Oral and maxillofacial surgery with reconstruction : University College London Hospitals NHS Foundation Trust

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This page explains what oral and maxillofacial surgery is. It provides information about the risks and benefits and what you can expect after surgery. If you have any questions, speak to your healthcare team. You may also wish to share this information with your friends and family.

Oral and maxillofacial surgery is used to treat conditions affecting the face, neck, mouth and jaws. These conditions include cancer. This page gives information about oral and maxillofacial surgery with reconstruction. This means using tissue or bone from another part of your body to rebuild facial structures.

There are different types of oral and maxillofacial surgery. Your healthcare team may have talked to you about one or more of the types listed below:

A partial glossectomy to remove part of your tongue.
Total-glossectomy to remove all of the tongue.
Hemi-mandibulectomy to remove part of the jawbone.
Floor-of-mouth resection to remove the tumour from under the tongue.

The aim of the operation is to cure your cancer by removing the tumour and a small area of healthy tissue or bone around it. This lowers the risk of cancer cells being left behind.

Removing the tumour will create a gap. This gap needs to be reconstructed to help you speak and swallow. To do this, the surgeons will use healthy tissue or bone from another part of your body. For example, your forearm or thigh. This is called ‘a free flap’.

The free flap includes blood vessels, which carry blood, oxygen and nutrients around your body. These blood vessels will be connected to the blood vessels in your neck. After the surgery, we will closely monitor the free flap to make sure it has a good blood supply.

Once the free flap reconstruction is done, the surgeon will repair the area where the tissue or bone was taken from. They will use a skin graft for this. A skin graft means taking healthy skin from another part of your body and using it to repair the area.

Every treatment and procedure come with some risks and possible side effects. We will talk to you about the risks specific to you before the surgery.

We have listed some common risks that apply to all operations. They affect between 1 and 10 in 100 people.

General anaesthetic: This is generally safe. Some common side effects from the anaesthetic drugs include sore throat, sickness or shivering. But risks vary between patients, depending on the surgery and anaesthetic technique used. For more information about the risks associated with general anaesthetic, visit the Royal College of Anaesthetists website.
Chest infection: People who smoke have a higher risk of developing a chest infection. We strongly suggest stopping smoking at least a few weeks before your surgery to reduce this risk. After surgery, we will encourage you to begin walking as soon as possible. You will also see a physiotherapist who will teach you deep breathing exercises. They will tell you how often you should do the exercises to help reduce the risk of chest infection.
Wound infection: To reduce the risk of wound infection, you may need to take a course of antibiotics.
Blood clots: There is a risk of blood clots in the legs (deep vein thrombosis) or in the lungs (pulmonary embolism). There are a few ways to reduce the risk of blood clots:
- We will give you daily blood-thinning injections during your hospital stay.
- We will ask you to wear special stockings during your hospital stay.
- A physiotherapist will teach you to do regular leg exercises and encourage you to walk as much as you are able.
- It’s important to stop smoking at least a few weeks before your surgery. If you need advice or support to stop smoking, speak to your key worker or another clinical nurse specialist (CNS). Or visit the NHS Better Health website.

There are also risks specific to oral and maxillofacial surgery with reconstruction. These risks can be different for each patient, based on your cancer and the type of surgery you have. We have listed the possible complications below. Your surgeon will talk to you about how likely these risks are for you.

Free flap failure (rejection of transplanted skin). There is a small risk that the blood flow to the transplanted skin may slow down or stop during or after surgery. If this happens, you may need more surgery to restore blood flow, or to replace the free flap with a new flap from another part of your body.
Bleeding. There may be bleeding from the area where surgery was done.
Difficulty swallowing.
Nerve injury or damage.
Airway blockage. Swelling after surgery can sometimes block your airway.
Difficulty to remove some healthy tissue around the tumour. Sometimes it’s not possible to remove a small amount of healthy tissue around the tumour, depending on where the tumour is. Also, very small cancer cells that are not visible might remain in healthy tissue.
Cancer recurrence. There is a risk that the cancer may return.

Your healthcare team recommends surgery as the best treatment option for you. If you choose not to have surgery, the cancer will continue to grow and may spread.

There may be other treatment options available to you, depending on your diagnosis and circumstances. They include:

Radiotherapy: This uses high-energy X-rays to destroy cancer cells while protecting normal cells as much as possible.
Chemotherapy: This works by stopping cancer cells from growing and spreading. It can be given through a vein or as tablets.
Combination of radiotherapy and chemotherapy.
Immunotherapy: This helps your immune system to destroy cancer cells.

Your doctor will talk to you about these options and advise you if any of them may be suitable for you. If you have any questions, speak to your doctor.

You will have a pre-assessment appointment before surgery to check your health. This appointment is usually with a nurse and an anaesthetist (the doctor who will put you to sleep for surgery). You will have several tests during this appointment to make sure you are ready for surgery. They include:

Blood tests.
A heart test called an ECG (electrocardiogram).
A cardiopulmonary exercise test (CPET), which involves riding a stationary bike. This helps us to assess your fitness for surgery.

You will also meet with the following healthcare professionals:

A speech and language therapist who will explain how your speech and swallowing might change, depending on your surgery. They will help you to adjust to those changes as well.
A dietitian who will talk to you about your eating and drinking needs after surgery. You may need a feeding tube for seven to 10 days while you heal, and the dietitian will explain what type of tube you may have.
A restorative dentist who will carry out a dental check because you might need some teeth removed during your surgery.

You can also see a psychologist if you’d like. Speak to your key worker or CNS if you want to be referred.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with the surgery, we will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. We will explain all the risks, benefits and alternatives before we ask you to sign a consent form. You will also have a chance to ask about anything you are unsure of. We will do our best to answer all your questions.

You will be admitted to the head and neck ward the night before your surgery. A nurse looking after you will tell you what to expect the next day. The operation will take about eight to 10 hours.

You will have general anaesthesia, so you will be asleep the entire time and you will not feel any pain. Once you are asleep, a small tube (catheter) will be placed in your bladder to collect urine in a bag.

Two teams of surgeons will operate at the same time:

One team will remove your cancer.
The other team will create a free flap.

The team removing your tumour will also remove some healthy tissue around it to help make sure there is no cancer left behind. If you have cancer in the lymph nodes in your neck, they will remove the affected lymph nodes too. They will close the cut in the neck with surgical clips.

At the same time, the other team will create a free flap by removing tissue, blood vessels and possibly bone from another part of your body (the donor site). They will move this tissue to replace the area where the tumour was removed. They will close the donor site with surgical clips and non-dissolvable stitches. A foam dressing and bandage will cover this wound.

A skin graft (a thin layer of skin) from your abdomen or thigh will cover the donor site. This part will not need stitches and will be covered with a simple dressing.

The tumour and any lymph nodes that are removed will be sent to the laboratory for testing.

After surgery, we will take you to the Post-Anaesthetic Care Unit (PACU) where we will monitor you closely. You may stay sedated for a few hours or overnight before we wake you up. While in PACU, you will be able to control your pain by pressing a button on a special pump. This is called patient-controlled analgesia (PCA).

After about two nights in PACU, we will transfer you to the head and neck ward.

When you wake up, you will have:

A urinary catheter to check how much urine (pee) you make. It will stay in for one to two days.
A feeding tube that goes from your nose to your stomach. This tube helps to give you the nutrition you need. It may be removed soon after surgery, or you may need it for a longer time. Some people go home with the feeding tube; your healthcare team will advise you.
Two or three drains in your neck and the donor site. These drains help to remove excess fluid. They will stay in for three to seven days, depending on how much fluid is drained.
Stitches and clips that have been used to close your skin wounds. We will remove them 10 to 14 days after surgery.

You may also wake up with a tube in your neck to help you breathe. This tube is called a tracheostomy. It goes into your windpipe (trachea) through a small opening in the front of your neck.

You may need this tube if you had surgery to your throat or mouth and there is swelling that makes it hard to breathe. The tube will be taken out once the swelling goes down, usually a few weeks after surgery.

A tracheostomy can also help to clear out mucous from your lungs and keep them clean. While you have this tube, you will be unable to speak. You may need to write down what you want to say. Once the tube is removed, we will help you start speaking again.

General anaesthetic can affect your judgement, coordination and memory. It's important that you do not make any important decisions or sign any legal documents for 24 hours after waking up from your surgery.

The length of recovery and the time you spend in hospital will depend on your surgery. On average, patients stay in hospital for around two weeks or longer.

In the hospital, we will give you a goals chart that outlines what you should try to do each day after surgery. This may include simple tasks like getting up and walking.

The chart will help to guide you through your recovery. Setting daily goals can be a great way to stay motivated. It can also remind you of the progress you have made so far.

ERAS is a care programme to help you recover faster after your operation. It supports you in getting back to your daily activities as soon as possible.

Studies show that people recover more quickly when they:

Start moving early.
Eat and drink soon after surgery.
Do gentle exercises.
Manage pain well.

ERAS focuses on all these and shows you how you can take an active role in your recovery.

An ERAS nurse will check on you while you're in hospital and support you during your recovery. They will help you to leave the hospital sooner and feel better faster.

This will depend on the results from examining the tissue removed during surgery. The results can take around two weeks to come back. Some people may need chemotherapy or radiotherapy to target any tiny cancer cells that may still be there. Your healthcare care team will talk to you about your individual treatment and answer any questions you may have.

Wounds inside the mouth

If you have a wound inside your mouth, a nurse will show you how to keep it clean. 

External wounds

Skin graft sites: These usually heal before you leave hospital. They do not need a dressing and can be left open to air.

Neck wounds: These do not need dressings. Surgical clips are usually removed before you leave hospital. If you go home with stitches or clips, we will tell you where and when to go to have these removed.

Free flap donor site wounds: The dressing and bandages put on during surgery stay on for 10 to 14 days. After they are removed, your surgeon and nurse will assess your wound. If it is healing well, they will remove all clips and stitches, and the wound can stay open to air. If needed, they may put a simple dressing on and change it every few days while you are still in hospital.

If you go home with dressings, you will have an appointment to have them removed and your wound assessed. You will also have a follow-up appointment one week after leaving the hospital to check how your wound is healing. This will be with your key worker or another CNS. The CNS team will support you in caring for your wound until it is fully healed.

Our web page about caring for your wounds after head and neck surgery provides more information.

Pain: It is normal to feel some pain or discomfort for a few weeks after your surgery. Your healthcare team will explain how to manage pain and prescribe pain relief if needed. If your pain is not well controlled, contact your key worker at UCLH.
Speech: Surgery to the mouth and throat may change how you speak. A speech and language therapist will explain what to expect before your surgery. There is more information about speech and voice after head and neck cancer treatment on the Macmillan Cancer Support website.
Swallowing: After your feeding tube is removed, you can start eating and drinking again. A dietitian will advise you on foods that are easy to chew and swallow. There is more information about eating and drinking after head and neck cancer treatment on the Macmillan Cancer Support website.
Numbness or changes in sensation: Surgery may affect the feeling in your mouth, face, ears, neck or shoulders. Some areas may feel numb if nerves were bruised during the operation. It may take several months for feeling to return.
Changes to your appearance: Your healthcare team will talk to you about any possible changes to the way you look before surgery.

Swelling: You may have some mild swelling around your operation sites. This is normal and can last for a few weeks. Contact your key worker at UCLH if:
- the swelling gets worse or becomes painful
- you notice swelling in other parts of your body.
Discharge from the wound: Clear fluid from your wound may simply be saliva. But if the wound becomes red and hot, and you notice discharge that is not clear, contact your key worker at UCLH without delay. This is because you may have an infection and you may need antibiotics to treat it.
Fever: If your temperature is 38 degrees or higher, contact your key worker at UCLH.
Bleeding: Contact your key worker at UCLH or go to your nearest Emergency Department (A&E) if there is bleeding from the site of surgery or from the free flap.

If you are worried or unsure about any symptoms in the first month after your surgery, contact your key worker at UCLH or your local CNS.

You will have an appointment with your key worker or another CNS one week after leaving the hospital. They will check how your wound is healing. This can be done in person or over the phone.

You will also have an appointment with your surgical team within two weeks of your surgery.

After that, you will have regular follow-up appointments with your healthcare team. We will give you the details before you leave the hospital.