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L. Ganry and A. Quimby
Table 5.2 Tests for genetically determined hypercoagulable states [40]
tions at the time of ap loss. Maintaining a high
index of suspicion for HIT in free ap failures is
important, especially in unexplained early thrombosis, as its onset is unpredictable [41].
Avoid Vein Graft if Possible andPlan
forSucient Pedicle Length
Extra-luminal mechanical complications such as
pedicle kinking, compression, or twisting are the
main causes of ap re-exploration (68–83% of
re-exploration cases) [42, 43].
Preventive strategies to avoid these major
complications can be taken during preoperative
planning: for example, with VSP of the pedicle
length and position in an FFF before the surgery,
or just with an appropriate free ap design including vessel side to avoid unnecessary kinking, and
good length of the pedicle to avoid any vein graft.
An intermediate RFFF is a classic solution to
bridge a vascular defect, working as a “owthrough” free ap.
Vein grafts are known to be linked with higher
rate of free ap failure in head and neck surgery.
It is thought to be due to the increased number of
anastomoses, and it also correlates to the length
of the vein graft itself [16, 44, 45].
A specic head and neck vascular loop known
as the “Corlett loop” [46] is probably safer than
regular arteriovenous vascular loops for extremity reconstructions [47] and utilizes a long length
of cephalic vein to achieve both arterial and
venous anastomosis. This solution should be
avoided if possible. It is a last solution in vesseldepleted neck, or in some cases of skull reconstruction when the supercial temporal pedicle is
not available anymore.
Preoperative Planning ofFree Flap
Design, “How toDo It”
Planning forSoft Tissue-Only
Reconstruction
The challenge in soft tissue-only reconstruction
is to map the pedicle or perforators of interest to
maximize the chance of a minimally invasive
skin design and to properly orient the pedicle,
especially if multiple skin paddles are planned.
Freestyle harvest can be safely executed in
aps with reliable anatomy and perforasomes,
especially in case of a large skin paddle harvest,
as it may lead to larger surgical access and better
visualization of the patient anatomy. For example, a freestyle harvest is usually performed in
ALT, fasciocutaneous skin paddle of an FFF, and
thin free ap elevation depending on the surgeon’s experience. For thin free ap elevation, it
is recommended to follow the concept of cold
and hot zones [48].
• How to perform a pedicle/perforator mapping?
– Handheld acoustic Doppler sonography
only—It remains as the most widely used
tool due to its low cost, fast learning, hand
portable design, and ease of use despite an
undesirable number of false-positive (it
does not allow the surgeon to evaluate the
real anatomy of the perforator) [49]
(Fig.5.6).
– Color duplex Doppler only—In the preop-
erative mapping, it helps in identifying
high velocity/ow/diameter of a perforator
(physiology) and mapping the pattern of
perforator (anatomy) (Fig.5.7). It is a game
changer for preoperative ap mapping,
especially in unreliable donor-site anatomy. Knowing preoperatively the location
where a perforator is going through the
deep fascia allows a faster and safer sur-
5 Surgical Optimization
67
a
c
d
b
e
Fig. 5.6 (a–f) Total mandibular resection for bilateral ORN, reconstructed with one FFF, associated with a total TMJ
prosthesis
f
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Fig. 5.7 Postoperative assessment of a free ap in PACU
with an acoustic Doppler
gery with the possibility for renement
such as a more supercial plane of elevation [50]. It can also help localize the dominant perforator (based on the size and the
inow velocity and volume) to the subdermal plexus of the skin or nd the perforator
with the less muscular pathway for simpler
dissection. It is also useful to locate supercial veins to include into the ap to avoid
any venous congestion (RFFF in obese
patients, SCIP ap) [3] and allows screening for anatomical variation (e.g., fascial
pedicle).
Use a regular or hockey-style probe of
15MHz to be able to visualize and evaluate perforator’s inow (higher resolution with higher frequency can be used
for smaller supercial vessels—for
example a 45–75MHz probe is used for
supercial lymphatic vessels of 0.2–
0.3mm in diameter).
L. Ganry and A. Quimby
Best preset programs are « breast », «
thyroid », and « vascular ». Favorable
device properties are depth focused to
2–5 cm, pulse repetition frequency
(PRF/scale) set low to 0.5–1.5kHz/3–
10cm/s, color gain high, and wall lter
(WF) low/off (<50Hz) [51].
The threshold perforator’s inow velocity for a reliable ap is a minimum of
15 cm/s [52], as for the recipient vessel—higher ow of 25 or 30cm/s is not
always better as it depends on the ap
design, size, and components. For
example, a larger ap should benet
from a higher ow velocity (or multiple
perforators), to avoid peripheral necrosis. In the situation of a perforator-only
cutaneous free ap, if the perforator is
anastomosed with an axial larger vessel,
the ap may undergo non-physiologic
overow and vascular congestion. This
concept is not true with a muscle-only
free ap as it has very low vascular
resistance in high ow setting and will
not suffer from any congestion. This is
the reason why it is better to connect a
perforator-only cutaneous free ap in an
end-to-side fashion to obtain a more
physiological perfusion and avoid any
overow congestion, leading to a possible partial or total failure, especially in
thin free aps. The true question is:
“What is the best inow for a particular
ap?” However, this question cannot be
answered yet in the literature. If the
recipient vessel has a ow velocity of
15 cm/s, it can be used, and over
20cm/s, it is very safe.
– Acoustic or color duplex Doppler to conrm
the ndings on an angio-CT scan—in case
of an ambiguous anatomy. Angio-CT scan is
currently considered as the gold standard
imaging tool in revealing the three-dimensional anatomical details of perforators over
1mm in diameter precisely [53, 54].
5 Surgical Optimization
69
– Preoperative perforator mapping tech-
nique with indocyanine green (ICG) angiography—intraoperative assessment and
postoperative monitoring of the viability of
free aps are of high relevance in reconstructive microsurgery and can be assessed
with ICG angiography [55] (Fig. 5.8). It
can also assess microanastomosis patency,
using a microscope-integrated nearinfrared angiography [56]. In preoperative
settings, it may provide information about
perforator mapping and selection before
the beginning of the case [57].
– Augmented reality—This technology uses
virtual planning with perforator mapping
in 2D or 3D, typically from an angio-CT
scan, where perforators are located in the
3D soft tissue image. The best way to project this data on a patient for a true mapping
solution in augmented reality should be a
user-friendly tool:
By smartphone/tablet: Thanks to the «
Fino » application in a smartphone, pro-
jecting in the device the perforator mapping from an angio-CT scan [58]
(Fig.5.9). It is an easy, noninvasive, and
accurate method for preoperative planning, showing a very high correlation
level with intraoperative ndings.
By projection mapping: It uses the same
concept as above with the superposition
of a vessel directly onto the patient, but
using a simple device called a pico projector and lights [59] (Fig. 5.10). We
were able to project efciently the perforators for DIEP and SCIP aps in our
practice. Advantages are to have a direct
vision of the mapping without any
devices in between like a smartphone or
a tablet [60].
By smart glasses: It uses one or multiple markers directly onto the skin of
the patient to align properly the VSP
(perforators and anatomical structures) onto the patient (Fig. 5.11).
Usually, a phase of data acquisition,
a
c
Fig. 5.8 (a–d) Planning of perforator’s anatomy with color duplex Doppler in a pre-expanded and thin DIEP ap har-
vest in a pediatric scenario, to allow primary closure of the donor site with appropriate contour of the defect
b
d
70
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Fig. 5.9 (a, b) Preoperative marking of an IMAP left perforator with ICG, for reconstruction of an infrastomal
recurrence
L. Ganry and A. Quimby
ab
Fig. 5.10 (a, b) Preoperative mapping of a right SCIP ap vascularization using the Fino app with a smartphone
like in infrared navigation, is mandatory for the alignment [61]. The downside of this approach is its complexity
and the fact that a surgeon cannot use
microvascular loupes at the same time,
which may be problematic during a
surgery.
• Specic considerations for soft tissue aps
– Radial forearm free ap (RFFF) and the
rarer dorsalis pedis free ap (DPFF, in
case RFFF is not available):
Provide very thin fasciocutaneous free
aps with good skin paddle size and
long pedicle.
Downside is the donor-site morbidity
for both.
Perform clinical Allen test for RFFF (or
using pulse oximeter/color duplex
Doppler) and an angio-CT scan for
DPFF (to evaluate for lower extremity
vascular axis to the foot and anatomical
variations).
5 Surgical Optimization
71
a
b
c
Fig. 5.11 (a–c) Preoperative mapping of a SCIP ap vascularization using a pico projector and the concept of projec-
tion mapping for FFF osteotomies
The design of the skin paddle should be
on top of the arterial and deep venous
pedicle course.
Harvest of the supercial venous system
is mandatory to possibly avoid venous
congestion (cephalic vein for RFFF,
saphenous vein for DPFF). The design
can be outside of the supercial venous
system, but a cuff of subcutaneous tissue should be preserved between the
edge of the ap and the distant supercial venous system.
In the RFFF, the cephalic vein is connected at the elbow level with the radial
deep venous system (venae comitantes)
by the coalesced vein, joining to form
the median cubital vein, vein which
therefore supports both venous systems
(Fig.5.12).
RFFF can be harvested with bone, but
it greatly increases the donor-site mor-
bidity (need to plate the remaining
radius to prevent postoperative fracture) and should not be considered the
rst choice for vascularized bone
reconstruction.
Both aps can be harvested with a tendon (palmaris longus tendon in RFFF,
extensor hallucis brevis tendon in
DPFF) (Fig.5.13).
Both aps usually need split-thickness
skin graft (STSG) for donor-site closure
(or a domino approach with a SCIP ap
for example) (Fig.5.14).
– Ulnar forearm free ap (UFFF):
Benets compared to RFFF: same tissue
quality with a glabrous skin, useful in
case where postoperative radiotherapy
is less likely (to avoid an intraoral hairy
reconstruction)
Cons compared to RFFF: dissection
close to the ulnar nerve, smaller pedicle
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Fig. 5.12 (a, b) Preoperative mapping of a DIEP ap vascularization using smart glasses
L. Ganry and A. Quimby
a
c
Fig. 5.13 (a) RFFF marking, with the classic
inclusion of cephalic vein on the radial side. (b
and c) Dissection of the RFFF pedicle at the level
of the cubital fossa, where the supercial cephalic
b
vein (green) and the deep venae comitantes (yellow) joined to become the median cubital vein
(red)
diameter without supercial venous
drainage (anastomosis on the venae
comitantes needed)
– Medial sural artery perforator (MSAP)
free ap:
A fasciocutaneous perforator free ap
which can provide a 12 cm of pedicle
length with good size match for head
and neck.
Patient in supine position, with hip and
knee externally rotated.
Perforators are found on a line drawn
from the midline of the popliteal crease
to the medial malleolus. Perforators are
usually located proximally 8–18 cm
from the popliteal fossa.
This ap harvest transects one of the
major lymphatic drainage pathways of
the lower extremity.
Intramuscular dissection is needed to
separate perforators from the gastrocnemius muscle.
ab
5 Surgical Optimization
Fig. 5.14 (a, b) DPFF
for lower lip defect
using the extensor
hallucis brevis tendon.
Donor site reconstructed
with STSG
ab
73
Fig. 5.15 (a) Reconstruction of an RFFF donor site with a domino SCIP free ap closed primarily. (b) Reconstruction
of an RFFF donor site with an STSG
– Anterior lateral thigh (ALT)/tensor fascia
lata (TFL)/iliac crest free aps:
The lateral femoral circumex system
provides medium-to-large skin paddle
size, of medium thickness, with a long
and good size match pedicle for head
and neck, and minimal donor-site morbidity. Designs can include skin paddle,
fascia, muscle, and bone (Figs.5.15 and
5.16).
Patient in supine position, with neutral
leg rotation (great toe facing the celling), hip externally rotated.
Draping of both ALT and TFL aps
should always be encouraged, as the
TFL free ap can be harvested with an
ALT or can be a backup solution in case
an ALT cannot be harvested as planned.
ALT free ap can be the location of
Monckeberg’s atherosclerosis and can
present with variable perforator types,
sometimes leading to a failure of the
harvest.
For ALT: Perforators are found on a line
drawn from the superior and lateral border of the patella to superior and anterior
iliac spine. Perforators are usually
located at the midpoint of the line, in a
circle of 3–4cm in diameter. Other minor
perforasome locations are 5 cm proximally or 5cm distally to this circle.
If decent sized perforators are not found,
the skin paddle should be harvested
with the underlying vastus lateralis
muscle with the septum still attached to
avoid any skin necrosis.
For TFL free ap: In supine position,
the pedicle is always found 8–10 cm
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L. Ganry and A. Quimby
a
c
e
b
d
f
Fig. 5.16 (a–f) Thin ALT chimeric free ap (raised above the fascia supercialis) with thin skin paddle and vastus
lateralis muscle, for anterior tongue and oor-of-the-mouth (FOM) reconstruction[63]
below the superior and anterior iliac
spine, on a line drawn from this spine to
the anterior and lateral border of the
patella. It runs below the rectus femoris
muscle. The design of this ap can be as
long as the proximal 2/3 of the lateral
thigh.
– The Gracilis muscle/PAP free aps:
Innervated muscle free ap transfer.
Gold standard for smile reconstruction
in long-term facial paralysis with facial
muscle atrophy (<12months).
Can be harvested and designed with
multiple muscular vectors for complex
smile reconstruction (Fig.5.17).
Recipient motor nerve can be the
remaining ipsilateral facial nerve, contralateral cross-facial nerve graft, and
ipsilateral masseteric nerve, and some
authors advocate for the ipsilateral
hypoglossal nerve.
Skin paddle is unreliable on top of the
gracilis muscle, especially if small. If a
skin paddle is also needed, the ap
5 Surgical Optimization
Fig. 5.17 (Intrinsic
lateral femoral
circumex (LFC) ap
based on the lateral
femoral circumex
system with iliac crest,
two separate skin
paddles, and rectus
femoris muscle
75
a
b
c
Fig. 5.18 (a–c) Gracilis muscle free ap, with exposure of the anterior aspect of the muscle and exposure of its pedicle
(fused with the PAP pedicle in the superior and proximal aspects of the muscle)
should be designed with a profunda
artery perforator (PAP) free ap as a
chimeric ap (Fig.5.18).
Gracilis muscle landmark is usually on
3–4 cm below a line going from the
medial condyle to the pubic bone on a
patient in supine position. The PAP ap
is usually 5–8cm below the same line.
– Lateral arm free ap (LAFF):
Best indication in head and neck could
be for a tongue reconstruction due to the
medium bulk and minimum donor-site
morbidity provided by this ap.
It is a less popular choice as it may be
sometimes difcult to harvest in a
double- team approach, and due to its
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