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RECONSTRUCTION OF THE
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FACIAL SUBUNITS
Melvyn S. Yeoh, Andrew T. Meram
CHAPTER 52
1. What are the principles related to closing large forehead defects?
• When encompassing more than half of the forehead, reconstruction of the entire forehead as a
single aesthetic unit should be considered.
• If the defect includes a portion of one eyebrow, consideration should be given to preserving the
intact eyebrow while reconstructing the affected eyebrow.
2. What area of the forehead has the thinnest and most pliable skin?
The glabella region.
3. Local blockade of which nerves can provide adequate anesthesia to the
forehead?
Supraorbital and supratrochlear nerves.
4. Where are the resting skin tension lines on the forehead?
Transversely in the forehead and vertically in the glabella region.
5. What are some of the options available for forehead reconstruction?
• Primary closure
• Closure by secondary intention
• Skin grafting
• Local rotational flaps
• Distant pedicled flaps
• Skin expansion
• Microvascular composite tissue transplantation
• Flap prefabrication
6. How must primary closure best be obtained, and what type of defect is best
suited for primary closure?
Most suitable for elliptical defects transversely oriented in anterior portion of forehead parallel to lines
of resting skin tension. Transverse dimension can be as long as the full width of the forehead but must
have limited vertical height.
7. How might one obtain additional length for flaps of the forehead and/or scalp?
Galeal scoring spaced 0.5 to 1 cm apart.
8. What are common types of forehead local flaps?
Rhomboid, dual rhomboid, banner, bilobed flaps, Worthen flap, shutter flap.
9. How is the eyebrow best reconstructed?
Hair follicular transplantation.
10. What are options for total eyebrow reconstruction?
• Hair plug transplants
• Hair strip grafts
• Pedicled scalp flaps
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11. What are some options for lower eyelid reconstruction?
• Direct closure: It can be used in full-thickness defects of up to 30% of the lower eyelid in a young
patient and up to 45% in an elderly patient.
• Tenzel semicircular rotational flap: It can be used for defects of up to 60% of the lid.
• Hughes tarsoconjunctival flap: It can be used for defects of more than 50% of the lower lid. This
upper lid to lower lid sharing technique requires a secondary stage to separate the flap.
• Mustardé cheek flap: It can be used for very large defects up to the entire lower lid.
12. What are some options for upper eyelid reconstruction?
• Direct closure: It can be used in full-thickness defects of up to 33% of the lower eyelid in a young
patient and up to 40% in an elderly patient.
• Tenzel semicircular rotational flap: It can be used for defects of up to 60% of the lid.
• Sliding tarsoconjunctival flap: It can be used on defects of the upper lid that are too large for direct
closure by horizontally sliding a section of tarsus from the remaining lid to close the defect and
placing a skin graft.
• Cutler-Beard (bridge) flap: It can be used to repair full-thickness upper lid defects of more than
60% up to defects of the entire upper lid. This procedure requires a secondary stage and an inset
ear cartilage graft to reconstruct the tarsus.
13. What are the nasal subunits?
Dorsum, tip, columella, paired sidewalls, alae, and soft triangles.
14. Can you describe skin quality on the different nasal subunits?
Skin quality differs from one region to the other. Skin of the nasal dorsum and sidewalls is thin,
smooth, and pliable. Skin of the tip and alar subunits is thick, stiff, and pitted with sebaceous
glands.
15. How do split-thickness skin grafts heal on the nose?
They always appear thin and shiny after transfer secondary to the temporary ischemia associated with
revascularization.
16. How does a full-thickness skin graft on the nose differ depending on the location?
It will blend well in the smooth-skinned zones of the dorsum or sidewalls. In contrast, a thin, shiny
skin graft will appear as a patch if placed within the normally thick, pitted tip or ala. These regions are
better suited for local or regional flap reconstruction.
17. What are potential donor sites for skin grafting of the nose?
Superficial defects of the upper two-thirds of the nose in the zone of smooth skin can be grafted with
full-thickness skin grafts with good results. Preauricular skin provides an ideal match. Postauricular
skin may also be harvested, but it tends to heal with a red hue. Supraclavicular skin is another choice
to resurface the entire nose, although color match is less satisfactory as it tends to heal with a brownish hue. Split-thickness skin grafts are generally not used in nasal reconstruction.
18. What are the indications for local flap reconstruction of the nose?
• Small nasal defects less than 1.5 cm in diameter with no cartilage grafts needed
• To reconstruct defects in the thin, mobile skin of the upper nose
19. What are some types of nasal local flaps?
Bilobed flap, nasolabial flap, paramedian forehead flap, rhomboid flap, single-lobed flap.
20. What are options for large defects?
As there is not enough nasal skin to redistribute over the nose to cover large defects, a forehead or
nasolabial flap is required for defects greater than 1.5 cm in diameter or those requiring reconstruction of
a cartilage framework.
21. What is the blood supply to the nasolabial flap?
Based on the perforators from the facial and angular arteries that pass through the underlying levator
labii and zygomatic muscles to the skin.
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22. What types of forehead flaps can be performed to reconstruct nasal defects, and
what are their blood supplies?
• New’s sickle flap (unilateral superficial temporal artery)
• Converse’s scalping flap (contralateral superficial temporal artery)
• Median forehead flap (bilateral supraorbital vascular arteries)
• Paramedian forehead flap (unilateral supratrochlear artery)
23. Can you describe the paramedian forehead flap?
The flap can be designed on either the right or left supratrochlear vessel, but the reach of the flap is
easier when it is based on the same side of the lateral defect. A template of the required missing
forehead skin should be placed at the hairline and designed with a 1.5-cm pedicle above the supratrochlear vessels. If the arc of rotation is short, an additional 1.5 cm can be added by extending the flap tip
into hair-bearing scalp. The flap should be designed vertically to maintain its axial blood supply.
24. When is a paramedian forehead flap divided?
The paramedian forehead flap can be divided as early as 2 weeks, but most advocate 3 weeks. Often a
contouring procedure is done at this time by elevating the flap at an intermediate operation, creating a
bipedicle flap that extends from the brow to the columellar inset. The flap can be defatted and thinned
and repositioned on the nose with peripheral and quilting sutures. The pedicle is not transected. Three
weeks later, the pedicle can be divided.
25. How and why are primary bone and cartilage grafts used in nasal reconstruction?
For nasal reconstruction, bone and cartilage create the framework for the soft tissue. A composite
defect will require reconstruction of both the covering soft tissue and the underlying framework.
26. What donor tissues are available for nasal support?
Septal cartilage is the first choice for most nasal grafts. Auricular cartilage is a good choice for ala and
tip support. Rib cartilage, cranial bone, and temporoparietal fascia mixed with diced cartilage can be
used for nasal dorsum support.
27. What is the normal size of the adult ear?
Height between 5.5 and 6.5 cm and width generally 66% of height in children and 55% of height in
adults.
28. What are general guidelines for proper aesthetic ear reconstruction?
• The ear should lie one ear length posterior to the lateral orbital rim.
• The lateral protrusion of the helix from the scalp is between 1.5 and 2.0 cm.
• The mean inclination of the ear from the vertical is 20° posterior.
29. Can an amputated ear be replanted?
Yes, by microanastomosis of the posterior auricular artery and a posterior auricular vein to donor
vessels.
30. In case of total ear avulsion, microvascular replantation is not possible; what
other options are available?
Mladick’s two stages pocket technique is a possible option. In this technique, skin of the avulsed ear
is removed, and the remaining cartilage is stored in the retroauricular area. This cartilage is retrieved
at a later time for construction of auricular framework. Alternatively, this denuded cartilage can be
reattached to its proper location and covered with temporoparietal fascia and a split-thickness skin
graft. Unlike Mladick’s procedure, this is a one-stage procedure.
31. When total auricular reconstruction is needed, which costal cartilages are
harvested?
The costal cartilages from ribs 6 to 9 are most commonly used.
32. What are the goals of lip reconstruction?
• Maintain oral sphincter competence.
• Restore anatomic landmarks.
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• Provide adequate stomal opening for speech and eating.
• Preserve sensation.
• Restore aesthetic appearance.
33. Restoration of what structure is critical in commissure reconstruction?
The orbicularis oris muscle.
34. What discrepancy in vermilion border can be noticeable and at what distance?
1-mm discrepancy is noticeable at 3 ft.
35. How much tissue loss still permits satisfactory closure of the lips?
Up to 25% of the upper lip and 33% of the lower lip.
36. Why is the lower lip a more suitable donor for reconstruction than the upper lip?
• It has no distinguishing features such as Cupid’s bow, philtrum, or tubercle.
• It may sustain greater tissue loss.
• It can donate tissue for upper lip reconstruction.
37. What are options for repair of localized mucosal or vermilion defects?
Notch or saddle deformities of the lower lip involving the vermilion can be managed by excision and
Z-plasty, V-Y mucomuscular advancement flap, or the lateral mucomuscular advancement flap.
38. What are the indications for an Abbe flap?
• A moderate-sized defect of the lower lip that is off-center and spares the commissure
• A defect of the philtrum of the upper lip
• Restoration of symmetry to an overly small lower lip
39. What is the Abbe flap?
It is a V-shaped lower lip flap based on the inferior labial artery and designed opposite the area of
defect for the central upper lip region. It is raised, transposed 180 degrees, and inset. The donor site is
closed primarily. Second stage division of the pedicle and final inset are performed 14 days later.
40. What are the indications for an Estlander flap, and what is its major
disadvantage?
Most useful in medium-sized lateral defects of the upper or lower lip that includes the commissure. It
produces a rounded commissure that may result in a smaller oral aperture, possibly requiring secondary revisions.
41. Can you describe the Estlander flap?
A triangular flap based on the superior labial artery and designed for reconstruction of the lateral
lower lip defects involving the commissure. The flap is transposed 180 degrees from the upper lip to
the lower lip.
42. What is the Karapandzic flap?
It is a technique that maintains the neurovascular pedicle in the soft tissue while rotating and restor-
ing sphincter continuity. Central defects of up to 80% can be reconstructed.
43. What is the Gillies fan flap?
Fan-shaped rotational advancement flap based on the superior labial artery and designed for large
defects involving greater than 50% of the lower lip. It is made lateral to the defect around the nasolabial fold with a 1 cm back cut.
44. What is a disadvantage of the Gillies fan flap?
It may result in decreased oral aperture.
45. Can you describe the McGregor flap?
Rectangular-shaped flap modified from the Gillies fan flap and based on the superior labial artery. It
is rotated around the commissure without altering the size of the oral aperture. The width of the flap
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equals the vertical height of the defect, while the length of the flap equals the width of the defect plus
the width of the flap.
46. What is a drawback to the McGregor flap?
A mucosal advancement flap is required to reconstruct the lip mucosa.
47. What structures must be accounted for in malar reconstruction to prevent a poor
esthetic outcome?
The lower eyelid and canthal areas.
48. How might one prevent lower lid ectropion?
By suturing the advancing flap to the periosteum of the zygoma.
49. What are the common reconstruction techniques for repairing cheek defect?
• Small: Primary closure and local flap
• Moderate defect: Nasolabial flap
• Large defect: Cervicofacial rotational flap or submental island flap
• Through-and-through defect: Anterolateral thigh (ALT) free tissue flap
50. What are the critical elements of the cervicofacial flap?
• Extensive undermining of the cervical cheek, retroauricular area, and chin
• Rotation is in a superomedial direction.
• Superior dissection lateral to the eye must be performed to prevent ectropion.
• Dissection into the mucosa can allow closure of intraoral and through-and-through defects.
BiBliography
Bauer BS, Bauer EM: Ear reconstruction. In Plastic surgery secrets plus, ed 2, Philadelphia, 2010, Mosby Elsevier,
pp 395–400.
Carlson ER, Guerra A: Lip cancer – ablative and reconstructive surgery. In Current therapy in oral and maxillofacial surgery,
St Louis, MO, 2012, Saunders Elsevier, pp 516–526.
Ghali GE, Herford AS: Local and regional flaps. In Peterson’s principles of oral & maxillofacial surgery, Shelton, CT, 2012,
People’s Medical Publishing House, pp 877–892.
Hebda PA: Wound healing of the skin. In Essential tissue healing of the face and neck, Shelton, CT, 2009, People’s Medical
Publishing House, pp 1–15.
Holmes JD: The temporalis system of flaps in head and neck reconstruction: temporoparietal fascia and temporalis muscle
flaps. In Current therapy in oral and maxillofacial surgery, St Louis, MO, 2012, Saunders Elsevier, pp 527–532.
Hong RW, Menick F: Nasal reconstruction. In Plastic surgery secrets plus, ed 2, Philadelphia, 2010, Mosby Elsevier,
pp 381–387.
Mankani MH, Mathes SJ: Forehead reconstruction. In Plastic surgery secrets plus, ed 2, Philadelphia, 2010, Mosby Elsevier,
pp 373–380.
McClure SA, Best SP: Ear reconstruction. In Current therapy in oral and maxillofacial surgery, St Louis, MO, 2012, Saunders
Elsevier, pp 558–565.
McConnell MP, Evans GRD: Local flaps of the head and neck. In Plastic surgery secrets plus, ed 2, Philadelphia, 2010,
Mosby Elsevier, pp 363–372.
Perciaccante VJ, Jelic SJ: Oral and maxillofacial reconstruction. In Oral and maxillofacial secrets, ed 2, St Louis, MO, 2007,
Mosby Elsevier, pp 389–403.
Salama AR: Flap classification and principles of flap design for head and neck reconstruction. In Current therapy in oral and
maxillofacial surgery, St Louis, MO, 2012, Saunders Elsevier, pp 11–18.
Seki JT: Lip reconstruction. In Plastic surgery secrets plus, ed 2, Philadelphia, 2010, Mosby Elsevier, pp 401–408.
Shetty V, Bertolami CN: Wound healing. In Peterson’s principles of oral & maxillofacial surgery, Shelton, CT, 2012, People’s
Medical Publishing House, pp 3–16.
MICROVASCULAR SURGERY
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Srinivasa Chandra, Rui Fernandes, Jacob Yetzer
1. What is microvascular surgery?
Microsurgery is simply any surgery performed using a microscope for magnification. Microvascular
surgery refers to microsurgery that includes repair and anastomosis of small blood vessels (generally
< 3 mm). This term is often used interchangeably with the term microvascular reconstruction. This
technique is important in head and neck reconstruction because it allows for tissue to be transferred
from a distant site to the defect site with its own blood supply intact. The tissue donor tissue is
harvested with the vascular pedicle (supplying artery and vein) and anastomosed or connected to
corresponding recipient site vessels.
2. How are flaps classified?
Free flaps can are most commonly classified on a basis of their tissue composition and their blood
supply. Flaps can be composed of skin alone, skin and fascia, skin and muscle, bone alone, or skin
muscle and bone together. The nomenclature for these flaps includes cutaneous, fasciocutaneous,
myocutaneous, osseous, and osteomusculofasciocutaneous flaps.
Numerous classifications based on blood supply have been published. Probably the most com-
monly referenced is the Mathes and Nahai classification of muscular flaps listed in Table 53-1.
Cormack and Lamberty and Nakajima also contributed named classifications for cutaneous
and fasciocutaneous flaps. The common feature these share is a description of the course of the
supplying perforator vessel. For practical purposes, perforator vessels can all be described as
“direct,” meaning they travel directly from the main vascular pedicle through a fascial plane to supply the skin, or “indirect,” meaning they pass through other tissue (usually muscle) before reaching
the skin.
3. What is a perforator vessel?
These are identifiable, but unnamed vessels arising from a named source vessel and directly or
indirectly supplying a portion of the skin. So-called perforator flaps allow for significant flexibility and
creativity in flap harvest.
CHAPTER 53
4. What is an angiosome?
The concept of the angiosome was introduced by Taylor and Palmer in 1987. They divided each half of
the body into 40 territories based on the source artery providing the vascular supply. Each anatomic
territory can be further divided based on perforators originating from the source vessel. Of clinical
importance is the fact that each angiosome is connected to adjacent angiosomes by anastomotic vessels referred to as choke vessels. Because of the presence of choke vessels a flap can have a clinical
territory somewhat larger than the anatomic territory of the feeding vessel.
5. What is a chimeric flap?
A chimeric flap is a flap that includes multiple tissue paddles that are physically independent from one
another, each with a blood supply that originates from a single vascular pedicle. An example would
be a scapula flap based on the circumflex scapular artery that includes latissimus dorsi as a separate
paddle fed by the thoracodorsal artery. Both the circumflex scapular and thoracodorsal arteries
originate from the subscapular artery.
6. When is microvascular reconstruction indicated?
• Posttraumatic defects
• Oncologic resections
• Post-radiation areas with vascular, chronic infection, functional, or structural complications
• Congenital and acquired malformations
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Table 53-1. The Mathes and Nahai Classification of Muscular Flaps
FLAP TYPE VASCULAR SUPPLY EXAMPLES
Type I One dominant vascular pedicle Gastrocnemius, rectus femoris, tensor fascia lata
Type II Dominant vascular pedicle and
minor pedicle
Type III Two dominant pedicles Gluteus maximus, rectus abdominis, serratus anterior
Type IV Multiple segmental pedicles Extensor digitorum longus, extensor hallucis longus,
Type V One dominant pedicle and
secondary segmental pedicles
7. What are the goals of microvascular reconstruction?
Essentially, this is an autotransplant with its own vascular pedicle. Flaps may be inclusive of skin,
fascia, muscle, and bone to an area deficient of structure, vascularity, and function. In general,
the goal is to achieve restoration of form and function by replacing “like with like”—that is, soft
tissue with soft tissue, bone with bone, and so forth. When insufficient local tissue is unavailable
or geometrically insufficient for reconstruction, a soft tissue flap is a solution. Osseous free flaps
are useful in reconstructing long bony defects (> 5 to 6 cm) or in those sites where the recipient
bed is poorly vascularized or irradiated. Finally, composite defects, where multiple tissue types
are needed to be replaced, are readily reconstructed by a composite free flap that suits the
needs of the defect.
8. What are contraindications to microvascular reconstruction?
There are few absolute contraindications to microvascular reconstruction. Relative contraindications
include a hypercoagulable state, ongoing infection at the recipient or donor site, a patient unable to
tolerate a prolonged surgery due to medical comorbidities, poor nutritional status, and inadequate
recipient vessels. Also, there are donor site-specific contraindications to consider. For instance,
history of upper arm trauma or cephalic vein harvest would be a contraindication for a forearm
flap. Likewise, a lower extremity flap would be contraindicated in the setting of peripheral vascular
disease. Each flap has its own donor site morbidities to consider that also bear weight in the decision
to use a flap.
Gracilis, peroneus longus, platysma, soleus,
sternocleidomastoid, temporalis, trapezius,
vastus lateralis
sartorius, tibialis anterior
Pectoralis major, latissimus dorsi
9. What is the success rate of microvascular free flap transfer?
Success rate is around 95% to 98%.
10. In which order are the artery and vein anastomosed?
The decision should be based on intraoperative anatomy. If repair of the artery will result in poor
exposure of the veins, venous repair should be done first. The reverse is also true.
11. What are the microvascular anastomotic techniques for diameter discrepancies?
Diameter of vessel mismatch can be resolved by proportional suturing, differential dilation. and bevel-
ling. Thickness discrepancy can be matched with radial proportional suturing the outer wall while
matching the inner diameter.
12. What are the commonly used soft tissue free flaps for craniomaxillofacial
reconstruction?
Radial forearm fasciocutaneous, lateral arm fasciocutaneous, latissimus dorsi myocutaneous, antero-
lateral thigh fasciocutaneous, rectus abdominis myocutaneous.
13. What are the bone flaps commonly used for craniomaxillofacial reconstruction?
Fibula osseous or osteocutaneous, iliac crest osseous or osteocutaneous, scapula osseous or osteocu-
taneous, radial forearm osteocutaneous.
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14. What is the arterial and venous supply to each of the flaps listed in question 13?
• Radial forearm: radial artery, vena comitantes, and cephalic vein (dual outflow)
• Lateral arm: perforators of the posterior radial collateral artery, vena comitantes, cephalic vein (dual
outflow)
• Latissimus dorsi: thoracodorsal artery and vein
• Anterolateral thigh: perforators from the descending branch of the lateral circumflex femoral artery
and vena comitantes
• Rectus abdominis: deep inferior epigastric artery and vein
• Fibula: peroneal artery and vein
• Iliac crest: deep circumflex iliac artery and vein
• Scapula: circumflex scapular artery and vein
15. What is unique about the scapula flap?
The scapula flap is based on the circumflex scapular artery, which is a branch of the subscapular
system. Branches of the subscapular system not only provide blood supply to the latissimus dorsi, but
the circumflex scapular artery has multiple distinct cutaneous and osseous branches. This means that
multiple areas of skin and tissue types can be harvested based on one vascular pedicle as a chimeric
flap. This allows flaps of the subscapular system to reconstruct geometrically complex defects. Also,
unlike the other osseous flaps often used in head and neck reconstruction, the scapula flap will not
interfere with postoperative ambulation.
16. Which recipient site vessels are commonly utilized in the head and neck?
Generally, one of several branches of the external carotid artery is selected for anastomosis. The most
commonly used are the ipsilateral facial artery, superior thyroid artery, and superficial temporal artery
(for upper facial reconstruction). If these are unavailable, other vessels may be selected, the contralateral neck can be used, and vein grafting or vessel transposition are options for the vessel-depleted
neck.
17. What should be included in the workup prior to microvascular reconstruction?
In addition to planning the reconstruction on a basis of the anticipated defect, the history and
physical should focus on prior surgeries or trauma to the recipient site. If there has been prior
surgery, obtaining the operative report can be helpful in elucidating which recipient vessels may
still be available. If this is still in question, a computed tomography angiography (CTA) and magnetic resonance angiography (MRA) of the neck may be helpful. If bony reconstruction is planned,
consideration ought to be given to obtaining a stereolithographic model to aid in planning and
plate contouring. Virtual surgical planning can also be very helpful in this setting.
Similar considerations should be given to the anticipated donor site. Again prior surgery or
trauma will affect the availability of local tissue or vascular pedicle. The particular morbidities of any
given flap should be considered in light of the patient’s overall status. For instance, a patient with
known peripheral vascular disease may be a poor candidate for a fibula flap.
18. When should imaging of the lower extremity be performed prior to harvesting the
fibula flap?
When planning a lower extremity flap such as the fibula flap, collateral blood supply to the distal
extremity must be confirmed or the patient may suffer disastrous outcomes such as loss of a foot.
Normally, the anterior and posterior tibial arteries as well as the peroneal artery supply the lower
extremity. When the fibula flap is harvested, the peroneal vessel is eliminated, and the patient loses
some of this vascular redundancy. Imaging such as CTA or MRA should be obtained if there is any
concern for peripheral vascular disease to confirm three-vessel runoff.
Be alert for risk factors such as smoking, hypertension, hypercholesterolemia, and history of
coronary or cerebrovascular disease. Also, claudication, cold extremities, hair loss, and absent pulses
are clinical indicators of peripheral vascular disease.
19. What is the Allen’s test?
This is a clinical test used to confirm collateral flow to the hand. This is important when planning
a radial forearm flap, which eliminates the radial artery as a nourishing vessel to the hand. The
patient raises his hand and makes a tight fist to exsanguinate the hand. The physician then occludes
both the radial and ulnar vessels by compressing them. The patient then opens his hand. When the
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surgeon releases the ulnar artery alone, blood flow in the form of blush should return to the hand in
less than 5 to 6 seconds. This indicates that the deep and superficial palmar arches are present and
communicate, thus assuring that the radial and ulnar vasculature share collateral flow. In a smaller
percentage of patients, this may not be the case—this is an absolute contraindication for a radial
artery flap.
20. Which of the flaps discussed above poses a risk of postoperative ileus or hernia?
The iliac crest and rectus abdominis free flaps both present a risk for ileus and hernia as dissection
of the abdominal fascia and retraction of the abdominal contents are unavoidable during harvest of
these flaps. Watertight closure of the fascia and gentle retraction during harvest will help avoid these
complications. However, patients should be monitored postoperatively for signs including abdominal
distention, nausea, vomiting, frequent belching, and lack of flatus or bowel movement.
21. What is the best way to monitor a free flap postoperatively?
Clinical examination. Hourly clinical exam of the flap during the first 24 hours after surgery includes
the following:
• Color: A white flap indicates arterial insufficiency; a cyanotic or blue flap indicates venous
congestion.
• Temperature: The temperature should be the same as surrounding tissue. A cool flap can indicate
either an arterial or venous problem. Note: This can be misinterpreted inside the oral cavity.
• Turgor: Decreased turgor may indicate arterial occlusion; increased turgor indicates venous
congestion.
• Capillary refill: A slow or absent refill indicates arterial occlusion; a brisk refill indicates venous
congestion.
• Pinprick: No bleeding may represent arterial occlusion, while brisk, dark block may be due to
venous congestion. Note: The pinprick test is not done regularly.
22. What are adjuncts to the clinical exam when monitoring a flap?
External, handheld Doppler monitoring is the most commonly used adjunct followed by implant-
able Doppler. Other modalities include laser Doppler monitoring, oxygen probe, and near infrared
spectroscopy.
23. Can you list the potential causes for flap failure?
• Thrombosis: This may be caused by vessel trauma during surgery, a hypercoagulable state, or
reperfusion injury.
• Mechanical problems: These may be kinking or compression of the pedicle due to patient position,
tight surrounding tissue or hematoma, or inadequate vessel match or size.
• Physiological: It may be caused by factors such as hypotension or hypovolemia.
24. Which is more common, arterial or venous occlusion?
Venous occlusion is the most common cause of flap failure.
25. What are postoperative considerations to treat or prevent flap congestion?
Topical nitric oxide paste can be applied to the flap, which acts on vascular smooth muscle to vasodi-
late local vessels. Warm compresses over the flap will have a similar effect. Leech therapy is another
consideration, which both increases outflow and has an antithrombotic effect due to the hirudin in the
leech’s saliva. If leech therapy is used, prophylactic coverage of Aeromonas hydrophila is required as
there is a risk of transmission.
26. What is meant by the term ischemia-reperfusion injury?
In any free tissue transfer there is an ischemic episode created when the flap is divided from its
vascular supply. This leads to anaerobic metabolism. With time, membrane transporters fail and
intracellular calcium accumulates, leading to an inflammatory cascade and production of free radicals.
The injury is compounded when the blood supply is re-established (reperfusion). The inflammatory
process, which has already begun, is continued by the influx of neutrophils and further production of
reactive oxygen species. This process leads to cell death in the form of apoptosis and necrosis, which
can lead to flap failure. The surgeon must be expeditious with flap harvest to minimize ischemia time
and maintain meticulous tissue handling during anastomosis to prevent secondary ischemia due to
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vaso-occlusive episodes. In essence, consideration is needed to eliminate Virchow’s triad of stasis,
hypercoagulability, and vessel injury as the key to increase flap survival.
27. What methods can be used to minimize ischemia?
Meticulous planning is the most important factor to minimize the effects of ischemia. All recipient ves-
sels should be selected before donor vessels are ligated. In general, muscle does not tolerate warm
ischemia well for more than 2 hours. Skin and fasciocutaneous flaps can tolerate longer ischemia
times (4 to 6 hours).
28. What is the no-reflow phenomenon?
After performing a patent anastomosis, the flap still fails to reperfuse. This no-reflow phenomenon
appears to be related to an obstruction in the microcirculation secondary to endothelial injury, reperfusion injury, or platelet aggregation.
29. How long does it take for new endothelium to cover the anastomosis site?
Pseudointima is formed within the first 5 days of healing. New endothelium starts to cover the anasto-
mosis site after 1 to 2 weeks.
BiBliography
Budd M, Evans G: Postoperative care. In Wei and Mardini flaps and reconstructive surgery, London, 2009, pp 137–142.
Foster RD, Anthony JP, Sharma A, Pogrel MA: Vascularized bone flaps versus nonvascularized bone grafts for mandibu-
lar reconstruction: an outcome analysis of primary bony union and endosseous implant success, Head and Neck
21(1):66–71, 1999.
Hidalgo DA: Fibula free flap: a new method of mandible reconstruction, Plast Reconstr Surg 84:71–79, 1989.
Mathes SJ, Nahai F: Classification of the vascular anatomy of muscles: experimental and clinical correlation, Plast Reconstr
Surg 67:177–187, 1981.
Pratt GF, Rozen WM, Westwood A, et al.: Technology-assisted and sutureless microvascular anastomoses: evidence for
current techniques, Microsurgery 32:68–76, 2012.
Song YG, Chen GZ, Song YL: The free thigh flap: a new free flap concept based on the septocutaneous artery, Br J Plast
Surg 37:149–159, 1984.
Taylor GI, Palmer JH: The vascular territories (angiosomes) of the body: experimental study and clinical applications, Br J
Plast Surg 40:113–141, 1987. Accessed February 26, 2014.
Urken ML: Atlas of regional and free flaps for head and neck reconstruction, New York, 1995, Raven.
Van den Heuvel MG, Buurman WA, Bast A, van der Hulst RR: Review: Ischaemia-reperfusion injury in flap surgery, J Plast
Reconstr Aesthet Surg 62:721–726, 2009.
Wei FC, Jain V, Celik N: Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps, Plast
Reconstr Surg 109:2219–2226, 2002. discussion 27–30.
Yap LH, Butler CE, Principles of microsurgery, Grabb and Smith’s plastic surgery, ed 6, edited by C. Thorne. Philadelphia,
2007, Lippincott Williams & Wilkins, pp 66–72.
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