Jun 20, 2019
Treating cancer on the head or neck can seem intimidating, as people fear surgery could leave unwanted scars around their face. However, with the techniques we use today, people often end up cancer-free with very few changes to their appearance.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.
Dr. Giurintano: Thank you so much for having me today.
Host: Today we’re discussing reconstructive surgery for head and neck cancers. When a patient has cancer in such a visible area of the body, it’s important for them to have options to not only remove the cancer, but also keep them looking like themselves after surgery. Dr. Giurintano, what are some of the more common cancers for which patients might need reconstructive surgery after treatment?
Dr. Giurintano: So, while approximately 90 percent of cancers that occur in the head and neck region are a type of cancer called squamous cell carcinoma, this type of cancer can affect multiple areas within the head and neck. Some examples include the tongue, the jaw bones, the palate, the inner surface of the cheeks, the back of the throat, carotid or saliva glands, and the voice box. Oftentimes, the surgery required to remove tumors from these locations results in very large, noticeable defects that affect not only the patient’s physical appearance but oftentimes their ability to speak, breathe or swallow. More recently, legendary Buffalo Bills quarterback Jim Kelly has been in the news for his fight against head and neck cancer. His cancer was a squamous cell carcinoma located in the maxilla, or the upper jaw bone, and he initially underwent treatment consisting of chemotherapy and radiation therapy but unfortunately developed a recurrence of the cancer after his initial treatment. Because of this, surgery was performed to remove the recurrent cancer in his upper jaw bone and the salvage setting. And, in a patient who’s previously had radiation therapy, it’s very difficult for this area to heal after surgery and the result leaves a communication between the mouth and the nose, which can make speech abnormal, as well as swallowing. So, Jim Kelly underwent his surgery in New York by Dr. Mark Urken, who’s one of the most nationally known and most experienced surgeons, using what we call free flaps to reconstruct head and neck defects. So, a free flap is a piece of tissue that’s harvested from an area of the body outside of the head and neck, that often consists of either skin, fascia, muscle, bone, fat or a combination of all of these. And, it’s a piece of tissue that can be harvested with an artery and a vein that can supply blood to this piece of muscle or bone or fat. We can then take that tissue from the leg or the arm or the thigh and then transfer that up into the defect site and use it to reconstruct things like the tongue, the voice box or the jaw bone. Then, using a microscope, under very high magnification, we can actually sew the artery and the vein that are from the flap to an artery and a vein in the neck and that will actually provide that piece of tissue with its own blood supply. This is especially important in head and neck cancers because most of our patients receive radiation therapy as part of their treatment and without a robust, healthy blood supply, most pieces of tissue will die from the radiation therapy. We do know these pieces of tissue have a robust vascular supply and that they can withstand the radiation treatment, leading to very good results in reconstructing the donor site defect. In Mr. Kelly’s case, Dr. Urken performed what’s called a fibula free flap. And that’s when a piece of bone from the lower leg, called the fibula, is harvested with some overlying skin and an artery and a vein and he was actually able to use that bone to recontour the upper jawbone that was missing after the surgery. And he was able to use the skin from the flap to seal the hole in the palate so that Mr. Kelly was able to talk, eat and look normal essentially. In Mr. Kelly’s case, he was then able to have titanium dental implants inserted into that bone so that he could actually have teeth in his upper jaw again. And, if anyone’s seen him in the news lately, they did a fantastic job and he looks almost the exact same as he did before surgery. And, that is really the ultimate goal of cancer and reconstructive surgery nowadays.
Host: How do patients feel when they learn that their appearance might be affected by the surgery that will remove their cancer?
Dr. Giurintano: So, patients often feel a mixture of emotions. Receiving a diagnosis that you have cancer is very difficult. And, to add on to that diagnosis that you might require major surgery that might result in a physical deformity can be even more devastating to patients. Our facial structure is often a major part of our identity and it can be very psychologically devastating to learn that your visual appearance might be affected. This goes for the voice, as well. We all have unique voices that we can recognize very distinctly. And the possibility that you might lose your own unique voice can be very devastating to patients. In the past, patients would often have these tumors removed without any technology to reconstruct them and this could lead to crippling deformities that were very easily noticeable upon first glance. And this has a major psychological impact on patients. Some can often lead to depression and anxiety in our cancer patients. And while it’s impossible to perform a surgery that’s completely scar-less, all surgery requires at least an incision, today we have advanced techniques that limit the deformity that’s caused by removing cancers from the head and neck. We also have to give credit to the body itself. The body is pretty incredible in that anytime we take skin from the arm or the leg and we place it into the mouth, the body can actually recognize this change in the environment that the skin is in and it actually begins to change the cell types of that flap. And through a process that we call mucosalization, the flap actually begins to take on the appearance of the native tongue or the native surface of the mouth. In many of these patients, when you see them one or two years down the road, it is actually very difficult to tell which piece of tissue in the mouth came from the arm or the leg. It just looks like normal tissue.
Host: Is the reconstruction procedure performed separately from the cancer surgery?
Dr. Giurintano: So, we actually work together in what we call a two-team approach so that we can both remove the cancer and reconstruct the defect at the same time. This means that while the ablative, or the cancer removing surgeon, is working in the head and neck to take the cancer out, the reconstructive surgeon is, at the same time, working on the arm or the leg to harvest the flap so that as soon as the cancer is removed and the defect is made, the reconstructive surgeon can then take that flap, remove it from the arm or the leg and begin in-setting it into the defect. So, by doing the cases in this manner, we can typically finish an entire cancer removal and reconstruction in anywhere from 6 to 10 hours. Back whenever these types of surgeries were invented 20 or 30 years ago, the cases could often go over 24 hours. So, it’s actually been a big advance in our medical practice that we can finish these cases generally in under 12 hours. Our goal, essentially, is to limit the time the patient has to spend on the operating table under general anesthesia and to try to get patients back on their feet as quickly as possible after surgery to help quicken the recovery process.
Host: What does a patient have to do to prepare for head and neck surgery with a reconstruction?
Dr. Giurintano: Most of the preparation, from the patient standpoint, is more mental and emotional. We recommend that they have a good support system in place, whether it’s family or friends, to help them cope with the psychological impact of undergoing a major surgery and a, typically, 7 to 10-day hospitalization. There are some tests that we may perform in our clinic or in the radiology suite before we schedule a patient for a free flap. Nowadays we really try to tailor what type of free flap we are doing individually to each patient. In the past, physicians would often do one flap as their main flap, regardless of what the defect was or what the patient’s lifestyle included. But nowadays, for example, say if a patient of mine was a classically trained pianist and they wanted to continue playing piano after their surgery, I would be very hesitant to take any tissue from around their forearm or wrist. I would not want to interfere with their ability to play the piano at all. So instead I would go to a different donor site, either the side of the body or the leg. I’d take a similar piece of tissue and contour this to match the defect site. Occasionally, some patients require some tests such as angiography. This is a special test performed in the radiology suite to determine if the blood vessels are good enough to support a flap. For the fibula flap, especially - that’s a flap of the bone called the fibula in the lower leg that we often use to reconstruct the jaw- we know that there’s 3 distinct blood vessels that carry blood into the lower part of the leg to supply the foot. By taking the fibula, we have to take one of those blood vessels out to apply the flap, leaving 2 blood vessels to supply the leg. Normal patients - this is not a problem to remove this blood vessel. However, some patients only have 1 or 2 blood vessels supplying the lower leg, not 3. In these cases, it could be potentially disastrous to take the 1 blood vessel that’s supplying the lower leg. So, in this type of flap, we’ll always do a test before to make sure that the blood vessels are sufficient to sustain the flap. But otherwise, typically, we do not have many other special tests that are required before pursuing a major reconstruction.
Host: How long is the recovery time for these patients?
Dr. Giurintano: So, in general, our patients who undergo free flap reconstructions generally spend the first two days after surgery in the intensive care unit setting. During this time, it’s not that they’re so sick they require a stay in the intensive care unit. It’s actually that we have to frequently check the blood vessels supplying the flap to ensure that the blood is flowing to the flap and that the flap is getting the nutrients that it needs. Once the first two days have passed, as long as the patient is doing well, they often go to the floor. And from that point on, most patients spend anywhere from 3 to 5 days on the floor, receiving basic medical care as they recover. Oftentimes they’re receiving physical therapy or occupational therapy during this time to recover their strength. And all of the basic preparations for that patient to go home are being arranged. Typically, if all goes well during the surgery and during the hospitalization, most patients spend about 5 to 7 days total in the hospital and then either go home or sometimes go to a lower level of care, such as a rehabilitation facility to help regain their strength before they’re ready to go home. Once at home or in a rehab facility, it still takes a couple of weeks for the patients to completely recover. And, in general, the entire recovery process takes about 4 to 6 weeks total. But, most patients are back swallowing, speaking, and doing normal activities within 2 weeks of surgery.
Host: What additional treatment or care do patients need after reconstructive surgery?
Dr. Giurintano: Depending on the complexity of the case and how the hospitalization proceeds, some patients are able to go straight home and essentially require very minimal extra care. Occasionally, patients require the placement of feeding tubes or tracheostomy tubes. Tracheostomy tubes are special breathing tubes that are inserted into the neck that some patients may require because, occasionally, there’s too much swelling or the flap is too bulky inside of the mouth for them to breathe or to swallow well. Generally, this is a short-term procedure that patients do not require permanently, but sometimes this may require some extra care by a home health nurse or at a rehabilitation facility. Occasionally, if patients have trouble swallowing in the post-operative period and we a concerned that they might accidentally aspirate their foods, a tube can be placed into the stomach to help facilitate nutrition while they’re recovering. And, generally, this is also a short-term procedure that most patients are able to have removed after 6 to 8 weeks.
Host: How do the surgeons at MedStar Washington Hospital Center help patients achieve the best cancer related outcomes and cosmetic outcomes with these complex procedures?
Dr. Giurintano: So, at MedStar Washington Hospital Center, we work together as a team. Our team includes multiple members within the department of otolaryngology head and neck surgery. And this includes both ablative cancer surgeons (so those are surgeons who remove the cancer), reconstructive surgeons (such as myself), as well as facial plastic and reconstructive surgeons (so these are surgeons who are specially trained in cosmetic procedures of the head and neck). In caring for these patients, we, as surgeons, are responsible for the removal and the reconstruction of their cancer and the subsequent defects. But, in treating their cancer, we also share equal responsibility with our colleagues in the departments of radiation oncology and medical oncology. There are some types of head and neck cancer that can be managed through surgery alone, but most patients who have a head and neck cancer will also require either radiation therapy or chemotherapy as part of their treatment algorithm. We actually have a regular meeting at the MedStar Washington Hospital Center where the surgeons (such as myself), the medical oncologists, the radiation oncologists, the speech pathologists, the pathologists and the radiologists all meet to discuss new patients who have been diagnosed with cancer, as well as patients that have recently been treated for their cancers. And, during this meeting, which is what we call a multidisciplinary treatment conference, we are able to actually stage each patient’s cancer. We’re able to decide on a treatment that best suits that patient’s cancer. And, we’re able to put all of the right consults and all of the right steps in order so that patient can begin their treatment as soon as possible.
Host: Could you share the story of a patient who had a particularly successful outcome?
Dr. Giurintano: Yes. A patient, who had recently had several previous head and neck cancers, presented to the MedStar Washington Hospital Center, in my partner, Dr. Matt Pierce’s, clinic. This patient had previously undergone multiple surgeries and he had essentially received the maximum dose of radiation therapy that the body could receive in that area. And, unfortunately, there was a new cancer that had developed. This was a very devastating diagnosis to him, as he was a cancer survivor already. But, we were able to perform, essentially, a removal of the entire voice box and the entire back wall of the throat and then reconstruct that with tissue from his upper thigh. And, he had an absolutely amazing postoperative course. He was out of the hospital by postoperative day number 7. And this gentleman, who had not swallowed in 6 months, we had just obtained a swallow study to evaluate how the flap had healed, and he was able to swallow again - well - for the first time in 6 months. So, he was a particularly good outcome and we were very pleased with how he healed.
Host: Thanks for joining us today, Dr. Giurintano.
Dr. Giurintano: It was my pleasure. Thank you so much for having me.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.