that one can adapt to, it is a long and frustrating 3 weeks.
Long term: a singular advantage to the tongue flap is that it is very robust, particularly in dealing with large persisting oro-nasal fistula sometimes seen in cleft palate patients where previous surgery has not been successful.

A buccal fat pad flap - a useful extension of a simple buccal mucosal advancement flap.

Short term: discomfort and many stitches in the mouth.
Medium term: you will be encouraged to avoid blowing your nose which is harder than it sounds. Careful eating to avoid the area as much as possible but essentially that is it.
Long term: the buccal sulcus depth is decreased in the operating area, but that is irrelevant unless wearing a denture in that area.

There are numerous different local skin flaps – such as rhomboid, bilobed, subcutaneous advancement flaps. There are lots of local skin flaps used in facial skin surgery, especially facial skin cancer surgery but they all follow similar pathways.

Short term: visible sutures, often in a rather odd pattern, which feel tight. Discomfort rather than pain.
Medium term: keep clean, pat dry and use whatever aftercare regimen your surgeon recommends (some form of grease – antibiotic ointments are popular – applied regularly). If nothing else this makes suture removal at 5 to 6 days easier, which results in better wound healing.
Long term: scar massage with an emulsifier helps get the best scar you can.

The submental flap – varies in popularity; a large area of skin from underneath the jaw line is taken.

Short term: very tight and quite uncomfortable, visible sutures just underneath the jaw line. Some weakness of the lower lip might occur. Painkillers regularly for the first week is not unusual.
Medium term: the stitches may have to stay in longer than the optimal 6 days because of the tension required to close this flap. This can lead to some cross hatching but the site of the scar is very favourable. Weakness of the lower lip may persist.
Long term: the operated side of the neck is much tighter than the unoperated side (which may make it appear younger). The incision line heals well and is less obvious than at first.

Regional flaps

A forehead flap – quite an old flap with limited applications, but can provide an exceptional reconstruction for extensive nasal skin defects.

Short term: a split skin graft may have to be used (see above) if the defect cannot be closed primarily. If the donor site is properly chosen it can usually be closed by wide undermining and very tight stitches. These feel tight and can be quite uncomfortable, necessitating analgesia. They are visible in the centre of the forehead and the flap is attached at both the donor site and the recipient site for a minimum of 3 weeks (sometimes 6 weeks if extreme thinning is carried out). This is a very visible flap to contend with.
Medium term: three weeks of having a flap of skin from the head to the nose is a challenging time and there is no real way of making this less visible. The stitches feel very tight, the inserting stitches to the nose can be removed around 6 to 7 days as normal for facial skin, but the tension sutures on the forehead usually need 10 days to prevent wound breakdown.
Long term: the benefit is the long-term result which is about the best tissue and colour match possible to repair large nasal skin defects. Massage with emulsifiers and very careful sunscreen use will give the best possible result.

A deltopectoral flap - another old-school flap which can be very useful on specific occasions.

Short term: the donor site and repair (inset) site have to be visibly connected for 3 weeks and the most distal part of the flap (which will be the skin at the recipient site) has to be replaced with a split skin graft in almost all cases. There are multiple visible stitches, a pressure dressing for the skin graft on the chest/shoulder area and a Vaseline-gauze dressing inside the rolled connecting part of the flap to prevent it sticking to itself.
Medium term: this goes on for 3 weeks until the far end of the flap takes up its own blood supply and becomes the new skin at the repaired site. The flap is then divided and inset back into the position on the chest wall it was originally taken from. This does mean another week to 10 days of stiches on the chest wall and face but there is no visible connection between the two sites this time. The skin grafted area will always look different.
Long term: this flap leaves visible scars on the chest and an area at the front of the shoulder where it meets the chest with a thin obviously different appearance from the skin grafting of this site.

The pectoralis major flap - the workhorse flap for the 1980s, and finding a role in special cases even now.

Short term: although this is a pedicled flap, the connection between where it has come from and the nourishing blood supply is hidden underneath the skin of the chest wall. The stitches or staples closing the chest wall are often tight and usually move the nipple medially (towards the centre).
Medium term: the stitches inside the mouth or throat dissolve over a 3 weeks period, the stitches or staples on the chest wall are usually removed at 10 days. There is no second operation to divide and inset and no visible external connection between the part of the flap where blood vessels nourish it and the area of repair (which picks up a new blood supply even though no division takes place).
Long term: the muscle surrounding the feeding blood vessels gradually atrophies as the motor nerves are deliberately divided as part of raising the flap, so the quite bulky appearance in the neck gradually vanishes over a period of a12 to 18 months.

A latissimus dorsi flap - of more use in breast reconstruction than head and neck reconstruction as a pedicled flap, but used in specific instances. In head and neck reconstruction more often used as a free flap (see below). A bulky connection is present when used as a pedicled flap, when it is tunnelled underneath the skin of the armpit and this gradually atrophies in the same way as the pectoralis major flap (see above).

Short term: a linear incision from the back of the armpit down towards the hip is present. Closure is almost always primary.
Medium term: stiffness and limitation of movement of the shoulder can be troublesome initially. Sutures or staples are removed at 10 days
Long term: relatively little in the way of issues in the long term, except in sports enthusiasts (swimmers, climbers, cross country skiers).

Free flaps

The radial forearm flap – for 40 years the gold standard intra-oral reconstruction for thin, flexible stretchy areas. The donor site on the forearm has been progressively improved over the last 40 years, although suture lines will stay remain visible.

Short term: the forearm is usually repaired with a skin graft, increasingly a full thickness skin graft (leaving one less donor site issue to be bothered by). This is stitched in place and then covered by a pressure dressing of some sort which will be enveloped in a large cotton wool and crepe bandage. The arm is usually elevated for the first few days. A drain is used less often than originally.
Medium term: the dressings remain in place for 10 days when they are removed and all stitches removed. The grafts usually take well and only a light protective dressing, if any are needed from now on. There is quite often a bit of itching and altered sensation in the thumb area and the area of the skin graft.
Long term: particularly when full thickness skin grafts are used the long-term function and aesthetics of this very commonly used free flap for maxillofacial reconstruction is good, although it can never be as good as primary closure in a less visible site.

The fibula flap - the most commonly used single, combined bone and soft tissue facial reconstructive flap. The fibula is a fantastically useful free flap with relatively acceptable donor site morbidity.

Short term: a split skin graft (see above) on the distal leg is almost always necessary (full thickness skin grafts do not take as well), stitches, subcutaneous primary closure to avoid cross hatching where possible is helpful. A pressure dressing is needed for 10 days so the leg is wrapped in a thick cotton wool and crepe bandage. It is not necessary to immobilise the foot but care in flexing it helps the graft take. A drain is used in most cases.
Medium term: over the next 10 days walking progresses on a day by day basis, it seems surprising but the length of the fibula can be removed, as long as around 7 cm are preserved at the knee and ankle and you can walk relatively comfortably within a week in a normal shoe. The skin grafts take a bit longer to take than on the forearm so dressings may need repeating over a 3-week period.
Long term: a linear scar along the outside of the donor leg and a fairly obvious skin graft above the ankle are the obvious long-term issues. Surprisingly gait defects are not a limiting problem to anyone other than runners or hikers, but given the alternative donor sites this is still the better option in most cases.

The deep circumflex iliac artery flap - major bone flap with unfortunate postoperative issues in its original design, but much less problematic using newer computer guided techniques and a medial (from the front) approach. Rarely used with skin as the skin paddle is not very reliable

Short term: regardless of the technique used, there is a large suture line from the back of the hip to the pubis. There is no need for pressure dressings but 1 or 2 drains will be used, and these may stay in for several days.
Medium term: this bone defect is substantial but the next 3 weeks very much depend on the technique used. This ranges from extensive gluteal muscle stripping and combining the bone with internal oblique muscle which will create more of a defect, far longer postoperative recovery and a higher risk of herniation and abdominal wall weakness to a computer planned medial approach taking bone only which halves the recovery period and substantially reduces other donor site morbidity. Limping will be an issue regardless of technique, but the more minimally invasive the surgery the more quickly this will improve. There is an area of numbness over the upper thigh but oddly enough this is seldom commented on.
Long term: again, this is dependent on the technique used, but it is usual to have a general ache in the area of surgery and a degree of gait impairment. Abdominal wall weakness and hernia formation can occur with the older approaches.

The anterolateral thigh flap - valuable intermediate size, soft tissue flap. The donor site is virtually always closed primarily and is in a less visible area.

Short term: a subcutaneous suture closing a straight line in the upper thigh. A drain is used but dressings are largely not needed.
Medium term: the drain is only needed for 24 to 48 hours and it is usual to be mobile after only a day or two. Very little in the way of functional deficit is noticed. A seroma (accumulation of fluid) can be a problem if the drain is removed early or mobilisation is overly enthusiastic.
Long term: other than the scar and some minor sensory changes very little in the way of long-term problems.

The rectus abdominus flap - the bulkiest soft tissue flap, useful in very cachexic patients or when massive bulk is required. In its basic form there is a substantial donor site series of issues to address, but a combination of operative technique modifications can reduce these.

Short term: the closure of the abdominal wall involves multiple layers of tension sutures which feels very tight and can make breathing uncomfortable. Local anaesthetic infusions can ease this. A drain is used.
Medium term: stitches are removed from the skin at 10 days but the wound still feels tight because of the tension sutures. The skin incision lines are sometimes unusual. The drain will stay in for a few days and there are a series of progressive steps forward before discharge from hospital.
Long term: abdominal wall weakness, herniation and other issues related to normal function of the abdominal wall can all occur but are irrelevant to the reason for the reconstruction.

The latissimus dorsi flap - almost as bulky as the rectus abdominus flap (see above) but with less fat. Patient positioning during surgery is probably the reason why it is not quite as popular as it should be.

Short term: a linear scar from the posterior aspect of the axilla down to the hip is usually closed by a subcutaneous suture. A drain is used.
Medium term: the drain can usually be removed in 24 to 48 hours and the sutures, if skin sutures are used, are removed in 10 days. Mobilisation is usually fairly easy and good arm movement is usually possible before discharge from hospital.
Long term: the donor site problems with this flap are actually very few outside active sportspeople.

The scapula flap - a divisive flap, full of potential in some people’s eyes, more trouble than it is worth in others’.

Short term: if taken as a skin flap with a vertical approach (called a parascapular flap) then a straight-line incision of sutures and a drain are all that is needed. If bone is harvested in conjunction with the flap, especially with a neck dissection, considerable discomfort and mobility issues with the shoulder can be expected.
Medium term: shoulder mobility is a major issue with the combination flap. The drain may be needed for several days. Discomfort and mobility problems with the operated side shoulder will continue for many weeks.
Long term: shoulder function long term is the main and poorly addressed issue with this flap when it is used in conjunction with bone. Protracted physiotherapy is common, although the skin-only scapula flap presents no more problems than the latissimus dorsi flap (see above).

Note that the perforator flaps taken from the sites discussed above have similar but usually very much reduced postoperative sequalae, being designed to minimise the amount of tissue harvested in order to reduce the donor site morbidity.

There are many other flaps. However, the most frequently used in maxillofacial reconstruction are listed above. Some units specialise in flaps not used commonly elsewhere (for example, the ulnar flap (another forearm flap)). It is worthwhile asking those who have greater experience (your treating clinician) about what to expect after your operation.