This document discusses head and neck cancer reconstruction using free flaps. It begins by outlining the anatomy of the head and neck region and factors to consider for reconstruction such as integrity, function and form. Common free flap options are described including the anterolateral thigh flap, radial forearm flap, rectus abdominis flap, fibula flap and jejunum flap. Key steps in planning a reconstruction including evaluating the defect, donor site, patient factors and surgical experience are highlighted. The importance of microvascular expertise and equipment for free flap reconstruction is emphasized.

1. DR.HARSH AMIN

2. Problem

 In india->30% of all cancers are head neck ca.
 In head neck ca. upper aerodigestive tract is most
common site- with oral cavity being most common
site followed by oropharynx followed by larynx
 90% of all upper aerodigestive tract ca. is SCC.

3. Relevant anatomy

Upper aerodigestive tract constists of
-oral cavity
-oropharynx
-hypopharynx
-larynx
-nasopharynx and paranasal sinuses

4. Oral cavity
 Function
 Mastication/
Bolus/deglutition
 Speech
 Sphinchter/seal
 Direction of saliva

5. Oropharynx-
Hypopharynx
 Deglutition
 Pessage
 Seal

6. Larynx
 Respiratory pessage
 Speech
 Prvent aspiration
 seal

7. mandible
 Contouring
 Teeth bearing
 Mastication/swallowing
/speech

8. External carotid and its
branches

9. Veins

10. Things to consider for best
functional and aesthetic result

 Skin quality-color, texture, hair bearing etc.
 Middle lamella-muscles of facial expression,
muscles of mastication
 Deeper tissue-bone (contour) and soft tissue
 Mucosal lining

11. Goals for reconstruction

Integrity (must)
Function
Form

12. Why Integrity is must?

 continence (feeding)
 Protect vital structures from Blow Outs
 Separation from intracranial structures in skull base
(to prevent infection in/leak out)
 Prevent aspiration
 So must for survival

13. Function (Minimal goal if patient fit)

E.g.
 Restoration of tongue bulk
 Restoration of floor
 Restoration of mandible
 So better Quality of life

14. Form-aesthetics

E.g.
 Maxillary defect- obturator vs free fibula (projection
and implant)
 Aesthetic subunits
 Secondary surgeries
 Free flaps instead of pedicle

15. 
 If possible reconstruction should be done primary
-as post operative and post radiotherapy scarred
tissue hampers recipient vessel dissection.
-vein grafts to opposite side has more chances of
thrombosis

16. Factors affecting planning

Defect
Donor site
Patient
Doctor

17. Defect

 Surface area(cutaneous/mucosal) (2D)
 Volume (bulk/support) (3D)
 Type of tissue involved
 Vessels (proximity/caliber/flow/)
 Radiation (pre-op ?/post-op)

18. Donor site

 Availability ( previous operations / trauma /vessel)
 Donor site (so that 2 team approach)
 Tissue quality (according to plan)
-to restore coverage (skin , mucosa, muscle to
mucolise)
-bulk ,support (flap thickness, muscle, fat, bone
,cartilage)
-if possible function
 For free flaps- also Pedicle (length/caliber/no. of
veins/nerve/direction)
 Residual donor defect

19. Patient

 Fitness/age
 Preference (expectation/stages)
 compliance
 Post op radiotherapy

20. 
 Experience
 Set up/ team
Doctor

21. Reconstructive options
(Even though actual defect only known intra-operatively
reconstruction must be planned )

Primary closure/secondary healing
Grafts-skin/bone..
Local flap/Regional flap
Free flap---single/chimeric/compound/flow through

22. Why Reverse ladder ?

 Robust new tissue with own blood supply
 Enough volume
 Variety of Aesthetically pleasing combinations
 More radioresistant
 Osteo-integrated implants
 Cost??

23. History

 1951-Edgerton-concept of immediate reconstruction
 1959-1st free jejunum for esophagus
 1963-McGregor-laterally based forehead flap
 1965-Bakamijan-deltopectoral flap
 1976-Panje and Harashina described free flap for oral
defects
 1979-Ariyan-PMMC flap
 1980s and early 1990-osteocutaneous free flaps for
mandibular defects.

24. 
 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
 1984 –Song et al. – Antero lateral thigh flap
 1983 – Baek et al. – lateral cutaneous thigh flap
 1985 – Drever et al. – rectus Abdominis myocutaneous flap
 1986 – scapular osseocutaneous flap

25. Primary closure & secondary
healing

 Primary closure – for small defects of lateral tongue
/ buccal mucosa.
 Small defects of buccal mucosa, sulcus, floor of
mouth, hard palate left open or packed with
xeroform to allow healing by secondary intention

26. Skin grafts

 STSG – used to close superficial defects of alveolus,
palate, dorsum or lateral edge of tongue.
 Contraction of graft unlikely to cause a functional
problem in these areas.
 Disadvantages –
 Tendency to contract in extensile areas like floor of
mouth / buccal surface makes them less useful.
 Increased risk of partial / total graft loss due to
scarring & radiation.
 Immobilization of intraoral grafts -challenging

27. Local & regional flaps

 Tongue flaps- used to close small oral defects in past,
fallen into disfavor because of tethering & resulting
functional disturbances.
 Forehead, temporalis muscle flaps rarely used now
because of free tissue transfer.
 Facial artery musculomucosal flap for small defects of
hard palate, alveolus, tonsillar fossa & floor of mouth, but
limited application.
 Deltopectoral flap- an axial –pattern cutaneous flap based
on 2-4 the branch of internal mammary artery
Revolutionalized head & neck reconstruction, but fallen
into disfavor- questionable reliability without delay.

28. Submental flap


29.  Based on submental artery
 Elevation started from inferior border of mandible
between 2 angles
 Plane is under plastysma
 Anterior belly of digastric incuded to ensure
inclusion of perforator

30. Facial artery myomucosal flap
• Based on facial
artery
• Course within
buccinator
• 2x9 cm

31. Nasolabial flap
 Based on angular artery
 2x5 cm
 Superiorly or inferiorly
based
 Temporary
orocutaneous fistula
 Best for old age with lax
skin
 It requires bite block for
14 days

32. Deltopectoral flap


33. Anatomic landmarks


36. Musculocutaneous flaps

 Superiorly based sternocleidomastoid flap- useful to
augment mandibular coverage, but unreliable & rarely
used.
 Lateral & inferior trapezius flap used for intraoral
defects; lateral- poor flap reliability, inferior – reliable
(intraoperative positioning difficulties).
 Latissimus dorsi- safe & reliable , but patient must be
repositioned for access to donor site, extensive
dissection required, used in salvage situations.
 Pectoralis major still widely used
 platysma limited role

37. PMMC flap


38. Flap design


39. 
Preserve 2nd 3rd perforator for future DP flap

42. Free flaps

 Microvascular surgery revolutionalized management of
carcinoma of head & neck.
 Reliable immediate single- stage reconstruction yields
superior functional & aesthetic results,reduces mortality
& maximizes quality of life in patients with reduced life
expectancy.
 Introduction of well vascularized bed increases chances of
primary wound healing.
 Free flaps demand microsurgical expertise, patient
management skills,proper anesthesia, appropriate
instrumentation,well equipped postoperative care unit
 Favorite flaps –ALT,radial forearm & rectus abdominis,
 second line flaps- lateral thigh, parascapular, LD

43. Antero lateral thigh


44. 

45. Radial forearm

 Arterial source
 Radial artery
 Venous Source Paired vena commitantes and/or
 cephalic vein

47. Ractus abdominis musculo-cutaneous


48. Arterial supply based on
deep inferior epigastric
artery
Venous supply form
vena commitantes
joining external iliac
vein

49. Lateral arm


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

51. 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

53. 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

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

55. --·--- t - - - - .- -

56. 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

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

58. Osteo-cutaneous flaps


59. 

60. Scapula osteocutaneous free
flap


61. 

62. DCIA osteocutaneous flap


65. Radial forearm


66. Free fibula

69. 

70. Recipient vessels

 Look for atherosclerosis, previous surgery, radiotherapy
 Some may prefer to dissect it prior to flap dissection
 Best if more than one recipient artery is available to
choose best if location permits.
 At least 2 veins anastomosis should be goal
 2 major sources for recipient arteries-ext.carotid system
and thyrocervical system

71. artery

 Superior thyroid is most suitable
 when anastomosis with ext.carotid- 2-3 cm after
bifurcation.
 When prior radiation, surgery, age limit use of ext.
carotid –thyrocervical system
 Benefit of transverse cervical artery-less
atherosclerosis and as it riches mid neck greter
caliber donor artery can be used as no trimming is
required as in ext.carotid.

72. Veins

 Extternal jugular, transeverse cervical best(if not
ligated during dissection)
 Anterior jugular if not demaged while tracheostomy
 Cephalic vein-mosrtly pos irradited areas.

73. Principles of microvascular
surgery

 Delay flap mobilization till creation of defect
 Preserve recipient vessels (atleast 1 cm)
 Select vessel with similar lumen size
 Pedicle lengh carefully measured
 Better to give inset 1st-to avoid maneuvering of
completed anastomosis/suturing of bleeding flap
and misjudgment of pedicle length
 Tissues sculpted once vascularization completed

74. Site specific treatment
goals


75. Buccal mucosa

 Size of the defect is measured with mouth fully open
 Soft, pliable, sizable flap is best
Defect if-
 Thin defect -radial/ulnar forearm fasciocutaneous
 Thicker defect-thin ALT
 Full thickness defect-thick fasciocutaneous or
musculocutaneous
 Marginal mandibulectomy-ALT myocutaneous
 Reconstruction goal-Avoid trismus

76. Flaps


77. 

78. Buccal sulcus

 Small superficial defects- closed primarily or allowed to
heal by secondary intention.(this may make sulcus
shallow)
 Large defects- skin / mucosal grafts / mucosal rotation
flaps- limited by loss of excursion ,
 so thin , pliable flaps( platysma, radial forearm free flap)
 Marginal mandibulectomy-ALT myocutaneous
 Excess bulk avoided- patient tends to bite the flap..
 Reconstruction goal- to maintain the sulcus

79. Trigone

 Defect here may expose mandible
 Direct closure may distort tongue and pillar

80. Tongue

 Reconstruction goal- tongue mobility and restore
bulk
 Less than 1/3-1/2– primary closure vs. STSG

85. Floor of mouth

 Soft, sensate, mobile with Preservation of tongue
mobility.
 Small defects-heal secondarily / skin grafting.
 Flap- thin & supple ( free radial forearm ); reliable
 Anterior segmental mandibulectomy- osteocutaneous
flap (free fibula).
 Reconstruction goal- to maintain lingual vestibule,
sufficient height to floor of mouth avoiding pooling of
saliva & food particles

86. Lower and upper
alveolar ridge

 Tumors of lower gingiva - involve bone requiring partial
mandibular resection.
 For small cancers- adequate remaining mucosa- direct
closure over bone, if not- raw surface accepts a skin graft.
 After extensive marginal- reinforcement with a low-profile
reconstruction plate, when postoperative
radiotherapy planned covering it with well vascularised
soft tissue, preserving sulcus ( e.g.. radial forearm free
flap)
 If segmental mandibulectomy- osteocutaneous
 Maxillary- small superficial cancers- excised, left to heal
by secondarily, large- alveolectomy/ maxillectomy

87. Hard Palate

 Hard palate- minor salivary gland tumors predominate.
 Small defects- skin grafting/ heal secondarily.
 Bone involvement- alveolectomy / partial / total
maxillectomy- palatal obturator, Osseo integrated
implants, osteocutaneous flap.

88. Soft palate

 Soft palate- large defects, best prosthetically as flaps
sag & ineffective in this highly dynamic region.
 A delayed surgical prosthesis followed by a
definitive obturator , interacts with the normally
functioning velopharyngeal complex on the opposite
side to help restore speech & swallowing.
 if flaps used till radition completed and dentures
fitted—they must be tight enough to prevent
respiratory obstrction

89. Mandible


90. 

91. Free fibula

95. Scapula osteocutaneous free flap

96. DCIA osteocutaneous flap

99. Oropharynx-esophagus


100. Radial forearm


102. jejunum


104. 

106. Algorithm for surgical
treatment

 Position- supine with shoulder roll to extend neck.
 Prepare potential flap donor sites /skin / vein graft
donor sites.
 Through out the operation strict sterile precations
are important
 Ther has to be different trolley for oncosurgery and
reconstruction.
 Adequate exposure for resection & reconstruction.

108. 

109. 

110.  Tumor removed with frozen section control of margins.
 Once nature of defect known- reconstruction team
begins to harvest flap.
 If free flap- best to evaluate recipient vessels before
raising the flap.
 Recipient vessels prepared.
 An A-V loop created before flap harvest to minimize
ischemia time.
 Defect measured , tissue needs (bulk, lining ) identified

111.  Flap designed & elevated.
 Flap rotated into position / harvested & brought to
recipient site.
 For free flap orientation of flap is very important to
ensure most vascularized portion for water tight seal of
gullet.
 In free flap, some insetting done before anastomosis to
allow accurate placement of sutures.
 Insetting done with vertical or horizontal mattress or
tightly spaced interrupted sutures of 3-0 vicryl
attempting to secure a water- tight closure.
 Simultaneously closure of donor site/STG done

112.  Before starting anastomosis remove sand bag.
 Microvascular anastomosis performed to large high- flow
vessels.
 End to side to external carotid artery / internal jugular vein
preferred.
 If atherosclerosis suspected, branch of external carotid to
minimize risk of embolic stroke.
 It’s most important to prevent infection in this region and
protect it from any leakage with adequate tissue.
 Drains are placed as indicated.
 A site for external doppler monitoring marked with a suture
on flap skin.
 Neck incision closed in layers.
 Donor site closed over drains / grafted,dressed & splinted as
needed

113. 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

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

115. Postoperative Management
Temperature measurements
SPECT scanning
Infrared spectroscopy
Transcutaneous and intravascular devices
Technicium scanning

116. Thank You
