head and neck free flaps

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