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Free Flap Reconstruction
of Head and Neck Defects
Christopher Muller, M.D.
Faculty Advisor: Shawn Newlands, M.D., Ph.D.
Faculty Advisor: Anna M. Pou, M.D.
The University of Texas Medical Branch
Department of Otolaryngology- Head and Neck Surgery
Grand Rounds Presentation
May 2002
Introduction
Last 3 decades
Advances in head and neck oncologic therapy
• Multimodality therapy (Surgery, XRT, chemo)
• Laryngeal preservation therapy
• Modifications of the radical neck dissection
Plateau in survival rates
• Last 2 decades have focused on improved functional
and reconstructive outcomes
Introduction
Prior to 3 decades ago
Majority of H/N defects were closed with
• Local tissue
• Random skin flaps “Walked” up to the H/N from other sites
1963 – McGregor performed the forehead flap (axial skin flap)
• Large forehead defect requiring skin grafting
1965 – Bakamjian – deltopectoral flap
• Limited reach
Introduction
Early 1900’s Alexis Carrel
Free tissue transfer in animals (jejunum to neck)
1950’s Jacobsen and Suarez-- first anastomoses in animal
1959 Seidenberg– free jejunum segments to repair pharyngoesophageal defects
1972 McLean and Buncke – omental flap to cover a cranial defect
1973 Daniels and Taylor– “free flap”
First free cutaneous flap
History
1976 Baker and Panje– first free flap in
head and neck cancer reconstruction
Groin pedicled on the circumflex iliac artery
Other cutaneous flaps • Axillary
• Dorsalis pedis
Introduction
Free flaps grew out of favor in the late
1970s to early 80s
Few donor sites
Inconsistent small pedicles
• Technically difficult
• High morbidity
Introduction
Pedicled flaps grew in favor (70s and 80s)
1976 – Tansini – Latissimus dorsi
Pectoralis major
Trapezius
Sternocleidomastoid
1979 – Ariyan – harvest rib with PMC
1979 – Demergasso and Piazza – harvest spine
of the scapula with trapezius flap
REGIONAL FLAPS
Advantages/Uses:
Bulky
Quick and easy to harvest
Single stage
Minimal donor site morbidity
Required one surgical team
Large Tongue Base/TG Defects
Carotid Coverage
Disadvantages:
Bulky
Downward Pull of Flap
Atrophy
Arc of Rotation Limiting
Distal Flap Necrosis
Introduction
Last 15 years
Search for new and better donor sites
Resurgence of free tissue transfer
Introduction
1979 – Taylor et al. – iliac crest composite flap
1980 – dos Santos et al. – scapular cutaneous flap
1981 – Yang et al. – radial forearm free flap
1982 – Nassif et al. – parascapular cutaneous flap
1982 – Song et al. – lateral arm fasciocutaneous flap
1983 – Baek et al. – lateral cutaneous thigh flap
1985 – Drever et al. – rectus Abdominis myocutaneous flap
1986 – scapular osseocutaneous flap
Advantages of Free Tissue Transfer
Two team approach
Improved vascularity and wound healing
Low rate of resorption
Defect size little consequence
Potential for sensory and motor innervation
Permits use of osseointegrated implants
Advantages of Free Tissue Transfer
Wide variety of available tissue types
Large amount of composite tissue
Tailored to match defect
Wide range of skin characteristics
More efficient use of harvested tissue
Immediate reconstruction
Disadvantages of Free Tissue Transfer
Technically demanding
Increased operating room time
Increased flap failure rate
Functional disability at donor site
Preoperative Planning
Amount and type of tissue required
Bone, soft tissue bulk, external vs. internal lining
Anticipated functional gains
History of previous surgery or injury around the donor site
Donor morbidity
Patient positioning and donor location
Operative time
Need for carotid coverage
Patient factors
General medical status
Wishes and expectations
Preoperative Planning
Patient selection
Age
Diabetes
Arteriosclerosis/Cardiac
Tobacco use
Collagen vascular disease
Coagulopathies
Hypercoagulable states
Reconstructive Planning
Must consider all options for particular defect and
patient
Options
Secondary intent
Primary closure
Skin grafts
Local flaps
Myocutaneous flaps
Free flaps
Fasciocutaneous Free Flaps
Radial forearm
Lateral arm
Lateral thigh
Radial Forearm Free Flap
Arterial source
Radial artery
Venous Source
Paired vena
commitantes and/or
cephalic vein
Forearm
Radial a. w/ vena
commitantes
Later intermusc-
ular septum
Antebrachial
cutaneous n.
Radial Forearm Free Flap
Advantages
Thin, pliable skin with long,
large pedicle
Easy positioning
Potential for sensate flap
Potential for unusual shapes
Potential for vascularized
bone
Ease of preoperative
evaluation
Disadvantages
Loss of hand
Poorly aesthetic donor site
Requires skin graft
Potential for pathologic
fractures
Loss of hand function
Superficial palmar arch, Allen's test
Surgical Pearls - RFFF
Choose the nondominant hand
No venous access in the chosen donor arm
Avoid raising the flap over the ulnar artery
Leave Paratenon
Volar splint X 2 weeks
10-15 degrees of extension
Lateral Arm Free Flap
Arterial supply
Posterior radial collateral artery from profunda
brachii artery
Venous supply
Vena commitantes in spiral groove of humerus
Lateral Arm Free Flap
Advantages
Low donor site
morbidity (vertical
scar)
Easy positioning
Potential for sensory
innervation via
posterior cutaneous
nerve
Disadvantages
Short and smaller
caliber artery (1.55
mm, up to 8-10 cm)
Longer dissection than
RFFF
Thicker subcutaneous
tissue
Pressure dressing
• Risk to radial n.
Lateral Thigh Free Flap
Arterial supply is from third perforator of
profunda femoris artery
Venous output from associated vena
commitantes
Lateral intermuscular septum is marked
Lateral Thigh Free Flap
Advantages
Large amount of thin,
hairless skin
Low donor site
morbidity (primary
closure)
Easy positioning
Sensation potential
with lateral femoral
cutaneous nerve
Disadvantages
Difficult dissection
• Retraction of vastus
lateralis
Short, variable pedicle
• 15 cm, 2-4mm
Muscle and
Musculocutaneous Free
Flaps
Rectus abdominis
Latissimus dorsi
Rectus Abdominus Free Flap
Arterial supply based
on deep inferior
epigastric artery
Venous supply form
vena commitantes
joining external iliac
vein
Versatility of the
inf epig. a.
Periumbilical
perforators
A. Transverse
B. Extended
C. Extended
Less muscle
D. Longitudinal
Thick
E. Subarcuate
Thinner
Rectus Abdominus Free Flap
Advantages
Easy positioning and
harvest
Constant anatomy
Long (8-10 cm) and large
caliber vessel (avg 3.4 mm)
Donor site closed primarily
Large flap obtained
Anterior rectus sheath
durable
Disadvantages
Often bulky
No sensation potential
Potential for hernia
formation if dissection
below arcuate line
Rectus Abdominis Free Flap
Preoperative evaluation
Previous abdominal surgery
Presence of umbilical hernia
Presence of rectus diastasis
Latissimus Dorsi Free Flap
Arterial supply based on thoracodorsal artery
Venous drainage from thoracodorsal vein
Motor nerve innervation potential with thoracodorsal nerve
Latissimus Dorsi Free Flap
Advantages
Large flap with long pedicle ( artery 2-3 mm, vein 3-5 mm, length: 7-10 cm)
2nd largest skin paddle
Possibility for “axillary megaflap”
Multiple skin paddles
Low donor site morbidity
Possibility of muscle reinnervation via thoracodorsal nerve
Disadvantages
Difficult positioning
and two team harvest
• 30-45% LD
Postoperative seroma
formation
Bulky flap
• Unable to tube
Composite Free Flaps
Radial forearm
Fibula
Scapular/Parascapular
Ilium
Fibular Free Flap
Arterial supply – peroneal artery
Dual supply
• Endosteal
• Periosteal
Venous supply – vena commitantes
Fibular Free Flap
Advantages
Longest and strongest bone stock (25 cm of bone)
Pedicle 12 cm
Can be a sensate flap
• Lateral sural n.
Low donor site morbidity
Easy positioning
Excellent periosteal blood supply (contouring)
Support osseointegrated implants
Disadvantages
High incidence of
peripheral vascular disease
Small cutaneous paddle
Decreased ankle strength
and toe flexion
Small risk chronic ankle
pain
Requires invasive study for
preop. evaluation
Fibula is outlined
Skin paddle centered over junction of middle and
distal third to encompass dominant
septoperforators
•Leave 6 cm of proximal and distal fibula
Fibula Free Flap
Aberrations in blood
supply (10%)
Peripheral vascular
disease
Fibular Free Flap
Iliac Crest Free Flap
Arterial supply from
deep circumflex iliac
artery
Venous supply deep
circumflex vein
Iliac Crest Free Flap
Advantages
Thick bone stock
Easy positioning
Defect closed primarily
Minimal donor deformity
Support osseointegrated implants
Disadvantages
Bulky soft tissue component
Poor reliability of skin paddle
Pelvic pain and risk for hernia formation
Decreased postop ambulation
Risk to peritoneum
Iliac Crest Free Flap
Most commonly used for mandibular
defects in the head and neck
best for angle/body defects
can be used for symphyseal and
parasymphyseal defects
Iliac Crest Free Flap
Iliac Crest Free Flap
Skin paddle
based on cutaneous perforators
must be made large enough to incorporate
perforators
has poor mobility
• Can be improved by placing the paddle more
cephalad
Iliac Crest Free Flap
Postoperative care
Progressive mobilization
Assisted ambulation POD # 3 or 4
Stair climbing 3 weeks
Scapular/Parascapular Free Flap
Arterial supply
Circumflex scapular
Venous Supply
Vena commitantes
Scapular/Parascapular Free Flap
Advantages
Large skin paddle
Easy to harvest
Low donor site
morbidity (closes
primarily)
Availability for bone
Disadvantages
Thick skin
Difficult positioning
Jejunum Free Flap
Seidenberg (1959) - First case report in a
human
Roberts and Douglas (1961) – first patient
to survive
Primarily use for reconstruction of
pharyngoesophageal defects
Jejunum Free Flap
Arterial supply from
portion of superior
mesenteric arterial
arcade (2nd or 3rd
arcade)
Venous supply from
venous branches along
arcade
Jejunum Free Flap
Advantages
Tubular
Mucosal surface may
help with lubrication
Minimal donor defect
Disadvantages
Bowel or pharynx fistulas
Need for laparotomy
• Gen. Surg. team
No neovascularization
Reverse peristalsis
Poor TE speech
Short pedicle
Difficult in obese persons
Jejunum Free Flap
Jejunum Free Flap
Contraindications
Ascites
History of extensive abdominal surgery
Involvement of the thoracic esophagus
H/o of intestinal disease (Crohn's)
Intraoperative Management
Operating microscope, instruments, sutures
Irrigation supplies
Anticoagulants and volume expanders
No pressors
Patency assessment (15-20 minutes)
Pulsation
Doppler
Postoperative Management
Skilled nursing important
No pressure on pedicle (no ties on neck)
Eliminate cooling of flap
Keep head in neutral position
No pressors– keep BP stable
Hematocrit important
Frequent inspections and doppler pedicle
Postoperative Management
Inspection and prick test
Arterial vs. venous insufficiency
Pharmacotherapy
Heparin, dextran, aspirin
Postoperative Management
Temperature measurements
SPECT scanning
Infrared spectroscopy
Transcutaneous and intravascular devices
Technicium scanning
Oral Cavity and Oropharynx
Reconstruction
Thin pliable mucosa
Possibilities Radial Forearm
Scapular/Parascapular
Lateral Arm
Lateral thigh
Tongue Reconstruction
Reconstruction aimed at preserving what has not been resected
Less than 1/3-1/2– primary closure vs. STSG
Over ½--consider free free flap if expected contracture makes
speech/bolus transit difficult (sensate)
Anterior 2/3–consider coned RFFF (sensate)
Tongue Reconstruction
For tongue base and total glossectomy
defects—need adequate oral mound to
approximate with palate for speech and
bolus transit
May consider rectus abdominus and latissimus
dorsi free flaps
Hypopharynx and Cervical Esophageal
Reconstruction
Must be prepared for possibility of complete
circumferential pharyngeal defect
Over 3 cm remains– primary closure
Less than 3 cm—pec flap vs. RFFF
Total loss above thoracic inlet– tubed pec flap,
RFFF, scapular FF, lateral thigh free flap, or free
jejunum flap
Total loss below thoracic inlet– gastric pull-up
Mandibular Reconstruction
Loss of anterior mandibular arch Loss of chin/lip support
Sensory loss
Malocclusion
Retrognathia
Lack of oral competence/eating/speaking
Consider osteocutaneous free flaps-- fibula,
iliac crest, scapula, radius
Mandibular Reconstruction
Loss of lateral mandible Concavity of cheek
Mandible rotation to defect side with cross bite
Remnant rotation superiorly and medially
Mental nerve loss
Easier for patient to adjust
Consider osteocutaneous free flap
Case 1
57 y/o man with complaint of diplopia and
left cheek numbness
History
Left maxillary sinus squamous cell carcinoma
• Treated with left medial maxillectomy and XRT
PMHx: severe COPD, MI
PSxHx: multiple abdominal surgeries including
laparotomy
Social: + smoker, +etoh
Case #2
Case #3
Case #4
Case #5
ENT resident
CC – I’m
deformed!
Treatment
palliative
