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L. Ganry and A. Quimby

Fig. 5.32 (a–c) The “scissors” in “rock-paper-scissors” concept for orientation of the DCIA free ap—(a) in a lateral view, where the two ngers mimic the anterosuperior and anteroinferior spines of the iliac crest; (b) in a

The convexity of the iliac crest is matched with the dental arch, midface, and lower face reconstruction. The pedicle is short (5 cm) and small (1–1.5mm in diameter), but designing the bone ap more posteriorly allows for greater pedicle length (up to 10cm). The donor site needs to be repaired with a non-resorbable mesh.

– A good indication of this ap is for recon-

struction of the mandible on a benign tumor, with complete dental rehabilitation, especially in a young male patient (to avoid abdominal wall weakness and possible lateral hernia in a young female with future pregnancy plans), or for cases requiring

superior view, showing the concavity of the hand mimicking the iliac crest, and the thumb mimicking the pedicle; (c) position of the ipsilateral hand to match the scapula in a standing position

high bone volume, typically a large maxillary defect with infraorbital rim reconstruction and without the need for large soft tissue reconstruction (depending on the team experience).

– Morbidity management of the donor site:

The skin paddle is classically not as reliable as in other osseous free aps, unless a perforator from the DCIA ascending branch is encountered. The internal oblique muscle is usually taken during the harvest, to be wrapped around the bone, providing soft tissue coverage and allowing spontaneous mucoepithelialization in the oral or nasal cavity.

5 Surgical Optimization

Non-resorbable mesh is always needed to reconstruct the internal oblique muscle harvest. Resuspension of the inguinal ligament is also mandatory in case where the anterosuperior iliac spine was used to reconstruct the mandible.

– Management of pedicle length for maxil-

lary reconstruction:

Facial pedicle should be prepared high above the inferior border of the mandible, taking great care to visualize and protect the marginal mandibular branch of the facial nerve. In case of short pedicle which cannot reach the neck, there are at least four solutions to overcome this problem:

○ Perform intraoral anastomosis. ○ Perform extraoral anastomosis at the

level of the cheek (at the cost of a small facial scar).

○ Perform extraoral anastomosis at the

level of the supercial temporal vessels.

○ Perform an arterial and venous vein

graft (last resource).

– Maximum length of bone in mandibular

reconstruction:

As previously said, a design 4–5 cm behind the anterosuperior iliac spine can maximize the length of the pedicle, being cognizant that the further back you go, the thinnest the iliac crest cortex will be, and that the DCIA will also be more supercial. The maximum bony reconstruction can be a hemimandible, from a condyle to a

symphysis, but is usually used for smaller defect (<10cm of bony reconstruction). One wedge osteotomy can be done safely to reconstruct an angle without the need for anterosuperior iliac spine harvest, or multiple linear monocortical osteotomies (as for the scapula lateral border osseous free ap) for better curvature of the bone.

– Can support dental implants during the

same procedure, but usually performed in a second surgery with regular dental implants for maxillary reconstruction. In immediate mandibular reconstruction, dental implants are placed in cancellous bone (loose bone) not allowing immediate prosthesis like the bula free ap for example.

• Medial Condyle Free Flap: It is an unusual free ap used in the head and neck region. However, two major indications seem to benet from this donor site:

– Cleft reconstruction, typically in double-

cleft cases, in which avascularized graft may be particularly challenging to be performed in the setting of chronic stulas and large defect. This free ap can bring a 2×2cm of vascularized bone.

– ORN defect, to reconstruct a bone defect,

or for the robust vascularized periosteum, which can be harvested from this donor site. In this setting, a skin paddle from the medial thigh should be used.

– This free ap has a pedicle of 5–7cm, but

small vessels (<1 mm in diameter). Therefore, intraoral anastomosis to the facial pedicle should be used for maxillary reconstruction.

Table summerizing osseous free ap orientations

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L. Ganry and A. Quimby

Comments

Left maxillary defect for scapula: scapula tip (horizontal reconstruction)=left side with pedicle on the right side (anterior if hemi-tip, posterior if full tip), right side with pedicle on the left side (anterior if hemi-tip, posterior if full tip)

Right maxillary defect for scapula: scapula tip (horizontal reconstruction)=right side with pedicle on the left side (anterior if hemi-tip, posterior if full tip), left side with pedicle on the right side (anterior if hemi-tip, posterior if full tip)

• Unusual Free Flap Harvest Planning from the

Head and Neck Area

• Flaps harvested from head and neck allow for

reconstruction of like tissues with like tissues.

These specic free aps are designed from the

supercial temporal system:

– Supercial temporalis fascia (STF) free

ap: an extremely thin fascia to reconstruct the nasal cavity (such as the septum), the orbital cavity, or the contralateral ear in case the ipsilateral supercial temporal pedicle is not available (due to burn/trauma/ previous ipsilateral failure) (Fig.5.33)

– Temporal artery posterior auricular perfo-

rator skin (TAPAS) free ap: to reconstruct a maximum of 5×7 cm glabrous skin or mucosal defect, with thin and color match aspect. Can also be used for a septal recon-

struction and nose reconstruction (with vascularized cartilage) (Fig.5.34)

– Anterior helix free ap: skin and cartilage

to reconstruct an alar base defect of the nose (Figs.5.35, 5.36, and 5.37)

• Composition of new aps When the solution is Not straight forward:

– Train or bridge free aps (second ap con-

nected into the distal pedicle of the rst one):

Usually, RFFF is used as a bridge connected to any other free ap. This may be needed to be able to reach the defect and/or bring the specic tissue needed (e.g., RFFF and helix free ap for complex nose and midface reconstruction).

– Prelamination with or without expansion:

Example of a jaw-in-a-day procedure with skin graft (Figs.5.38 and 5.39) Example of a PIE ap, for facial burn, where the skin of the neck is expanded over a supercial temporalis fascia ap before its transfer

– Delayed phenomenon:

Example of a Juri ap for hairy scalp reconstruction, where incisions of the tip of the ap are made 3weeks before the surgery to improve its distal vascular reliability, or the classic example of the older tubular ap

Fig. 5.33 (a, b) Supercial temporalis fascia ap, before its transfer

5 Surgical Optimization

Fig. 5.34 (a–d) Chimeric TAPAS ap stage 3 (with cartilage), pedicle to the supercial temporal vessel [72]

Fig. 5.35 (a, b) Helix free ap for alar base reconstruction, in a facial cleft patient

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Fig. 5.36 Intermediate result of a helix free ap before secondary rhinoplasty

L. Ganry and A. Quimby

Fig. 5.37 (a, b) Result after secondary rhinoplasty

Fig. 5.38 (a, b) Dental implants and STSG placed as a rst step of an FFF prelamination

5 Surgical Optimization

Fig. 5.39 (a–d) FFF procedure 3weeks after the prelamination, where the STSG is rmly attached to the periosteum, mimicking attached gingiva

Double-Team Approach

TDAP and LD fasciocutaneous skin paddles rather than from the circumex system in scapula

In free ap procedures, donor sites are usually accessible for a double-team approach. The most challenging area would be where the donor site is from the proximal upper extremity such as for a lateral arm free ap or from the proximal trunk such as a scapula free ap.

free ap.

Acknowledging and predicting high risk of intraand postoperative complications by having planned strategies to avoid or how to deal with them can decrease their rate and improve the patient’s reconstructive journey in head and neck reconstruction.

In such settings, the reconstructive team may be challenged to harvest the free ap, while the head and neck team performs an ipsilateral neck dissection. It is the same problem in neurosurgical/skull base surgery when the position of the head may be xed by the neurosurgeon (especially for trapezius muscle in posterior skull base surgery). Such a situation is unfortunately classic, and the double-team approach is still possible thanks to good communication and using only

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5 Surgical Optimization

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Free Flap Considerations andComplications

NeelPatel, HishamHatoum, PaulAmailuk, ArshadKaleem, andRamzeyTursun

Complications inHead andNeck Microvascular Free Tissue Transfer

Introduction

Microvascular reconstruction of the head and neck has become a mainstay in the management of large, complex, and composite defects of the

N. Patel (*) HCA Florida Head and Neck Oncology and Reconstructive Surgery, NOVA School of Medicine, HCA Florida General Surgery Residency Program, Miami, FL, USA

H. Hatoum Department of Oral and Maxillofacial Surgery, LSU School of Dentistry, New Orleans, LA, USA

P. Amailuk Oral/Head and Neck Oncology, Microvascular and Reconstructive Surgery, Queensland, NSW, Australia

A. Kaleem Diplomate of the American Board of Oral and Maxillofacial Surgeons, Head and Neck Oncologic and Microvascular Surgeon, Oral and Facial Surgery, University of Texas Health Sciences Center, San Antonio, TX, USA

Texas Tech University Health Sciences Center, El Paso, TX, USA e-mail: axk1074@med.miami.edu

R. Tursun Maxillofacial Surgery, Head and Neck Oncology and Microvascular Reconstructive Surgery, Department of Otolaryngology/Head and Neck Surgery, Miami, FL, USA e-mail: r.tursun@med.miami.edu

https://doi.org/10.1007/978-3-031-38898-9_6

head and neck, with the average free ap success rate now at about 95% [1], with higher success rates reported up to 99% in the literature [2]. Despite the low rate of complications reported in the literature and well-documented success rates, even the most experienced of surgeons often face the potential of complications, either in the preoperative phase, in the OR, or after surgery. These complications can result in the need for additional procedures and can result in partial or complete loss of the free ap, necessitating surgeons to perform salvage surgery. These complications can result in increased morbidity, length of hospital stay, treatment cost, and overall compromised functional and esthetic results.

Preoperative Phase

When considering the management of free ap complications in the preoperative period, it is important in our experience that the surgeon consider four distinct points: (1) recognition that complications can and do happen to the best surgeons, (2) anticipation of possible sources of complications specic to each patient, (3) actively take steps to prevent these complications from occurring or to minimize the risk, and (4) institute a plan for monitoring for the presence of these complications including consideration of alternative treatments in the event of ap failure. The active plan should include patient education and advice as part of the consent process. Free ap surgery is a

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