Microvascular reconstructive surgery involves transferring autogenous tissue using microsurgery to reconstruct defects, commonly in the jaws, mouth, throat, face, scalp and neck. Microsurgery uses magnification to anastomose small blood vessels and nerves. Successful reconstruction depends on preventing vessel wall damage during anastomosis so that the platelet plug that initially forms will gradually disappear over 1-2 weeks as new endothelium forms.

2. Microvascular surgery
 Microvascular reconstructive surgery involves the transfer of
autogenous vascularized tissue to reconstruct extensive tissue
defects.
 Areas commonly reconstructed include the jaws and mouth,
the throat, and all areas of the face, scalp, and neck.
 Microsurgery uses the operating room microscope or high-
powered loupe magnification to aid in the techniques of
microvascular surgery to anastomose small vessels and nerves

3. How does it help?
 With intimal injury, exposed collagen triggers platelet
adhesion. Platelets aggregate and activate fibrinogen,
which adheres to platelets and acts to link platelets
together to form a platelet plug. Fibrinogen is converted to
fibrin, strengthening the platelet plug. If the vessel walls
are not damaged and the anastomosis is secure, the platelet
plug gradually disappears over the first 3-5 days. New
endothelium covers the anastomotic site 1-2 weeks later.

4. Reconstructive Ladder
 The term coined by reconstructive plastic surgeons to describe
levels of increasingly complex management of wounds.
 Rung 1: Healing by secondary intention
Rung 2: Primary closure
Rung 3: Delayed primary closure
Rung 4: Split thickness graft
Rung 5: Full thickness skin graft
Rung 6: Tissue expansion
Rung 7: Random flap
Rung 8: Axial flap
Rung 9: Free flap

6. Free Tissue Transfer
Defect Type Tissue Defect Common Flaps
Coverage of exposed
structures
Open tibial fractures in the
distal third of the leg
Latissimus dorsi muscle free flap; gracilis
muscle free flap
Dead space Obliteration of maxilla defect
after maxillectomy for cancer
Rectus abdominus muscle free flap
Tissue defect Breast reconstruction Transverse rectus abdominus
myocutaneous (TRAM) free flap; deep
inferior epigastric perforator (DIEP) flap;
superior gluteal artery perforator (SGAP)
free flap
Facial muscle
denervation
Facial paralysis with muscular
atrophy
Gracilis muscle free flap
Digital amputation Thumb amputation Great toe composite free flap
Digestive tract defect Esophageal reconstruction Jejunum free flap; anterior lateral thigh
(ALT) free flap

7. Work up
 Preoperative planning includes finding the optimal donor site and
designing the flap to maximize soft tissue coverage, functionality,
and appearance and to minimize complications. In oncologic cases,
the timing of free flap reconstruction should be coordinated with
the oncology team, taking into consideration chemotherapy and
radiation treatments.
 After the decision has been made to proceed with a microsurgical
reconstruction, the optimal flap must be chosen. This decision is
based on the size of the defect, the type of tissue required for the
repair (bone, muscle, fascia, tendon, nerve, skin), and the reliability
of the flap.

8. Common Flaps
 Anterior lateral thigh flap
 Radial forearm flap
 Lateral arm flap
 Scapular flap
 Latissimus dorsi flap
 Rectus abdominis flap
 Superficial inferior epigastric artery flap (SIEA)
 Gracilis flap
 Tensor fascia lata flap
 Omental flap
 Jejunal flap
 Fibula flap
 Great toe flap

9. Gracilis Flap

10. Gracilis Flap

11. Gracilis Flap

12. Gracilis Flap

13. Antero lateral thigh Flap

14. Antero lateral thigh Flap

15. Antero lateral thigh Flap

16. Antero lateral thigh Flap

17. Complications
Postoperative complications include the following:
 Flap compromise due to vein or artery thrombosis
 Flap congestion
 Fat necrosis
 Hematoma with pedicle compromise and need for transfusion
 Infection
 Wound breakdown
 Wound complication associated with the donor site
 Systemic complications associated with anesthesia
 Deep vein thrombosis and pulmonary emboli

18. Maxillofacial Surgery
 Oral and maxillofacial surgery is a branch of surgery to correct a
wide spectrum of diseases, injuries and defects in the head, neck,
face, jaws and the hard and soft tissues of the oral and maxillofacial
region.
 It is a recognized international surgical specialty.

19.  Treatments performed by maxillofacial surgeons include:
 Dentoalveolar surgery
 Diagnosis and treatment of benign and malignant pathology, cysts,
tumors etc.
 Diagnosis and treatment of congenital craniofacial malformations
such as cleft lip and palate
 Diagnosis and treatment of soft and hard tissue trauma of the oral
and maxillofacial region (jaw fractures, cheek bone fractures, nasal
fractures, LeFort fracture, skull fractures and eye socket fractures).
 Diagnosis and treatment of chronic facial pain disorders.
 Diagnosis and treatment of temporomandibular joint (TMJ)
disorders.

20. Craniofacial Surgery
 Craniofacial surgery is a surgical subspeciality of plastic
surgery and oral and maxillofacial surgery that deals
with congenital and acquired deformities of the skull, face,
and jaws.
 Defects typically treated by craniofacial surgeons include
rare craniofacial clefts, acute and chronic sequellae of facial
fractures, cleft lip and palate, micrognathia, and many others.

21. Cleft lip

22. Cleft lip

23. Cleft lip