Microvascular Free Flap: An Overview of Reconstructive Surgery
Guest: Dr. Judith Skoner – Otolaryngology/Head & Neck Surgery, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Judith Skoner, who is Assistant Professor of Otolaryngology; that’s Ear, Nose, and Throat, at the Medical University of South Carolina. Dr. Skoner, I know you have a very interesting subspecialty that you’ve developed here at MUSC. Can you describe the sorts of operations you do?
Dr. Judith Skoner: We call it microvascular reconstruction of the head and neck. It’s also referred to as free flap surgery. The concept behind it is that we reconstruct defects resulting from surgery, such as cancer resections, or trauma in which there are large defects. We reconstruct them by using tissue from other parts of the body, along with their blood supply, then bringing those other parts of the body up to the head and neck area that needs reconstruction, and giving that tissue life by sewing the blood vessels into native vessels in the neck.
Dr. Linda Austin: So, let’s walk through what sounds like a very fascinating procedure. I’m sure it’s daunting for patients when they first hear about it, so I’d like to just kind of walk it through step by step. Start with an example of a typical patient who you might be asked to perform a reconstruction for.
Dr. Judith Skoner: If we have a patient who has a tongue cancer, and they’ve decided their treatment modality is going to be surgical, it will typically begin with a surgeon, and then might include other things afterwards, like radiation or chemo. But initially, the first step is surgery. So, it depends, then, on how extensive the cancer is as far as what the resection will be like. For example, they would have a cancer that involved half of their tongue. And, if we would just remove half of the tongue and not do any sort of reconstruction, they’ll have significant defects with speech and articulation, and swallowing. And if it was the back of the tongue, they’d potentially even have difficulty controlling their secretions, or keeping food out of their airway. What we do, then, is try to replace the bulk of the tongue that’s been resected, or taken out, with a patient’s own tissue.
Dr. Linda Austin: So, what tissue might you use?
Dr. Judith Skoner: One of the tissues that we typically use is the forearm tissue; the tissue at the lower part of the arm. It’s no muscle, and no bone. We don’t take that, unless there are other circumstances.
Dr. Linda Austin: In other words, the skin?
Dr. Judith Skoner: Yeah. It’s just the skin, and the sort of fatty tissue underneath the skin. We take it and leave it attached to the radial artery, or the ulnar artery. It’s just one or the other.
Dr. Linda Austin: In the arm?
Dr. Judith Skoner: In the arm, because the hand is fed by one or the other of those arteries. So, in the majority of patients, you only need one left intact to still perfuse the hand. So, we take that tissue, keep it attached to one of those arteries, and then we actually remove the tissue along with that artery, and the veins. So, it has the artery bringing the blood to the tissue, and then the veins taking the blood away from the tissue. Then, we detach that from the patient’s body completely and bring it up to the head and neck. Then we mold the arm tissue into sort of a new tongue, replacing bulk, and trying to keep in mind that we need a little bit of mobility so that the remaining tongue can kind of move it around still. Then we sew the artery from the arm into a branch off the carotid artery in the neck, and then the veins from the arm off into branches of the internal, or external, jugular vein, or other veins in the neck. So, it gets a completely new circulation. And then we count on the body sort of accepting that as its new home.
Dr. Linda Austin: How long does a procedure like that take?
Dr. Judith Skoner: Including the resection, it takes anywhere from 12 to 15 hours. The more we do, the faster we get. So, here, we’re trying to decrease our time, but certainly, I’d say, 12 to 15 hours is not unreasonable. The average we tell people is around 12 hours.
Dr. Linda Austin: Now, tell me, for you, as a surgeon, that is a long time, are you on your feet the whole time?
Dr. Judith Skoner: Typically, we try to do a two-team approach. My partner, who’s take the cancer out, will begin the case, and I’ll get the arm prepared, or the other donor site that I’m going to be using for the tissue. And then, while they’re doing the resection, I can sort of relax a little bit, kind of planning in my mind what we’re going to do. Then, somewhere in between, when he’s identified, clearly, what the defect size is going to be, I’ll go ahead and begin. I don’t have to be in there the entire 12 hours. Again, we’re sort of overlapping in our work. He’ll start the resection, and then I’ll come in kind of halfway and start the reconstruction. He can, then, leave, and I stay and finish the reconstruction. Families always ask me, aren’t you tired; it’s been a long day? It never seems long. It always just flies by.
Dr. Linda Austin: Surgeons always say that about doing operations; that the time goes very fast. But it sounds like you do at least get to get something to drink and have some lunch along the way, and take breaks.
Dr. Judith Skoner: Yeah. We can take little breaks, yeah, but try to move quickly so we don’t keep the patient asleep any longer than we have to. And we know that it’s a long surgery. My partners and I that do the free flap reconstructions, we know that and it’s all sort of part of our lifestyle. so it doesn’t seem taxing, or extremely long.
Dr. Linda Austin: Having watched operations myself, I know that they can look almost like a ballet, where it’s so well-choreographed. Each person, not just the surgeons, but the technicians and circulating nurses, everybody knows what they’re supposed to do. There’s a timing to it. There’s, really, almost a beauty to it.
Dr. Judith Skoner: It’s very much exactly what you’ve said. It’s very much a team effort. You know, we can’t do it without the nurses and the anesthesiologists, and the residents, everyone. It takes everyone in order to get that type of surgery done in an effective way. We’re lucky that we have a really good team here in the OR, and even on the floor and ICU, to take care of all the issues.
Dr. Linda Austin: How many days a week do you operate, personally?
Dr. Judith Skoner: It kind of varies. I guess in my ideal life, I’d be doing something like this twice a week, and then my partner would do it twice a week as well. So, probably, as a team, as a department, we do anywhere from two to three, and possibly more, per week like this, reconstructing different kinds of defects.
Being at a large tertiary care center, we see, sort of, the worse of the worst cancers oftentimes. They’re very late-staged, or very advanced. That’s when this reconstruction really comes in as most helpful, because you really don’t have any other options for reconstruction. And in the past, people would just leave large defects, or use other sorts of reconstruction techniques, that just didn’t allow you to try to regain the function that you had before.
Dr. Linda Austin: What is the youngest patient you’ve operated on, and the oldest?
Dr. Judith Skoner: In fellowship, actually, the youngest patient was three, and had esophageal atresia; the esophagus wasn’t developed. We did a reconstruction of the esophagus on her, which did well, thank goodness. And the oldest, probably 80, I guess, I would say.
Dr. Linda Austin: So, you really take care of the entire lifespan?
Dr. Judith Skoner: The average for this sort of thing is probably between 50 and 75, something like that, or into the late 70s. We’re seeing, now, unfortunately, younger patients; more in their forties, and even some in their thirties.
Dr. Linda Austin: Why is that?
Dr. Judith Skoner: We don’t really know yet. Some people hypothesize that there are viral factors, like HPV, that might be involved in head and neck cancer, which is now becoming more prevalent, or that there are just other factors associated with head and neck cancer that we haven’t identified yet. We’re seeing some younger non-smoking patients, especially men, that fall out of the typical, traditional, head and neck cancer patient profile whose risk factors include smoking and alcohol use.
Dr. Linda Austin: Can you give any rough estimates as to what percentage of your head and neck cancers seem to be related to smoking and/or alcohol?
Dr. Judith Skoner: Yeah. It’s high. I would say 90, 90 plus, percent, is probably related to smoking and drinking, and they tend to be synergistic. So, smoking, alone, is a big risk factor. Alcohol, alone, is another big risk factor. But alcohol and tobacco use together, then, put you at even much greater risk than just either of those two alone.
Dr. Linda Austin: And, I think I might put in a plug here, as a psychiatrist, that even though tobacco and alcohol can be dreadfully addictive substances, there are really excellent treatments available, especially now, for smoking. Chantix is such a good medication for smoking, and can help so many people; maybe make your life a little bit easier, as a surgeon.
One last question, Dr. Skoner, it sounds as if the surgery you do is really remarkable. Tell us a little bit about the training that was required for you to be able to do these very complex, delicate, procedures.
Dr. Judith Skoner: Well, of course, I finished my otolaryngology residency. And that was here, at MUSC, that I finished. Then I did my fellowship in Portland, Oregon, at the Oregon Health and Science University. The fellowship was one-year long. It was focused primarily on this reconstruction, free flap surgery. We would do, on average, about three of these per week. It was just my fellowship director and me. In the realm of the free flap, it’s actually a really large number. After my fellowship, I went on staff as one of the head and neck surgeons at Temple University in Philadelphia. I was there for almost two years before I came back down to Charleston, which is my home.
Dr. Linda Austin: We are very lucky to have you here.
Dr. Judith Skoner: I feel very lucky to be here. We have a really great head and neck team.
Dr. Linda Austin: Any interesting new directions in research that you’re pursuing now?
Dr. Judith Skoner: Well, we’re always looking to see if we’re doing any benefit, of course. So, if we’re undertaking these huge surgeries that take 12 to 15 hours, and putting people asleep for so long, are we really making a difference in their lives? So, we’re trying to gather data, which we refer to as functional outcomes data, looking at people’s speech and swallowing, communication, sort of quality of life issues, before and after. It’s a huge task to try to collect all of that data and really quantify something that is, really, more quality. But that’s what we’re trying to do.
We have a Functional Outcomes Center, headed by Dr. Betsy Davis, a maxillofacial prosthodontist, and Dr. Josh Hornig, who’s one of my partners. All of the head and neck team are trying to put all of this data in so we can show what we believe we already know; that the flaps allow us to kind of recreate things the best we can. It’s really, sort of, the Cadillac of reconstructions, because we can replace bone, or the bulk, and allow for mobility, and pliability, that we couldn’t get otherwise. So, functional outcomes; quality of life, that’s what we really want to be able to document and, again, sort of share with everyone else what we already believe and see in our patients.
Dr. Linda Austin: Well, thank you so much for the great work you do.
Dr. Judith Skoner: Thank you, very much.
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