This document provides an overview of free flap reconstruction techniques for head and neck defects. It discusses the history and evolution of free flaps, describes various flap types including fasciocutaneous, musculocutaneous, and composite flaps, and covers considerations for preoperative planning and intraoperative management. Key free flap options described include the radial forearm flap, lateral thigh flap, rectus abdominis flap, fibula flap, and jejunum flap. The document emphasizes that free flaps allow for tailored reconstruction with a variety of tissue types to match specific defect needs.

1. Free Flap Reconstruction of
Head and Neck Defects
Parag Parikh, MD
UC-Irvine
April 7, 2004

3. Introduction
 Prior to 3 Decades Ago
 Majority of Head and Neck Defects closed with
 Local Tissue
 Local Skin Flaps from other sites to the H/N
 Forehead Flap…Indians then McGregor in 1963
 1965 Bakamjian…Deltopectoral Flap
 Limited Reach

4. 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
 1973 Daniels and Taylor– “free flap”
 First free cutaneous flap

5. 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

6. Introduction
 Free flaps grew out of favor in the late 1970s to
early 80s
 Few donor sites
 Inconsistent small pedicles
 Technically difficult
 High morbidity

7. 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

8. 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

9. Free Tissue Transfer
 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

10. 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

11. 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

12. Disadvantages of Free Tissue
Transfer
 Technically demanding
 Increased operating room time
 Increased flap failure rate
 Functional disability at donor site

13. 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

14. Preoperative Planning
 Patient selection
 Age
 Diabetes
 Arteriosclerosis/Cardiac
 Tobacco use
 Collagen vascular disease
 Coagulopathies
 Hypercoagulable states

15. Reconstructive Planning
 Must consider all options for particular defect
and patient
 Options
 Secondary intent
 Primary closure
 Skin grafts
 Local flaps
 Myocutaneous flaps
 Free flaps

16. Fasciocutaneous Free Flaps
 Radial forearm
 Lateral arm
 Lateral thigh

17. Radial Forearm Free Flap
 Arterial source
 Radial artery
 Venous Source
 Paired vena
commitantes and/or
cephalic vein

19. Radial Forearm Free Flap
 Forearm
 Radial a. w/ vena
commitantes
 Lateral intermusc-
ular septum
 Antebrachial
cutaneous n.

20. 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

22. Radial Forearm Free Flap
 Choose the nondominant hand
 No venous access in the chosen donor arm
 Avoid raising the flap over the ulnar artery
 Volar splint X 2 weeks
 10-15 degrees of extension

23. Lateral Arm Free Flap
 Arterial supply
 Posterior radial collateral artery from profunda
brachii artery
 Venous supply
 Vena commitantes in spiral groove of humerus

25. 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.

28. Lateral Thigh Free Flap
 Arterial supply is from third perforator of
profunda femoris artery
 Venous output from associated vena
commitantes

33. 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

34. Muscle and Musculocutaneous Free
Flaps
 Rectus abdominis
 Latissimus dorsi

35. Rectus Abdominus Free Flap
 Arterial supply based
on deep inferior
epigastric artery
 Venous supply form
vena commitantes
joining external iliac
vein

36. Rectus Abdominis Free Flap
 Versatility of the inf
epig. a.
 Periumbilical perforators
 A. Transverse
 B. Extended
 C. Extended
 Less muscle
 D. Longitudinal
 Thick
 E. Subarcuate
 Thinner

38. 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

39. Rectus Abdominis Free Flap
 Preoperative evaluation
 Previous abdominal surgery
 Presence of umbilical hernia
 Presence of rectus diastasis

40. Latissimus Dorsi Free Flap
 Arterial supply
based on
thoracodorsal artery
 Venous drainage
from thoracodorsal
vein
 Motor nerve
innervation
potential with
thoracodorsal nerve

43. 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
 Postoperative seroma
formation
 Bulky flap
 Unable to tube

47. Composite Free Flaps
 Radial forearm
 Fibula
 Scapular/Parascapular
 Ilium

48. Fibular Free Flap
 Arterial supply – peroneal artery
 Dual supply
 Endosteal
 Periosteal
 Venous supply – vena commitantes

50. 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

51. Fibula Free Flap
 Fibula is outlined
 Skin paddle centered over junction of middle
and distal third to encompass dominant
septoperforators

52. Fibula Free Flap
 Leave 6 cm of proximal and distal fibula

55. Fibula Free Flap
 Aberrations in
blood supply
(10%)
 Peripheral vascular
disease

63. Iliac Crest Free Flap
 Arterial supply
from deep
circumflex iliac
artery
 Venous supply
deep circumflex
vein

64. 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

65. 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

66. Iliac Crest Free Flap

69. 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

70. Iliac Crest Free Flap
 Postoperative care
 Progressive mobilization
 Assisted ambulation POD # 3 or 4
 Stair climbing 3 weeks

71. Scapular/Parascapular Free Flap
 Arterial supply
 Circumflex scapular
 Venous Supply
 Vena commitantes

75. 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

76. 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

77. Jejunum Free Flap
 Arterial supply
from portion of
superior mesenteric
arterial arcade (2nd
or 3rd arcade)
 Venous supply
from venous
branches along
arcade

79. 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

80. Jejunum Free Flap
 Contraindications
 Ascites
 History of extensive abdominal surgery
 Involvement of the thoracic esophagus
 H/o of intestinal disease (Crohn's)

81. Intraoperative Management
 Operating microscope, instruments, sutures
 Irrigation supplies
 Anticoagulants and volume expanders
 No pressors
 Patency assessment (15-20 minutes)
 Pulsation
 Doppler

82. 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

83. Postoperative Management
 Inspection and prick test
 Arterial vs. venous insufficiency
 Pharmacotherapy
 Heparin, dextran, aspirin

84. Oral Cavity and Oropharynx
Reconstruction
 Thin pliable mucosa
 Possibilities
 Radial Forearm
 Scapular/Parascapular
 Lateral Arm
 Lateral thigh

85. 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

86. 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

87. 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

88. 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

89. 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