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19 Free Tissue Transfer forHead andNeck Reconstruction
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should consider the tissue components, amount
of tissue bulk and length of the vascular pedicle
unique to different ap types. The characteristics
of different aps will be described later in this
chapter.
Some aps allow for simultaneous ap harvest and tumour resection, thus shortening the
overall operative times. Prolonged operative
times, specically longer than 18 h, have been
signicantly associated with increased rates of
free ap failure [5]. Therefore, the logistical
organisation between the ablative and reconstructive team is critical when deciding the free ap of
choice.
Knowledge of the vascular supply to the neck
is fundamental to avoiding ap ischemia or loss.
Knowing the dose and elds of any prior radiation therapy will facilitate a prudent choice of
skin incision and recipient vessel selection.
19.3.6 Tracheostomy
The indication for tracheotomy is dependent on
the presence of cardio-respiratory comorbidities,
tumour stage, location and planned resection, the
planned extent of neck dissection and previous
head and neck radiation. Elective tracheostomy is
a relatively safe procedure for adults; however,
can be associated with risks, more extended hospital stays and increased costs of care [3]. Many
institutions have a policy and procedure regarding the management of tracheostomy patients.
Ward staff and junior team members should be
equipped and trained to manage such patients in
an emergency. Many studies report that patients
can often be successfully decannulated within
2 weeks after surgery, but reports vary on the
appropriate pathway to decannulation. Nearly all
studies agree that a patient should pass a capping
trial before decannulation [3].
19.4 Subsite Use ofFree Flaps
Each ablative subsite poses unique anatomical
and functional challenges in free ap reconstruction. The table below shows the suggested ap
choice for different subsites. This is not prescriptive by any means and each defect should be
examined to identify the ideal ap that can
address its decits (Table 19.1). Common soft
tissue and composite aps are described later in
this chapter.
Table 19.1 Suggested free aps for each ablative subsite
Ablative subsites
Oral cavity/
oropharynx
Free
ap
Abbreviations: RF radial forearm, ALT anterolateral thigh, LD latissimus dorsi, MSAP medial sural artery perforator,
RA rectus abdominus, DCIA deep circumex iliac artery
RF
ALT
LD
MSAP
RA
Fibula
DCIA
Scapula
✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓
✓ ✓
✓ ✓
Pharyngolarynx Maxillomandibular Craniofacial Cutaneous soft
tissue
✓ ✓
✓
✓
✓
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19.5 Common Soft Tissue Free
Flaps
19.5.1 Radial Forearm
The radial forearm fasciocutaneous ap (RFFF)
was originally developed in 1978 and reported in
1981. The ap with a rich axial pedicle consisting
of the radial artery, venae comitantes and cephalic
vein made reconstructive surgery breakthroughs.
It can be harvested as a composite ap incorporating muscle, tendon, nerve or bone. Once the
radial artery is harvested, the perfusion to the
hand depends on the continuity of the palmar
arch. It is therefore important to perform an
Allen’s test to assess an adequate inow from the
ulnar artery. It is a workhorse ap for head and
neck reconstruction and is commonly used for
the reconstruction of oral tongue, cheek, oor of
mouth, laryngopharyngeal, oesophageal and surface defects (Fig.19.1).
19.5.2 Anterolateral Thigh
The anterolateral thigh (ALT) ap was described
by Song etal. The application to the maxillofacial region was described in the 1990s. It is generally raised as a fasciocutaneous ap based on
the septocutaneous perforators of the descending
branch of the lateral circumex femoral artery
and venae comitantes. The other variations of this
ap include adipofascial, myocutaneous, muscle
only (Vastus lateralis Flap), or a combination as
chimeric option with the anteromedial thigh ap.
The body habitus of the patient should be considered when choosing this ap. An increased adiposity will make the ap unexpectedly bulky
which can impair function and cosmesis. This is
another workhorse ap for the head and neck
reconstruction and has particular advantages of
large surface area, a discrete scar and minimal
donor site morbidity. The neurotised version can
be used for dynamic reanimation of the face [6]
(Fig.19.2).
19.5.3 Latissimus Dorsi
Latissimus dorsi (LD) was rst reported as a free
ap in 1979 for breast reconstruction. Reports of
its use in the head and neck soon followed, with
Fujino etal. reporting a case of successful reconstruction of a total cheek defect in 1981. It is particularly useful for defects of the entire scalp
where a defect requires broad soft-tissue coverage. The pedicle comprises the thoracodorsal
artery, a terminal branch of the subscapular
artery, and its accompanying venae comitantes.
The muscle ap is typically covered with a splitthickness skin graft which will give an excellent
cosmetic result. Most commonly used for large
surface defects coverage as a free ap, it can also
be used as a pedicle ap in a recipient vessel
depleted neck or salvage scenarios. Despite the
size, donor functional decit is minimal. The
rotation axis and the pedicle length limit the
reach of the pedicled ap but allow for reconstruction of defects on the neck or parotid region
(Figs.19.3, 19.4, 19.5, and 19.6).
Fig. 19.1 Radial forearm free ap with associated vascular pedicles
Fig. 19.2 ALT free ap demonstrating fasciocutaneous
ap with two perforators
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Fig. 19.3 Scalp defect
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Fig. 19.5 Two weeks post latissimus dorsi free ap and
split skin graft
Fig. 19.4 Latissimus dorsi free ap with associated
pedicle
19.5.4 Medial Sural Artery
PerforatorFlap
Medial sural artery perforator ap (MSAP) was
rst described by Cavadas etal. in 2001. It was
rst used for lower limb reconstruction, and then
the clinical application was increased to include
head and neck. MSAP ap has low donor site
Fig. 19.6 One year following latissimus dorsi free ap
and split skin graft in the same patient
morbidity, adequate vascular pedicle length and a
thin fasciocutaneous component even in obese
patients. The pedicle consists of a medial sural
artery and two venae comitantes. The greater
saphenous vein can also be used as drainage. The
versatility of MSAP comes from its ability to be
elevated as a thin fasiocutaneous ap or elevated
with the underling gastrocnemius muscle to ll
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T. E. Yabe and R. Jayaram
mandibular reconstruction with this ap was rst
reported in 1989 by Hidalgo. The vascular pedicle consists of a peroneal artery and its accompanying two venae comitantes. Care must be taken
to protect peroneal nerve and ankle joint stability
by leaving at least 5cm of proximal and distal
bula bone intact (Fig.19.8).
19.6.2 Deep Circumex Iliac Artery
Fig. 19.7 Medial sural artery perforator ap with associ-
ated vascular pedicles
the deep defect, or it can also be elevated as a
chimeric ap. The sural nerve, the lesser saphenous vein or the plantaris tendon can also be harvested within the ap (Fig.19.7).
19.5.5 Rectus Abdominus
The rst free rectus abdominis ap was performed by Holmstrom in 1979. Hasegawa etal.in
1994 reported a rst clinical report describing its
use in the head and neck. The vascular pedicle
consists of the deep inferior epigastric artery and
venae originating from the external iliac artery
and vein. The main advantage of this ap is bulk
and hence is used for reconstruction of total glossectomy and skull base defects. This ap has generally been superseded in head and neck
reconstruction by the ALT.
Deep circumex iliac artery (DCIA) ap was rst
reported, as a bony ap, in 1979 by Taylor etal.
then as an oromandibular reconstruction in 1989
by Urken etal. The vascular pedicle consists of a
deep circumex iliac artery from the external
iliac system, accompanying venae comitantes. It
provides an alternative to the bula and scapula
free aps with thicker bone more suited to
implant placement. At least six vascular systems
contribute to the iliac crest, and free aps have
been reported based on all 6 (Fig.19.9).
Fig. 19.8 Fibular free ap with associated vascular
pedicles
19.6 Common Composite Flaps
The composite free ap contains more than one
tissue unit such as skin, muscle and bone.
19.6.1 Fibula
The bula free ap was rst described independently in Japan and Australia in 1973. The work
of Wei etal. in 1986 employing this ap as a chimeric ap expanded its utility in complex composite head and neck reconstruction. The
Fig. 19.9 Deep circumex iliac artery free ap with
associated vascular pedicles
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19.6.3 Scapula
The scapular fasciocutaneous free ap, based on
the circumex scapular artery, is a part of the
subscapular system. It was initially described in
an anatomic study by Saijo in 1978. Batchelor
and Sully used a scapular and latissimus dorsi
free ap to reconstruct a scalp defect in 1984
(Figs.19.10, 19.11, and 19.12).
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Fig. 19.12 Reconstructed post-operative CT image
Fig. 19.10 Segmental mandibulectomy defect with
reconstruction plate in situ
Fig. 19.11 Chimeric scapula free ap
19.7 Post-operative Management
19.7.1 Intensive Care
Most head and neck free ap patients are admitted to the intensive care unit (ICU)
post- operatively, to monitor the patient’s early
recovery, undertake high frequency ap observations, and to manage the airway as required.
Vasopressor use is often frowned upon due to
concern that vasoconstriction caused by such
agents could compromise the ap blood supply.
There is conicting evidence regarding the use of
vasoactive agents in free ap surgery. Vasoactive
agents can cause vasoconstriction and decrease
ap perfusion, while others suggest no adverse
outcomes. The judicious use of such vasopressors should be employed with input from intensivists, as uid overload can compromise the
ap’s viability. Fluid overload is thought to cause
pedicle thrombosis from endothelial damage,
extravasation, oedema and venous stasis.
Furthermore, free aps are more sensitive to
oedema from loss of lymphatic drainage and
autonomic innervation. It is imperative there is
clear communication between the surgical,
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anaesthetic and ICU team so that everyone is
aware of when the medication is started and when
it is stopped. Notwithstanding technical surgical
issues, if the patient is well, the ap will not be
harmed.
19.7.2 Flap Monitoring
The purpose of ap monitoring is the early detection of vascular compromise (venous or arterial)
and to prevent ap loss. The highest risk for vascular compromise is during the rst 24h, when
the intimal injury is the highest, and the risk signicantly drops after the rst 3 days following
surgery [7]. The free ap monitoring should be
performed hourly for the rst 24h with tapering
of intensity after the initial 24h [3]. The assessment should include a physical exam of ap
warmth, turgor, capillary rell, colour, and
Doppler assessment of the vascular pedicle.
Handheld or implantable doppler devices are routinely used.
19.7.3 Anticoagulation
Immediate to early thrombosis is mainly attributed to technical failure. There are no pharmacologic measures that have been proven to reduce
free ap anastomotic thrombosis or ap necrosis
[3].
After surgery, maintaining a neutral head
position can prevent kinking or pressure on the
pedicle with the subsequent ow compromise.
Ties around the neck (i.e., tracheostomy ties,
oxygen mask) can have a tourniquet effect and
should be avoided. Advanced atherosclerotic disease, diabetes mellitus, prior radiotherapy, and
prior neck dissection can also contribute to poor
vessel quality [8], compromising the integrity of
the anastomosis. In our practice, head and neck
free ap patients receive either subcutaneous
injection of unfractionated heparin or lowmolecular weight heparin depending on their
body weight and renal function.
19.7.4 Antibiotics
Oropharyngeal surgery is classied as a Class II
Clean/Contaminated procedure. Infection risks
inherent in head and neck free ap surgeries are
long duration, malnutrition, use of a bone ap,
prior radiotherapy and tracheostomy. Preoperative antibiotics at induction and 24 h of
post-operative antibiotics (usually cephazolin 1g
three times a day with or without metronidazole
500 mg twice a day) have consistently demonstrated a signicant reduction in surgical site
infections [9].
19.7.5 Nutrition
Following an initial nasogastric or gastrostomy
feeding, there should be a multidisciplinary
approach to the commencement of oral feeding.
There is a theoretical risk of wound breakdown
and stula formation when the reconstruction
involves the oral cavity and pharynx. A return to
oral feeding as early as the sixth post operatively
day is observed to be safe without increasing the
risk of orocutaneous stula or ap related complications [10, 11].
19.8 Problems andPotential
Complications
19.8.1 Wound Infection
andDehiscence
Head and neck operations often breach the upper
aerodigestive tract, and hence are considered
clean-contaminated procedures. This means a
20–30% risk of developing a wound infection
justifying the use of antibiotics during the early
post-operative period.
When wound dehiscence occurs, the principles of care involve managing drainable collections by aspiration or exploration, regular sterile
dressings, wound culture, appropriate antibiotic
therapy and attention to nutritional support.
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Extensive tissue loss may require a skin graft,
myocutaneous or a further free ap for cover
(Figs.19.13 and 19.14).
19.8.2 Flap Ischaemia
Regular and frequent monitoring of ap health is
to recognise the vascular insufciency early and
to prevent a ap loss. Prompt re-exploration and
revision are crucial as most aps fail to recover
after 10–12h of ischaemia. Venous insufciency
is more common than arterial and tends to
develop later. Venous congestion gives the ap a
bluish appearance with swelling, oedema, and on
the needle prick test, a brisk dark venous ooze. In
contrast, the ap with arterial ischaemia is pale,
cool to touch and does not blanch. The thrombosed vessel should be resected to a healthy vessel wall before re-anastomosis. If that is not
possible, an alternative recipient vessel should be
sought. Authors often use external carotid artery
(for more proximal and better calibre) or transverse cervical artery (for non-radiated eld) in
the vessel depleted neck when more distal
branches of vessels are of inadequate calibre.
Other causes of early ap failure are haematoma
and recipient vessel problems. Late ap compromise (>48 h) is usually due to infection or
mechanical stresses on the pedicle leading to
compromise. Prior radiotherapy to the recipient
neck, signicant medical co-morbidities such as
diabetes, hypercoagulable states and alcohol
withdrawal may also contribute to ap failure
[12] (Fig.19.15).
Fig. 19.13 Wound dehiscence during adjuvant radiotherapy following extended orbital exenteration and ALT free
ap
Fig. 19.14 Bolstered ap as a temporary measure to
complete adjuvant radiotherapy
Fig. 19.15 Venous ischaemia of RFFF for right hemiglossectomy on day 1 post-op
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19.8.3 Fistula
Orocutaneous stula is a complications of major
head and neck surgery that may delay much
needed adjuvant treatment and place a patient’s
life at risk with neck sepsis. The reported incidence is up to 20%, and a large percentage of
stulas received a major second operation to
achieve wound healing. The vacuum-assisted
closure (VAC) device is useful when the ap is
viable, not infected or is a low-output stula.
The authors advise against using VAC when the
major vessels are exposed or within the wound
bed.
When the defect is too large to be closed by
secondary intension, a second free ap or regional
ap depending on prognosis, tissue quality, and
stula size should be planned within a week after
the rst debridement.
When patients present with the stulae while
on radiotherapy, radiotherapy should not be interrupted, and the stula managed conservatively by
less aggressive but effective wound care until
radiotherapy is completed and a denite reconstruction planned. However, this is only true if
there is no risk of carotid blowout. Many of these
patients present not only with stula but also with
other coexisting unfavourable conditions such as
tissue atrophy, plate exposure, trismus, or even
occult recurrence, which ideally can be addressed
at the same time.
Hypothyroidism can complicate head and
neck cancer treatment and is an under-recognised
cause of failure to heal following surgery. Thyroid
function should be tested for and corrected in all
head and neck cancer patients, especially those
with free ap reconstruction.
19.8.4 Carotid Blowout
Carotid blowout is a rare but signicant complication following major neck surgery. In a series
of 280 patients who underwent major head and
neck surgery, 3% suffered carotid artery rupture.
Of the 3%, most died, and 11% survived but with
adverse neurological outcomes [13]. Neck sepsis
and previous radiation are the most signicant
risk factors. The management depends on its acuity of presentation.
In the event of life-threatening massive bleeding on the ward, the focus should be on arresting
life-threatening haemorrhage with direct pressure and securing the airway. Denitive exploration and repair will follow in the operating
theatre. Angiography with embolization can offer
a safe and rapid alternative method of achieving
vascular control in patients with spontaneous
rupture of the common carotid, carotid bulb or
external carotid system once the patient has been
stabilised.
19.9 Tips andTricks
19.9.1 Vessel Selection
andOrientation
The availability of recipient vessels can be predicted pre-operatively based on presenting
pathology and the planned extent of neck dissection. There are common vessels that are used
based on location in the head and neck region.
The supercial temporal artery and vein are used
in the upper third of the head, the facial and superior thyroid artery and vein for the lower third of
the face, and the external carotid artery branches
and jugular veins in the neck. In the vessel
depleted neck, nding a vessel in the contralateral neck, outside the previous radiation or surgery elds (e.g., transverse cervical) or more
proximally (e.g., external carotid) can help prevent arterial problems (Table19.2).
The free ap pedicle often has more than one
vein as a draining vessel. If the separate veins can
be traced to a conuence, a single venous anastomoses can be achieved. If no conuence and both
veins have good ow and calibre, both these vessels should be anastomosed to suitable recipient
veins. If the pedicle geometry permits, they
should be anastomosed to separate systems (i.e.,
internal and external jugular). In this arrangement, one will act as a backup drainage system if
the other one fails.
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Table 19.2 Extent of neck dissection, associated common pathology and typical recipient vessels
Neck
dissection
levels
1–3/1–4 Tongue,
1–4/1–5 Metastatic
1–4/2–4 Parotid Artery: Supercial
Primary
pathology Typical recipient vessels
Artery: Facial, superior
oor of
mouth
SCC of neck
thyroid, lingual
Veins: Common facial
vein/internal jugular vein
Artery: Facial, superior
thyroid, occipital artery,
transverse cervical artery
Vein: Internal jugular,
external jugular
temporal, facial, superior
thyroid, transverse
cervical artery
Vein: Supercial
temporal, internal/
external jugular vein
19.9.2 Perforator Based Chimeric
Flaps
The chimeric concept for free tissue transfers in
the head and neck setting was initially proposed
by Koshima etal. Chimeric aps consist of multiple spatially independent units with their own
vascular supply, joined to a common vessel. Such
vascular arrangement is particularly useful for
complex defects needing tissue of varying structural and or functional components simultaneously. These are also useful when surgeons are
presented with vascularly depleted necks due to
previous surgery or radiotherapy. Compared to
employing multiple free aps, chimeric aps
offer good versatility while maintaining a similar
complication rate (Fig.19.16).
19.9.3 Reanimation
Functional and psychological morbidity caused
by facial paralysis should not be underestimated. Facial reanimation can be categorised
into primary versus secondary procedure and
dynamic versus static reconstruction. The aetiology and duration of facial paralysis are the
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Fig. 19.16 Chimeric ALT free ap with vastus lateralis
muscle and fasciocutaneous paddle
most important considerations when determining what kind of reanimation surgery would
most benet the patient. In general, younger
patients with viable facial musculature and an
intact neuromuscular junction who had an intentional sacrice of facial nerve would benet
more from nerve transfer to achieve dynamic
reanimation. In the setting of radical parotid
surgery with a need for free tissue transfer,
donor nerves are often available in reconstructive aps. For older patients with multiple
comorbidities, static facial suspension with tensor fascia lata (TFL) graft, tarsal strip and eyelid
gold weight are often used to achieve oral competence and corneal protection.
Key Take Aways
1. Free tissue transfer is a key component of
head and neck reconstruction.
2. This is a common procedure with very low
failure rates in high volume centres.
3. A very thorough history and examination of
both the neck and proposed donor site
enhances free ap success.
4. No ap survives without adequate arterial
inow.
5. Venous anastomotic thrombus is more common than arterial.
6. Early free ap compromise or failure is usually technical, and regular post operative
observation of a free ap provides early
opportunity to address insufciency of
perfusion.
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19.10 Conclusion
In this chapter, we have outlined the variety of
free aps commonly used in head and neck
reconstruction and salient points in managing
patients who need free tissue transfer to achieve
biologically robust, functional and cosmetic
reconstruction. Familiarity with these reconstructive options will give ablative surgeons the skills
to balance the extent of resection versus potential
outcome. The mutual understanding and collaboration between ablative and reconstructive surgeons will produce the best possible outcomes in
head and neck surgery.
References
1. Steel BJ, Cope MR. A brief history of vascularized
free aps in the oral and maxillofacial region. J Oral
Maxillofac Surg. 2015;73(4):786.e1–11.
2. Leung JS, Seto A, Li GK.Association between preoperative nutritional status and postoperative outcome in head and neck cancer patients. Nutr Cancer.
2017;69(3):464–9.
3. Dort JC, Farwell DG, Findlay M, Huber GF, Kerr P,
Shea-Budgell MA, et al. Optimal perioperative care
in major head and neck cancer surgery with free
ap reconstruction: a consensus review and recommendations from the enhanced recovery after surgery society. JAMA Otolaryngol Head Neck Surg.
2017;143(3):292–303.
4. Motakef S, Mountziaris PM, Ismail IK, Agag RL,
Patel A.Perioperative management for microsurgical
free tissue transfer: survey of current practices with
a comparison to the literature. J Reconstr Microsurg.
2015;31(05):355–63.
5. Ishimaru M, Ono S, Suzuki S, Matsui H, Fushimi
K, Yasunaga H. Risk factors for free ap failure in
2,846 patients with head and neck cancer: a national
database study in Japan. J Oral Maxillofac Surg.
2016;74(6):1265–70.
6. Hasmat S, Low TH, Krishnan A, Coulson S, Ch’ng
S, Ashford BG, etal. Chimeric vastus Lateralis and
anterolateral thigh ap for restoring facial defects and
dynamic function following radical parotidectomy.
Plast Reconstr Surg. 2019;144(5):853e–63e.
7. Kroll SS, Schusterman MA, Reece GP, Miller MJ,
Evans GR, Robb GL, etal. Timing of pedicle thrombosis and ap loss after free-tissue transfer. Plast
Reconstr Surg. 1996;98(7):1230–3.
8. Vincent A, Sawhney R, Ducic Y.Perioperative care of
free ap patients. Semin Plast Surg. 2019;33(1):5–12.
9. Rodrigo JP, Alvarez JC, Gómez JR, Suárez C,
Fernández JA, Martínez JA. Comparison of
three prophylactic antibiotic regimens in cleancontaminated head and neck surgery. Head Neck.
1997;19(3):188–93.
10. Aires FT, Dedivitis RA, Petrarolha SM, Bernardo
WM, Cernea CR, Brandão LG. Early oral feeding
after total laryngectomy: a systematic review. Head
Neck. 2015;37(10):1532–5.
11. Kinzinger MR, Bewley AF.Perioperative care of head
and neck free ap patients. Curr Opin Otolaryngol
Head Neck Surg. 2017;25(5):405–10.
12. Novakovic D, Patel RS, Goldstein DP, Gullane
PJ.Salvage of failed free aps used in head and neck
reconstruction. Head Neck Oncol. 2009;1(1):33.
13. Stell PM.Catastrophic haemorrhage after major neck
surgery. Br J Surg. 1969;56(7):525–7.
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