Free Flap Reconstruction of Head and Neck Defects

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Free Flap Reconstruction of Head and Neck Defects

• Parag Parikh, MD
• UC-Irvine
• April 7, 2004

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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 FlapIndians then McGregor in 1963
• 1965 BakamjianDeltopectoral Flap
• Limited Reach

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Introduction

• Early 1900s Alexis Carrel
• Free tissue transfer in animals (jejunum to neck)
• 1950s 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

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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

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Introduction

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

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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

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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

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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

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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

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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

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Disadvantages of Free Tissue Transfer

• Technically demanding
• Increased operating room time
• Increased flap failure rate
• Functional disability at donor site

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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

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Preoperative Planning

• Patient selection
• Age
• Diabetes
• Arteriosclerosis/Cardiac
• Tobacco use
• Collagen vascular disease
• Coagulopathies
• Hypercoagulable states

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Reconstructive Planning

• Must consider all options for particular defect
  and patient
• Options
• Secondary intent
• Primary closure
• Skin grafts
• Local flaps
• Myocutaneous flaps
• Free flaps

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Fasciocutaneous Free Flaps

• Radial forearm
• Lateral arm
• Lateral thigh

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Radial Forearm Free Flap

• Arterial source
• Radial artery
• Venous Source
• Paired vena commitantes and/or cephalic vein

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Radial Forearm Free Flap

• Forearm
• Radial a. w/ vena commitantes
• Lateral intermusc-ular septum
• Antebrachial cutaneous n.

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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

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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

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Lateral Arm Free Flap

• Arterial supply
• Posterior radial collateral artery from profunda
  brachii artery
• Venous supply
• Vena commitantes in spiral groove of humerus

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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.

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Lateral Thigh Free Flap

• Arterial supply is from third perforator of
  profunda femoris artery
• Venous output from associated vena commitantes

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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

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Muscle and Musculocutaneous Free Flaps

• Rectus abdominis
• Latissimus dorsi

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Rectus Abdominus Free Flap

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

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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

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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

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Rectus Abdominis Free Flap

• Preoperative evaluation
• Previous abdominal surgery
• Presence of umbilical hernia
• Presence of rectus diastasis

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Latissimus Dorsi Free Flap

• Arterial supply based on thoracodorsal artery
• Venous drainage from thoracodorsal vein
• Motor nerve innervation potential with
  thoracodorsal nerve

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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

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Composite Free Flaps

• Radial forearm
• Fibula
• Scapular/Parascapular
• Ilium

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Fibular Free Flap

• Arterial supply peroneal artery
• Dual supply
• Endosteal
• Periosteal
• Venous supply vena commitantes

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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

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Fibula Free Flap

• Fibula is outlined
• Skin paddle centered over junction of middle and
  distal third to encompass dominant
  septoperforators

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Fibula Free Flap

• Leave 6 cm of proximal and distal fibula

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Fibula Free Flap

• Aberrations in blood supply (10)
• Peripheral vascular disease

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Iliac Crest Free Flap

• Arterial supply from deep circumflex iliac artery
  
• Venous supply deep circumflex vein

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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

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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

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Iliac Crest Free Flap
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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

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Iliac Crest Free Flap

• Postoperative care
• Progressive mobilization
• Assisted ambulation POD 3 or 4
• Stair climbing 3 weeks

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Scapular/Parascapular Free Flap

• Arterial supply
• Circumflex scapular
• Venous Supply
• Vena commitantes

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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

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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

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Jejunum Free Flap

• Arterial supply from portion of superior
  mesenteric arterial arcade (2nd or 3rd arcade)
• Venous supply from venous branches along arcade

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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

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Jejunum Free Flap

• Contraindications
• Ascites
• History of extensive abdominal surgery
• Involvement of the thoracic esophagus
• H/o of intestinal disease (Crohn's)

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Intraoperative Management

• Operating microscope, instruments, sutures
• Irrigation supplies
• Anticoagulants and volume expanders
• No pressors
• Patency assessment (15-20 minutes)
• Pulsation
• Doppler

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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

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Postoperative Management

• Inspection and prick test
• Arterial vs. venous insufficiency
• Pharmacotherapy
• Heparin, dextran, aspirin

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Oral Cavity and Oropharynx Reconstruction

• Thin pliable mucosa
• Possibilities
• Radial Forearm
• Scapular/Parascapular
• Lateral Arm
• Lateral thigh

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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 2/3consider coned RFFF (sensate

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Tongue Reconstruction

• For tongue base and total glossectomy
  defectsneed adequate oral mound to approximate
  with palate for speech and bolus transit
• May consider rectus abdominus and latissimus
  dorsi free flaps

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Hypopharynx and Cervical Esophageal Reconstruction

• Must be prepared for possibility of complete
  circumferential pharyngeal defect
• Over 3 cm remains primary closure
• Less than 3 cmpec 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

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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

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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

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