Rebuilding after head and neck surgery

What happens, step by step

1. 1
   Before the day: the planning that decides most of it.

   Scans are looked at again to work out how much has to be removed and therefore how much has to be replaced. A dentist checks your teeth, and any that are beyond saving are taken out before the operation rather than after it, because a tooth that gives trouble later is much harder to deal with in rebuilt tissue. Blood tests, a chest check and a heart check say whether a long anaesthetic is safe for you. If the forearm is being considered, a simple bedside test on your wrist checks that the hand has a good blood supply from its second artery, because one of them is going to travel with the flap. You meet the speech and swallowing therapist and a dietitian before anything is done, not afterwards. If you use tobacco or alcohol, stopping now genuinely changes how well tissue heals, and the team will help you do it.

2. 2
   Choosing where the tissue comes from, with you in the room.

   Each donor site costs something different, and you are entitled to know what before you consent. The forearm gives thin, soft skin that folds well inside a mouth, and it leaves a patch on the arm that is covered with a thin skin graft taken from the thigh — a scar on the forearm that is visible when sleeves are short. The thigh gives thicker tissue and a scar that clothes cover. The lower leg gives bone for a jaw, and you work with a physiotherapist to get walking again afterwards. Your surgeon will say which sites are suitable for your operation and why one is preferred; ask what the arm or the leg will look like and what it will and will not do afterwards.

3. 3
   The morning of the operation.

   You will have been asked not to eat from midnight, with sips of water allowed up to a stated time. Consent is taken again in the morning, and this is a good moment for the questions you thought of overnight. Marks are drawn in pen on the neck and on the donor limb. A bed in intensive care or a high dependency unit is booked in advance for you — that is planned, not a sign that something has gone wrong. Whoever is waiting should be told where to wait and that they will hear nothing for a long stretch, because that silence frightens families more than anything else about this day.

4. 4
   In theatre: two pieces of work at the same time.

   Once you are asleep, part of the team works on removing the cancer, and often the lymph nodes on that side of the neck with it, while another part raises the flap from the arm or the leg. Working in parallel is what keeps the day as short as it can be. This is one of the longest operations in cancer surgery, and no website should give you a figure for the clock — ask your own surgeon the day before for the expected length of yours, and pass that number to whoever is waiting outside.

5. 5
   Joining the vessels.

   The flap is detached, moved, and set into the gap. Then its artery and vein, each about the width of a matchstick tip, are stitched to vessels in the neck under, with thread too fine to see clearly from arm's length. When the clamps come off, colour returns to the tissue and it begins to bleed at the edges — which is exactly what everyone in the room wants to see. This part is quiet and slow and it is the part the rest of the day is built around.

6. 6
   Waking up, and why somebody checks you every hour.

   You wake in intensive care or a high dependency unit. The mouth and neck swell after an operation of this size, so a temporary breathing tube is often placed through a small opening in the front of the neck — a tracheostomy — to keep the airway easy while the swelling settles; it is removed once it is no longer needed, and it is a planned step rather than an emergency. A fine tube through the nose carries feed to the stomach so nothing has to pass through the healing mouth. There are drains in the neck and a dressing on the donor site. A nurse looks at the flap every hour, day and night: colour, warmth, a gentle press to see the colour come back, sometimes a small probe held against it that makes a sound when blood is flowing. Being woken hourly is deliberate. A flap whose blood supply is failing can often be taken back to theatre and rescued if it is found early, and cannot be if it is found late.

7. 7
   The first days on the ward.

   The head of the bed stays up. Nothing tight goes round the neck — no collar, no tie, no tape across the join — and you are asked not to lie on the side where the vessels were joined. Your mouth is cleaned several times a day with a soft syringe of solution rather than a brush. You are helped out of bed to a chair earlier than you would expect, because chests and legs both do better for it. A physiotherapist starts work on the donor arm or leg and on the shoulder, which stiffens after neck surgery if it is left alone. The drains come out one at a time as they dry up.

8. 8
   Eating, speaking, and going home.

   The speech and swallowing therapist tests your swallow before you are allowed to drink, then you move from sips to soft food, and the feeding tube comes out when it is safe rather than on a fixed day. Speech takes longer than swallowing and improves for months with exercises. Before you go home, you and whoever is with you are taught to look after the wound, the donor site and the mouth, and you are given a follow-up date and a number to call. Expect to stay seven to ten days. Some plain facts about the flap itself: it will be numb and stays numb, it does not match the surrounding skin exactly, it looks bulky at first and settles over months, and if the skin came from a place where hair grows, hair will grow there.

Side effects, and the support that comes with them

There are two sets of after-effects here, one in the neck and one where the tissue came from, and both are worth knowing about in advance. In the head and neck: swelling that makes the face look unfamiliar for weeks, numbness of the skin over the neck and the ear which is often permanent, a stiff or dropped shoulder if lymph nodes were removed, a changed and tired voice, and a mouth that feels crowded until the swelling settles. Taste changes, and so does the amount of saliva you make. Swallowing is harder at first and improves with exercises rather than with time alone. The flap itself is a patch of skin that has no feeling, no sweat and no matching colour, and people usually notice it far less than the person who has it does. Eating in front of others is one of the things patients say they dread most, and it is worth practising at home first. At the donor site: a scar, weakness and stiffness, a numb area around the scar, and for a forearm flap a skin-grafted patch that stays visible; for a leg flap, walking that is unsteady at first and needs the physiotherapist. Feeding through a tube for a period is normal after this operation and does not mean anything has gone wrong. So is a low mood at around one to two weeks, when the shock of the operation has passed and the length of the recovery is becoming obvious. Tell somebody. It is common, it is not weakness, and there is help.

Questions we hear every week