Free flaps In Head and Neck Reconstruction:

One of the most important advances in reconstructive surgery for head and
neck cancer has been the development of techniques for microvascular tissue
transfer. This technique involves harvesting flaps of healthy tissue with their
blood supply from remote sites in the body and implanting the tissue in the
recipient wound bed. The blood vessels associated with the donor graft are
anastomosed with recipient vessels in the wound bed. The first reported free
tissue transfer was vascularized jejunum performed by Siedenberg in 1959.
Panje performed the first free flap for oropharyngeal reconstruction in 1976.
The fibula free flap was used for mandible reconstruction by Hidalgo in 1989.
Today the most common free flaps in head and neck reconstruction are the
radial forearm, the rectus abdominis, and the fibula.

Other important free flaps include:

► Radial Forearm Flaps

► Lateral Arm Flaps
► Lateral Thigh Flap
► Anterolateral Thigh Flap
► Rectus Abdominis Flaps
► Latissimus Dorsi Flap
► Gracilis Flap
► Temperoparietal Fascial Flap
► Fibular Osteocutanous Flap
► Iliac Crest Flaps
► Scapular Flaps
► Metatarsal Flap
► Rib Flaps
► Jejunum
 ► Omentum
► Gastroomentum

There are numerous advantages with free tissue transfer compared with
traditional pedicled flaps or non-vascularized grafts for reconstructive
surgery. A wide variety of tissue types including skin, muscle, fascia, and bone
are available for transfer. Large bulky flaps may be used for large defects and
thin pliable flaps for smaller defects. The variety of tissue type and size allows
for optimization of function and cosmesis. A second surgical team can often
harvest the donor flap at the same time as the cancer resection. The
vascularized tissue tolerates post-operative radiation. Also, if the patient has
already had radiation in the head and neck region then non-radiated donor
tissue can be moved into the recipient wound bed. Because the vessels may be
re-connected with any suitable-sized recipient vessels, numerous spatial
orientations are possible for the donor flap. Another big advantage for
vascularized bone flaps is the possibility of later acquiring osseointegrated
dental implants. Although the operative times are longer with microvascular
reconstruction, there is usually no need to stage procedures. Finally, the
success rates for free flaps are generally greater than 90%. Disadvantages
with this technique include longer operative times, the requirement of
significant technical expertise, and donor site morbidity. Nevertheless, free
flaps should be considered in many patients with significant defects after cancer
resection in the head and neck. This discussion will focus on the radial
forearm, rectus abdominis, fibula, and anterolateral thigh free flaps.

General Considerations
Once a flap is removed from the donor site, the insetting of the flap begins. If
the flap contains an epithelial surface then interrupted horizontal mattress
sutures are used for re-approximation with recipient tissue. The orientation
and position of the flap should allow for a tension-free vascular anastomosis
without any kinking of the vessels. Recipient vessels should be identified during
the cancer resection. The facial artery is often used for reconstructions
involving the oral cavity or pharynx. Other branches of the external carotid
may also be used if necessary. The recipient veins may be the internal jugular
(end-to-side) or external jugular (end-to-end) veins. Use of an operating
microscope is necessary for the vascular anastomosis. A microvascular set is
used that contains non-traumatic vessel clamps, jeweler's forceps,
microvascular scissors, vessel dilators, and a microvascular needle driver.
Either the artery or the vein may be done first depending on the surgeon's
preference. First, the adventitia is removed from the ends of the vessels. Then,
the lumen of the vessel is dilated and irrigated with heparinized saline to
remove any clots. The anastomis is performed with simple interrupted 9-0
nylon sutures. The vascular clamps are released and the flap is examined for
adequacy of perfusion. Papaverine may be sprayed on the pedicle after
anastomosis to help with vasodilation. Drain placement and closure of the
incisions must be done without traumatizing the vessels. A Doppler is used
after release of the vascular clamps and a corresponding place on the skin is
marked with a suture. The Doppler signal should be identified through the skin
after all incisions are closed.

Free flaps require long operative times so patients with significant co-
morbidities may not be suitable candidates for these procedures. The flaps
must be monitored closely for signs of ischemia after surgery. Arterial
insufficiency will result in a pale, cold flap without a detectable Doppler
signal. Venous insufficiency will result in an edematous, purple-appearing flap
that may have a detectable Doppler signal. In either case, the flap may not
survive unless the condition is reversed. In such a situation, the patient should
be promptly taken back to the operating room for exploration of the pedicle.
Simple measures to improve perfusion post-operatively include treating anemia
with transfusion, avoiding use of vasopressors, and keeping the flap warm with
a warming blanket. Usually, patients are kept in intensive care units for a
minimum of two days after surgery. The flap should be checked by a physician
or ICU nurse every hour for at least twenty-four hours after surgery.
RADIAL FOREARM FREE FLAP

The radial forearm free flap (RFFF) allows for the transfer of a large amount
of thin, pliable, well-vascularized skin. This flap was first described by Yang,
et al, in China in 1981. It is most often harvested as a fasciocutaneous flap
although a section of radial bone may be harvested with it as well. The RFFF
is excellent for reconstruction of oral cavity, oropharyngeal, and
hypopharyngeal defects, such as those found after hemiglossectomy or
laryngectomy with partial pharyngectomy. The RFFF may be fashioned into a
tube for total pharyngoesophageal defects. Another common use is for
reconstruction of total or subtotal lower lip defects. Advantages with this flap
include the large amount of thin, pliable skin that is available. The flap is
relatively easy to raise and has reliable vasculature. Disadvantages include
the need for a split-thickness skin graft and the unsatisfactory appearance of
the forearm scar.
The flap should be taken from the non-dominant hand and a pre-operative
Allen's test is necessary to establish the presence of adequate collateral blood
supply to the hand. It is best to avoid any needle sticks or blood pressure
measurements on the donor site arm before surgery. The arm is prepped and a
tourniquet is applied to the upper arm. The approximate size of the defect is
measured and a rectangular flap is outlined on the anterior-lateral surface of
the forearm.

This flap should be centered over the course of the radial artery. The radial
artery with its two vena comitantes comprise the vascular pedicle for this flap.
The cephalic vein may also be incorporated if more than one venous
anastomosis is desired. The lateral antebrachial cutaneous nerve may be used
to provide a sensate flap. The incision is extended towards the cubital fossa for
exposure of the vessels. The incisions are carried down through the fascia
overlying the forearm muscles on all sides of the rectangular flap except the
proximal side. The vessels are located distally and ligated. Care must be
taken to avoid injury to the superficial branch of the radial nerve to prevent
dorsal hand numbness post-operatively. The flap is raised in a sub-fascial
plane. The vascular pedicle with its septocutaneous perforators are identified
between the bellies of the brachioradialis and flexor carpi radialis muscles.
The pedicle is dissected in a distal to proximal direction to the origin of the
radial artery as the brachial artery bifurcates into the radial and ulnar
arteries. It is important to leave the paratenon intact to provide suitable tissue
for skin grafting. The wound is closed with a split-thickness skin graft and a
splint is placed on the forearm for protection.

RECTUS ABDOMINIS FREE FLAP

The rectus abdominis flap was originally used as a pedicled flap for breast
reconstruction. However, with the advent of microsurgical techniques the flap
has become quite useful as a free flap for reconstruction in the head and neck.
The rectus abdominis free flap (RAFF) provides a large amount of muscle and
skin for reconstruction of large defects. A second surgical team can harvest the
flap with the patient in the supine position at the same time as the cancer
resection. It is excellent for reconstruction after lateral temporal bone
resection, total glossectomy or maxillectomy with orbital exteneration.
Advantages for this flap include reliable large caliber vessels and the large
amount of bulk that is available for transfer. Also, the donor site can almost
always be closed primarily without the need for a skin graft. One disadvantage
is the possibility of later developing an abdominal hernia at the donor site.
The flap is usually taken as a fusiform flap in the paramedian position. Prior
inguinal surgery is a contraindication for this flap. The size of the defect is
measured and the appropriately sized flap is marked on the abdomen. The flap
should include the periunbilical skin as this area contains important
perforators that provide axial blood supply to a large amount of abdominal
skin. The incisions are carried down through skin and subcutaneous tissue.
The linea alba and linea semilunaris are medial and lateral landmarks,
respectively. The inferior deep epigastric artery and vein comprise the
vascular pedicle for the flap. The vessels are identified on the deep surface of
the rectus abdominis muscle. The flap is raised in a superior to inferior
direction and the vessels are dissected out to their origin off the external iliac
artery and vein. The posterior rectus sheath should be left intact. The anterior
rectus should should be closed primarily or with mesh to prevent a ventral
hernia. A suction drain is left in the wound to prevent hematoma.

FIBULA FREE FLAP

The fibula free flap was first used for mandible reconstruction by Hidalgo in
1989. It is the most common free flap for mandible reconstruction today. The
flap provides up to twenty-five centimeters of vascularized bone with or without
a skin paddle. The vascular pedicle includes the peroneal artery and vein.
Preoperative imaging of the vessels of the lower extremity is indicated to
identify those patients who have insufficient collateral blood supply to the foot.
If the patient's blood supply to the foot is dominated by the peroneal artery then
a FFF from that leg is contraindicated. If neither leg has sufficient vessels then
another bone flap, such as the iliac crest flap, should be used. The FFF is
popular for several reasons. It can be harvested by a second surgical team. It
provides a long segment of bone that can actually be cut into smaller segments
to re-create curvature of the mandible. Osseo-integrated dental implants can
often be placed post-operatively.
Disadvantages include the somewhat tenuous blood supply of the skin paddle
and the need for a skin graft to close the donor site if a skin paddle is harvested.
The flap may be taken as an osteocutaneous flap or simply a bone flap without
skin. To raise the flap, first the head of the fibula and the lateral malleolus are
identified and a line is drawn between them. If skin is to be harvested then
perforators are identified with a Doppler 15-25 cm distal to the fibula head.
The skin paddle should include several identifiable perforators for the best
result. The incision is made at the anterior edge of the skin paddle and extends
superiorly towards the fibula head for exposure of the pedicle. The incision is
carried down through the fascia of the peroneus muscles. These muscles are
then retracted anteriorly and the dissection continues to expose the
intermuscular septum. This septum divides the peroneus longus and soleus
muscles and attaches to the lateral surface of the fibula. Cutaneous perforators
are usually located within this septum. Next, the incisions is made along the
posterior border of the flap and carried down through the fascia overlying the
soleus muscle. The soleus muscle is then retracted posterioly and dissection
proceeds towards the intermuscular septum from the posterior side. If no
perforators were identified from the anterior side then a one-centimeter cuff of
soleus muscle should be taken with the flap so that any musculocutaneous
perforators can be saved.

At this point, bone cuts should be made. The proximal bone cut should be no
less than 6 cm from the fibular head to insure that the peroneal nerve is not
injured. Distally, the cut should be made at least 8-10 cm above the lateral
malleolus to prevent instability in the ankle joint. After the bony cuts are made
the segment of fibula will be more mobile. The bone is then rotated posteriorly
to expose the attachments of the peroneus longus and brevis muscles. These
muscle attachments on the fibula are divided, leaving a 2-3 mm cuff of muscle
on the bone so that periosteum is not injured. This exposes the anterior
intermuscular septum which is then divided in a similar fashion. Next, the
attachments of the extensor digitorum, extensor hallucis longus, and tibialis
anterior are separated from the fibula in the same manner. This will expose the
interosseous membrane, which is then divided 2-3 mm from the fibula. This
will expose the tibialis posterior muscle. The peroneal vessels will be just
posterior to the tibialis posterior muscle. Next, the peroneal vessels are
identified at the site of the distal osteotomy and ligated. The flap is raised from
a distal to proximal direction with careful identification of the peroneal vessels
as well as protection of the posterior tibial vessels. The attachments of the
tibialis posterior are divided as the peroneal vessels are traced proximally
towards the bifurcation of the peroneal and posterior tibial vessels. The last
muscles attachments are from the flexor hallucis longus and brevis muscles.
These are divided with direction visualization of the pedicle. The pedicle may
be left intact while the contouring of the reconstruction plate and any other
fibula osteotomies are performed. The pedicle vessels are ligated when the flap
is ready to be inset in the recipient site. The wound is closed with a skin graft
over the site from which the skin paddle was harvested. The remaining
incisions are closed primarily with a suction drain in place. A lower leg splint
is left in place for five days.

Post-operatively, the flap should be closely monitored for signs of vascular

insufficiency. If the skin paddle appears well-vascularized then the underlying
bone is assuredly well-perfused as well. If the skin paddle is not well-perfused,
it may be due to poor cutaneous perforators and the underlying bone may be
well-perfused. A nuclear medicine bone scan can determine the state of
perfusion of the bone if necessary. The patient should ambulate in a non-
weight bearing fashion as soon as possible. Weight-bearing should begin when
the splint is removed on post-operative day number five.

ANTEROLATERAL THIGH FREE FLAP

The anterolateral thigh free flap (ALTFF) was described in China by Song, et
al, in 1984 and used for head and neck reconstruction by Koshima, et al, in
1993. The flap is based on the descending brach of the lateral circumflex
femoral artery and its two vena comitantes. The ALTFF provides a large
amount of skin and a variable amount of muscle. The thickness of the flap is
intermediate between the RFFF and RAFF and is variable depending on how
much vastus lateralis is taken with the flap. Thicker flaps may be used for total
glossectomy or lateral temporal bone defects. Thinner flaps are well-suited for
oropharyngeal or hypopharyngeal reconstruction. Advantages of the ALTFF
include its versatility, large caliber vessels, and low donor site morbidity.
The flap is contra-indicated in patients with prior injury or surgery in the
region of the upper thigh. The entire leg should be prepped and draped. Like
the free flaps discussed above, a second surgical team may harvest the flap at
the same time as the cancer resection. The anterior-superior iliac spine and
lateral border of the patella are marked and a line is drawn between these two
points. The midpoint of this line is measured and a circle with a three-
centimeter radius is drawn around this point. Next, a Doppler is used to locate
cutaneous perforators within this circle. At least three perforators should be
identified. The flap design should incorporate the circle with these
perforators. The size of the defect is measured and the flap is designed to
match this size.
Usually, the flap is designed as a fusiform flap with the long axis centered on
the line between the anterior-superior iliac spine and the lateral border of the
patella.
The incision is made at the anterior border of the flap and carried down
through the fascia of the rectus femoris muscle. Subfascial dissection is
continued laterally towards the intermuscular septum between the rectus
femoris and vastus lateralis muscles. At this point the vascular pedicle should
be identified. The lateral circumflex femoral arterty branches off the common
femoral artery and divides into ascending, descending, and transverse
branches. Usually, the cutaneous perforator(s) will originate from the
descending branch although occasionally they will come from the transverse
branch. Sixty percent of patients will have musculocutaneous perforators that
pass through the vastus lateralis. The remainder of patients will have
septocutaneous perforators that pass through the intermuscular septum
between the vastus lateralis and rectus femoris. After suitable vessels are
identified the lateral incision can be made through skin and fascia latae. If
musculocutaneous perforators were present then a cuff of vastus lateralis
should be taken with these perforators. At least one perforator is necessary for
flap survival. The pedicle vessels are then dissected proximally to the origin of
the descending branch (or less commonly the transverse branch). Muscular
branches of the pedicle vessels should be carefully ligated to prevent post-
operative bleeding. Care must be taken to avoid injury to the femoral nerve
that innervates the vastus lateralis. The donor site can usually be closed
primarily unless a very large flap was taken, in which case a skin graft is
needed. A suction drain is placed in the wound bed prior to closure. The
patient should have full weight-bearing status on post-operative day one.

THE SCAPULAR/PARASCAPULAR SYSTEM

A unique system of flaps available for free tissue transfer based on the
subscapular artery and its branches. In 1978, Saijo was the first to describe the
scapular fasciocutaneous flap anatomy based on the circumflex scapular artery
(CSA). In a 1981 article, Teot et al identified the lateral border of the scapula
bone as a potential source of vascularized bone based upon periosteal branches
of the CSA. This donor site was popularized for head and neck reconstruction
by Swartz et al in 1986. In 1991, Coleman and Sultan identified the angular
artery as the blood supply to the scapula tip, allowing for 2 separate segments
of bone to be harvested and improving the reliability of the scapular tip when
harvested as a single segment. In 1984, Batchelor and Sully were the first to
describe the incorporation of the latissimus dorsi muscle with the
scapular/parascapular flap for reconstruction of a scalp defect.

Indications
The scapular/parascapular flap is the donor site of choice for complex 3-
dimensional defects of the head and neck given the amount and variability of
tissue available for harvest. It is excellent for through and through
oromandibular defects, which require tissue for oral and external lining as well
as bone. Up to 14 cm of bone can be harvested from the lateral border of the
scapula bone. According to a 1993 report by Frodel and a 1994 report by
Moscoso, the bone stock can be sufficient for the placement of osseointegrated
implants and subsequent dental restoration, particularly in male patients. This
donor site should also be considered in those patients in whom a fibula free flap
is contraindicated because of inadequate collateral circulation to the lower
extremity.

The scapular/parascapular system of flaps is also useful in reconstructing

complex midface defects, which require skin or muscle for intraoral lining and
external soft tissue defects, as well as bone for alveolar reconstruction and
globe support. One downside is that color match for an external skin defect is
less than optimal when compared to other donor sites. Scalp defects can be
reconstructed using fasciocutaneous scapular/parascapular flaps of the dorsal
thoracic fascia with a split thickness skin graft. Complex defects involving the
skull base, orbit, and midface can be restored with a single composite flap
providing bone for the maxilla or orbit, skin for an external cutaneous defect,
and muscle for the skull base defect to provide support for the brain and
separation of the dura from the nasal cavity and pharynx.

Relevant Anatomy: The scapular/parascapular system of flaps is based on the

subscapular artery and vein, branches of the third part of the axillary artery
and vein. The advantage of this donor site is the variety of tissue available for
harvest, which allows tissue to be tailored to complex defects of the head and
neck. A number of different flaps can be harvested on a single pedicle, as listed
below, including the scapular fasciocutaneous flap, the parascapular
fasciocutaneous flap, the scapular/parascapular fasciocutaneous flap, the
scapular/parascapular osteocutaneous flap, the latissimus dorsi muscle flap,
the latissimus dorsi musculocutaneous flap, the serratus anterior muscle flap,
and the serratus anterior musculocutaneous flap. A combination of these flaps
may be harvested as well depending upon the needs of the defect.

Flaps based on the subscapular arterial system include the following:

 Scapular/parascapular fasciocutaneous flap

 Scapular/parascapular osteocutaneous flap
 Latissimus dorsi muscle flap
 Latissimus dorsi musculocutaneous flap
 Serratus anterior muscle flap
 Serratus anterior musculocutaneous flap
 Dorsal thoracic fascia flap

The subscapular artery has a number of branches that are critical to the
understanding of this system of flaps. The 2 major branches of the subscapular
artery are the CSA and the thoracodorsal artery (TDA). The CSA runs through
the triangular space and branches into transverse and descending cutaneous
branches, which form the basis of the scapular and parascapular
fasciocutaneous flaps (Gilbert, 1982; Nassif, 1982).

The CSA also has periosteal branches, which supply the lateral aspect of the
scapular bone except the tip of the scapula, which is supplied by the TDA. Two
venae comitantes accompany the CSA and drain into the thoracodorsal vein;
however, the venous anatomy is variable. The TDA runs deep to the teres major
and has a number of critical branches important in the understanding of this
donor site. The angular branch that supplies the tip of the scapular bone is
important and must be preserved in order to successfully transfer this portion of
bone (Coleman, 1991). The branch to the serratus anterior also arises from the
TDA. The distal portion of the TDA terminates into vertical and transverse
branches, which supply the latissimus muscle and overlying skin.

The lateral aspect of the scapula bone is available for harvest based on the
periosteal branches of the CSA. Approximately 10 cm of bone is available for
harvest in females, and 14 cm of bone is available in males (Swartz, 1986). The
tip of the scapular bone is supplied by the angular artery, which has a variable
branching pattern (Coleman, 1991; Seitz, 1999). It arises as a branch of the
TDA or as a branch of the main serratus collateral (Seitz, 1999). This allows
the harvest of 2 separate segments of bone from the lateral aspect of the
scapula. The fascia of the scapular/parascapular region, termed the dorsal
thoracic fascia, can be harvested alone or in conjunction with bone. This option
can be particularly useful in patients with a significant amount of subcutaneous
fatty tissue where harvesting fascia and overlying skin would provide too much
bulk.

MONITORING OF FLAPS
Signs of abnormal perfusion
a)Arterial compromise
Skin – Pale, slow capillary refill; cool.
Muscle – Pale; no brisk bleeding; skin graft not adherent; no
doppler signal.
Fascia – No palpable pulse; skin graft not adherent; no Doppler
signal.
b) Venous compromise
Skin – patchy; bluish fast capillary refill; cool.
Muscle – Dark; dark red bleeding; skin graft not adherent.
Fascia – Dark; greyish, doppler signal may remain normal for a
longer period.

Possible causes of impaired perfusion

 Inflow –
 Arterial kinking
 Inset too tight
 Damage to pedicle
 Arterial insufficiency
 Thrombosis in extremity.
 Outflow –
 Venous occlusion
 Tunnel too tight.
 Venous thrombosis in major veins.
 Kinking of pedicle.
  Hematoma under flap

Monitors for Cutaneous Microcirculation

1. Clinical tests:
Skin colour
Temperature of flap
Capillary refill and bleeding characteristics.
2. Chemical methods:
Fluorescein (resorcinol pthalein)
Atropine – subcutaneous injection in flap to check the systemic
effects.
Fiberoptic flurometry
Fiberoptic dermoflourometer – with flourescein delivery.
3. Radioisotopic methods:
24
Na, 131I, 99mTc, 133Xe.
4. Instrumental methods:
Temperature
Transcutaneous gas measurements.
Photoelectric method – photoplathysmography & reflection
spectophotometry.
Doppler shift flowmetry
Electromagnetic flowmetry
Interstitial fluid pressure measurement.

FATE OF FLAP
Myers has emphasized that the fresh flaps are always both viable and ischemic.
Depending upon the degree of ischemia and the amount of time before recovery
of the blood supply, the flap will either survive or die. In surviving flaps, the
blood flow gradually increases if the flap is in a favorable recipient site, a
fibrin layer forms with in the first 2 days. Neovascularization of the flap begins
3 to 7 days after flap transposition. Early neovascularization has been detected
at 4 days in the pig and rabbit models. Revascularization adequate for division
of the flap pedicle has been demonstrated by 7 th day in animal models and man.
The transient ischemia developed initially after the development of the flap
causes early release of angiogenic growth factors, leading to activation of the
quiescent vascular endothelial cells, leading to the formation of new vessels.
The venous outflow from the skin also is impaired with flap elevation. Venous
flow can occur through the subdermal plexus or by venous channels that
accompany the feeding artery pedicle. An occluded vein can prove to be very
detrimental to the survival of the flap.
The impairment of lymphatic drainage also occurs with flap elevation.
Reduction of the cutaneous lymphatic drainage results in an increase in
interstitial fluid pressure, which is compounded by increased leakage of
intravascular protein associated with inflammation. The resulting edema can
decrease capillary perfusion by increasing the intravascular pressure.

Reperfusion
The return of blood flow to a flap that is ischemic due to excessive release of
norepinephrine occurs in approximately 12 – 48 hours. With norepinephrine
depletion and continued inflammatory response, blood flow can reach a
maximum at 24 hours. When oxygen becomes available with reperfusion, an
additional menace of free radical production affects the survival of the flap.
Free radical s are more detrimental to the flap survival as they can cause
damage at both cellular and subcellular level.
A major source of these free radicals in ischemic tissue is the enzyme xanthine
oxidase. With ischemia high energy phosphate compounds are converted to
hypoxathine, which accumulates in the tissues. When oxygen becomes available
with reperfusion, xanthine oxidase catalyzes the conversion of hypoxanthine
into uric acid and produces superoxides in the process. This reaction is an
important mechanism in ischemic tissue injury I skin flaps.

FAILURES IN FLAP TRANSFER

The failures that follow the transfer of skin flaps may be due to necrosis, to
infection of the flap, or to improper postoperative care.

Failure Due to Necrosis.

Necrosis of the whole flap or of a portion of the flap, generally the distal end,
because of a deficiency in the blood supply is caused by various planning and
technical errors. It is usually caused by improper planning and failure to
incorporate an adequate vascular supply in the flap. Survival of flap length is
not related to the width of the pedicle (Milton, 1970). A flap with sharp angles
survives with difficulty. The flap may also be designed too small.
The flap must not be sutured into position under tension in an effort to provide
a covering for the defect. Twisting, kinking of the flap, or placing the flap under
tension may result from poor designing and planning of the flap or from the
position of transfer, which is inadvertently changed when the immobilization of
the donor limb is secured. This is a frequent complication during the
application of a plaster cast for the immobilization of a cross-leg flap. To ob-
viate this danger, the two limbs should be firmly immobilized on an orthopedic
table before the plaster is applied, or Steinman pin fixation should be employed.
Not more than moderate pressure should be applied over a flap, lest the venous
return is obstructed, and superficial necrosis, blistering, epidermal
desquamation, or even a loss of a portion of the dermis results.
A frequent mistake in the covering of poorly vascularized areas is the
employment of a flap that is too small. It is essential that the scar tissue of such
areas be widely excised; moreover, a flap that is to cover an area devoid of a
normal blood supply should extend widely into the normal tissue around the
defect. In this manner, the flap will derive a sufficient blood supply from the
surrounding well-vascularized tissue. Failure to provide a wide area of
insertion of the flap may result in necrosis of a portion if the flap when the
pedicle is sectioned prior to designing a flap. The recipient lesion or
defect should be excised. Often the true defect
is larger than the apparent defect, and a larger flap will be required.
Separation and gaping over the secondary suture line after the section of the
pedicle of the flap are frequent complications when the design of the flap was
too small. The hinge flap procedure assists in obtaining a vascularized base of
insertion.

Failure Due to Infection. Skin flaps show resistance to infection, even when
applied over a septic area. However, the covering of a grossly suppurating
wound by a skin flap is a mistake. The flap tends to convert an open wound into
a closed one and impede drainage. Flaps arc rarely lost because of infection.

Failure Due to Improper Postoperative Care.

After a successful flap transfer, complications may occur because of the
imprudent treatment of the freshly transplanted tissue. This tissue has been
severed from its nerve connections and is insensitive; in addition, the inactive
sebaceous and sweat glands fail to provide the skin with its normal lubrication.
The patient may unduly traumatize the transplanted skin by exposing it to heat
and burning. The burn sustained by laying the foot, newly covered by a flap,
over a hot radiator is a typical complication. Even prolonged exposure to the
ultraviolet rays of the sun may cause further desquamation of the already dry
and scaly skin. The vascular connections arc delicate for weeks after
transplantation; slight trauma may cause ecchymosis, hematoma. blistering,
and ulceration of the flap.
Because of the peripheral barrier of scar tissue, the venous drainage is
sluggish, and the lymphatic circulation is only gradually reestablished. The
venous return from the flap it improved by wearing a pressure bandage over the
flap for months after the flap transfer. Physiotherapy will improve the
circulation and hasten the softening of the peripheral scar.
After the transfer of a flap to a weight-bearing area, the patient should avoid
full weight-bearing for several months, until the peripheral scar has softened
and normal circulation has been reestablished within the flap.
Care should be exercised in placing secondary incision lines and in
undermining flaps at the time of a subsequent operative procedure, such as
bone grafting. Necrosis of the flap may occur if an incision is placed in the
center of the flap and if the latter is undermined laterally.

MEASURES TO IMPROVE VIABILITY OF FLAPS

Vascular Augmentation or Enhancement of Survival of Skin Flaps
There has been a search for a substance or technique which, if used at the time
of flap reconstruction, would augment the vascular supply of the flap and
enhance the ultimate survival of the flap.
DeHaan and Stark (1961) reported that histamine iontophoresis, while
augmenting the afferent circulation, did not improve the efferent circulation of
the flap. Histamine iontophoresis did not increase the survival of flaps with a
longer and narrower pedicle. In a study by Milton and Corbett (1969),
histamine iontophoresis failed to increase the survival of experimental flaps in
rabbits. Ketchum and associates (1967) reported that, while pretreatment of the
pedicle tissue with histamine iontophoresis increased flap survival, the effect
was not predictable.
Systemic hypertension, i.e.. hypertensive perfusion, resulted in a larger portion
of the flap surviving (Ketehum and associates, 1967) but the finding could not
be duplicated in another study (Milton and Corbett, 1969).

Dimethyl sulfoxide (DMSO) was reported as being effective in enhancing flap

survival (Adamson and associates. 1966). However, other studies reported only
a marginal positive effect (Arturson and Khanna. 1970) or more extensive
sloughing following treatment with DMSO (Myers and Cherry. 1968;
Koehnlein and [Link], 1970).

An adrenergic blocking agent, phenoxybenzamine, is effective, when injected

subcutaneously into the flap (Myers and Cherry, 1968). In augmenting the
length of flap survival, It has been postulated that the agent causes the opening
of collateral vessels, with improvement in the perfusion of the distal portion of
the flap.

Recently Keinisch (1974) augmented the surviving length of flaps by chemical

treatment (6-hydroxydopamine and dilute epinephrine) and electrical
manipulation prior to elevating the flaps. It was speculated that both types of
pretreatment closed the sympathetically innervated arteriovenous channels of
the flap which shunt blood from the nutritive vessels in the distal end of the flap
and are responsible for distal flap necrosis of leg flaps.

The work of segarra & bennett (1972) has shown that a delay of several days
between division and inset of the flap pedicle may be indicated to decrease
distal necrosis of flaps with marginal circulation.

SALVAGING THE FLAPS OF MARGINAL VIABILITY.

The flap with inadequate vascularization inevitably reflects poor planning;
mechanical problems play only a secondary role.
Last-ditch efforts include releasing the sutures to relieve any tension which may
be compromising the circulation. Venous congestion can be relieved by
elevating the flap or changing it from a dependent position.
Hynes (1951) designed a mechanical intermittent venous occluder device,
which could be applied to the distal end of the flap.
The use of leeches for the treatment of venous congestion in a flap is practiced
in europe (derganc and Zdravic. I960).
Cooling is commonly employed for the treatment of a flap of doubtful viability
in an attempt to decrease its metabolic requirements. Cooling of flaps so that
the surface temperature of the pedicle was maintained at 20" C did not prevent
necrosis; rather, it postponed the onset of necrosis and made it less severe
(Kichn and Desprez, I960).
Hyperbaric oxygen has been successfully employed in increasing the survival
of experimental flaps (Champion, McSherry and CJoulian, 1967). Another
study on porcine flaps failed to show any significant beneficial effect of
hyperbaric oxygen on experimental (porcine) flaps (Kernahan, Zingg and Kay,
1965).
Low molecular weight dextran has been reported to decrease blood viscosity,
diminish red cell sludging, and increase capillary flow. However, a study by
Myers and Cherry (1967; showed that treatment with low molecular weight
dextran did not increase the vascularity or survival of experimental skin flaps.

THE DELAY OF FLAPS:

The blood supply of a flap may be enhanced by a preliminary procedure
consisting of partially dividing the blood supply to the flap before its
transplantation. If a flap is raised in two or more stages, it has been noted that
a greater length will survive than if the flap is raised and transferred at the
same procedure. The purpose of the delay is to condition a flap to be able to
survive in a state of relative hypoxia after it is raised and transferred.

Mechanism of delay: Although practiced by Tagliacozzi, Blair (1912) appears

to have been the first surgeon to employ the term “delayed flap,” and the term
has come into common usage in the English-speaking world.

After a flap has been outlined by incisions and raised, the vessels in the flap
increase in size and in number and become reoriented in the direction of the
long axis of the flap. German, Fine-silver, and Davis (1933) showed that these
changes in the vessels of the flap occur within seven days. Braithwaite (1950)
used microradiograph after the injection of pyelosil or 20 per cent colloidal
silver iodide to study the vascular channels in humans skin. He demonstrated
that the dermal and subdermal vascular plexuses play a dominant role in
maintaining the circulation of a skin flap. Peskova (1955) in a histologic study
showed that, four to five weeks after transfer of a tube flap, the number of blood
vessels increases in the flaps that have been repeatedly transferred, as
compared with the number and caliber of blood vessels in a flap that has been
tubed for the first time. Bardach and Kurnatowski (1961) noted that the main
role of the blood supply of the flap is played by the vessels in the dermis and
those situated in the subdermal layer at the junction between the skin and the
subcutaneous fat.
In a study of the delay phenomenon, Reinisch (1974) noted that necrosis of the
distal end of the flap may not be the result of ischemia in the usual sense but
may represent a microcirculatory alteration in which necrosis results despite
the presence of blood flow in the ischemic portion of the flap.

Optimum time for transfer after delay: The optimum time for transfer of a flap
following a delay procedure has been the subject of much controversy. Gillies
and Millard (1957) estimated that most flaps could be safely transferred ten
days after the delay procedure. Hoffmeister (1957) studied the rates of
clearance of radioactive sodium (Na) in canine flaps, concluded that raised a
flap during the first week after the delay procedure is hazardous and is best
performed about two to four weeks after the delay.

Types of delay: The type of delay varies according to the area in which the flap
is being prepared and also the position of the flap during the transfer. A simple
outline delay, making incisions around the flap without raising the flap, is
adequate in the forehead and the scalp region, where none of the vessels are of
the perforation type but instead originate from the periphery of the flap. In the
abdominal wall, where perforation vessels are numerous, such a delay would
not be satisfactory, and the preliminary raising of the flap is necessary. Silastic
sheets can be inserted beneath a flap at the time of delay to prevent the growth
of capillaries across the delayed surface. In addition to maintaining the anoxic
stimulus to the flap, it is reported that such a maneuver also reduces the
incidence of bleeding or hematoma formation when the flap is finally
transferred (Williams 1973).
In the delay of random pattern or cutaneous flaps, the flap should be
undermined in a plane that leaves sufficient subcutaneous fat on the flap to
protect the subdermal plexus. Axial pattern or arterial flaps (e.g., deltopectoral
flap) should be elevated deep to the muscular fascia to avoid injury to the direct
cutaneous artery.
Delaying a flap is no substitute for adequate design and properties of the
flap. Flap delay has certain inconveniences. For example, if a forehead flap is
raised and reapplied to its bed prior to its transfer, it will be found that flap has
stiffened considerably as a result of fibrosis during the period of healing. Such
changes make molding of the flap to construct a columella or alar rim, as
required in nasal reconstruction, extremely difficult. Since there are not
perforating vessels in the forehead, this problem can be obviated by simply
performing an outline delay.
The most obvious inconvenience of a delay procedure is the added
hospitalization. Often, however, states of the delay can be performed on an
outpatient basis. With the development of microsurgical free flap techniques,
many reconstructions previously requiring multiple stages may be reduced to a
single procedure.
 Reconstruction of specific regions
The different techniques used in reconstruction of head and neck is broadly
classified as follows: -
Intra-oral reconstruction techniques
Reconstruction of tongue
1. Superficial tumors of tongue
a. Primary closure
b. STSG
c. Healing by secondary intention
2. Partial glossectomy without mandibulectomy
a. Primary closure
b. Local flaps eg. Nasolabial flap
c. Regional flaps eg. Masseter flap
d. Distant flap eg. Pectoralis major flap
e. Free flap eg. Radial fore arm flap, Dorsalis
pedis flap.
3. Partial glossectomy with anterior mandibulectomy
a. Free Osseocutaneous flap eg. Osseocutaneous
medial forearm flap
4. Partial glossectomy with posterior mandibulectomy
a. Regional flap and mandibular swing
b. Distant flap and mandibular swing
c. Distant flap with reconstruction plate
5. Total glossectomy + laryngectomy or laryngoplasty
a. Regional myocutaneous flap eg. Pectoralis
major flap.
 b. Free myocutaneous flap eg. Rectus abdominis
flap, Latissmus Dorsi flap
Reconstruction of the floor of the mouth
1. Reconstruction of the anterior floor of
the mouth
2. Reconstruction of the posterior floor of
the mouth
Reconstruction of the buccal cavity
1. Using temporalis myofascial pedicled
flap
2. Using buccal fat pad.

Closure of oro-antral fistula

Management of acute oro-antral communication
1. Socket edge reduction and suturing
2. Use of supportive packs or protective
plate
Management of chronic / established fistulas or Large OAC
1. Local flaps
a) Buccal flaps
(i) Advancement flap (Welty, Von Rehrmann & Berger).
(ii) Modified advancement (Laskin & Robinson)
(iii) Sliding flap (Moczair)
b) Palatal flaps
(i) Straight advancement
(ii) Rotational advancement
(iii) Hinging and Island flaps
(iv) Palatal submucosal connective tissue flap.
c) Bridge flap
d) Combined local flaps
(i) Double flap
2. Distant flaps
a) Tongue flaps
(i) Anteriorly based
(ii) Posteriorly based
(iii) Laterally based
b) Temporalis muscle flap
c) Buccal fat pad flap
d) Osteoperiosteal flap
3. Grafts
a) Autogenous bone grafts
b) Allografts
(i) Gold foil.
(ii) Tantulum foil
(iii) Gold plate
(iv) Poly methyl methacrylate
(v) Hydroxy apatite blocks.
 Extra-oral reconstruction techniques

Reconstruction of midfacial defects

Classification of mid-facial defects
Type I: Loss of midfacial skin only; buttress of the maxilla, orbital floor
and palate intact
Type II: Partial maxillectomy with intact palate and orbital floor
Type III: Partial maxillectomy with resection of a portion of palate; orbital
floor and Lockwood’s ligament remain intact
Type IV: Total maxillectomy and palatectomy; orbital support remains
intact
Type V: Total maxillectomy and palatectomy with loss of orbital support or
eye.

Midface defects produce significant functional and aesthetic consequences.

Feeding and speech can be a problem. Oro-antral fistula and velopharyngeal
incompetence can develop. Resection of Lockwood’s ligament may result in
enophthalmos and orbital dystopia.

Type I defects
Patients with type I defects suffer from variable loss of soft tissues of cheek and
lips. Bony framework is not affected. Palate and orbital floor remain intact.
If the defect is small and the surrounding tissue lax, primary closure may be
possible. Small rhomboid flaps or subcutaneous pedicled flaps are used for
superficial midface defects. Tissue expansion has been used successfully for
superficial defects of cheek. This technique affords excellent colour and texture
match with least amount of scar tissue formed.
For larger defects, regional or distant flaps like pectoralis major, deltopectoral,
latissimus dorsi, temporalis and forehead flaps have been used with success.

Type II & III defects

The traditional method of reconstructing these defects is by skin-grafting the
internal cavity and the placement of a maxillofacial prosthesis. The prosthesis
usually serves as a denture and a palatal obturator, closing the oro-antral
fistula and providing projection of midface. An adequate residual palatal arch
and surrounding soft tissues are required to support the prosthesis. As the size
of the defect increases, problems with stability often are exacerbated especially
if the prosthesis must function as a support for orbital structures or reconstruct
a missing cutaneous segment.
Some limited maxillectomy defects may be reconstructed using autogenous
tissue. Choung et al described the use of ipsilateral or bilateral temporalis
muscle flaps. Calvarial bone may be included in the flap, making it a myo-
osseous flap. The zygomatic arch may be cut anteriorly and posteriorly so that
the muscle is mobilised to its insertion on the coronoid process. The composite
flap is passed into the oral cavity and sutured to the remaining septum or
palate.

Type IV defects
Individuals with extensive defects are best served by reconstruction with
regional or distant flaps to obturate palatal defects, to provide complete soft
tissue coverage and to aid in retention of a prosthesis. The reconstuctive goal is
to provide a healed wound, separation of oral and nasal cavities, support for
intracranial contents and obliteration of maxillectomy defects.
A variety of pedicled regional flaps have been advocated for midface
resurfacing. They include the deltopectoral flap, pectoralis major
myocutaneous flap, forehead flap etc.
Free tissue transfers advocated to repair midface defects include the free
omental flap combined with non-vascularised bone grafts, the free latissimus
dorsi flap, the rectus abdominis flap, the free scapular fasciocutaneous flap and
the free fibular osseocutaneous flap.
Each donor site has its own advantages and disadvantages. The rectus
abdominis flap allows a two-team approach, thus reducing operating time. Both
the latissimus dorsi and scapular flaps require a change in the patient position,
but they provide long vascular pedicles and large volumes of tissue. By de-
epithelising intervening segments of dermis between cutaneous paddles, the
palatal, maxillary and orbital components of the defects may be simultaneously
reconstructed.
Isolated soft tissue repair without bony reconstruction tends to lose midfacial
projection and result in sagging. Coleman and Sandham noted that by
preserving the angular artery to the tip of scapula, vascularised bone could be
harvested along with the scapular flaps. This helps in closure of massive
midface defects. The muscular component helps in the closure of dead space of
maxillary sinus. The cutaneous portion is used to resurface face and palate.

Type V defects
When orbital floor and Lockwood’s suspensory ligament are resected,
reconstruction should obliterate the orbital cavity and restore facial contour.
Ilankovan and Jackson described the split thickness vascularised calvarial bone
either pedicled on the temporalis muscle or with a free flap based on superficial
temporal artery, to reconstruct the floor of the orbit.
The temporoparietal fascial flaps have been used for orbital and eyelid
reconstruction. The free vascularised forearm flaps have been used to
reconstruct the orbital floor and provide overlying soft tissue.
In extensive maxillectomy defects, soft and hard tissue requirements are
massive, and free tissue transfer is preferred. It offers the advantage of one-
stage reconstruction without the constraint of fixed point of rotation observed in
regional flaps.

Reconstruction of the lip

The successful reconstruction of the lower lip must meet some criteria.
1. The reconstructed lip should be sensate.
2. Retain sphincter or muscle function.
3. Oppose vermilion to vermilion of the upper lip in a watertight
continent seal.
4. Allow sufficient space for food, dentures and so on.
5. Acceptable aesthetic appearance.
Defect of up to one third of the lip can be closed primarily. Larger defects
require tissue transfer, and the preferred donor site is adjacent cheek or upper
lip.

Defect of 30% to 50%: -

In moderate-sized defects, reconstructive techniques that use lip tissue will yield
an excellent result. Transfer of upper lip tissue (lip switch) pedicled on the
labial artery (Abbè technique), preserving the oral commissure, or rotated
around the commissure by the Estlander method can be accomplished.
Another method is Karapandzic technique of advancement rotation of segments
of skin, orbicularis and mucosa – after division of other supporting muscles.
This procedure redistributes remaining lip, yet preserves the motor and sensory
function. The principal disadvantage has been the relative microstomia and the
necessity of extensive circumoral incision and dissection.

Defects of 65% to 80%: -

A widely used technique is the advancement of the cheek tissue by the Webster-
Bernard approach. Initial results are good; the continued chronic tension of the
closure has culminated in a tight lower lip that functioned poorly.

A more satisfactory procedure for defects of this magnitude has been the
Karapandzic lip rotation, although a microstomia is inevitable. Denture
construction should be modified here.

The Karapandzic approach essentially is dissection of the remaining lower lip

segment, modiolus (bilateral) and lateral upper lip tissue in the neurovascular
pedicles and advancement of these components to reconstruct the lower lip
deficiency. The method requires incisions extended laterally and transversely in
adjacent cheek tissue, curving upward into the nasolabial folds and into the
lateral upper lip toward the alar base. Once skin incisions are made, the
residual depressions and elevations are divided, beneath which lie both the
facial nerve and artery branches to be preserved. Similar incisions need to be
made in the mucosa at the labial sulcus, extending into the labial mucosa.

After mobilization of the segments, closure of donor site defect in the cheek is
done in a V to Y fashion. Microstomia produced can be corrected later with a
lip-switch procedure.

Total resection of the lip: - (Karapandzic approach)

A massive resection of the lip, chin and mandible must be reconstructed with
distant flaps and requires reconstruction of the lower lip as a separate unit. The
transfer of composite flaps of skin and bone revascularised and the result
allows for institution of radiotherapy in the early post postoperative period.
Reconstruction of the lip and chin as a single unit can be accomplished with a
radial forearm flap, incorporating a plantaris tendon as a vascularised unit to
provide support. The tendon is sutured into either modiolus (if still present).
The provision of sensation to the reconstruction by suturing the antebrachial
cutaneous nerve of the flap into the stump of the mental nerve has been
included.

To effectively reconstruct the lower lip, one must provide not only skin and
mucosa, but also functioning mimetic muscle. Dissection of a platysma
myocutaneous flap with an extended muscle pedicle to include the cervical
branches of the facial nerve would empower the muscle component. Bilateral
flaps would also provide sufficient tissue for mucosa reconstruction.

Another use of a full thickness inferiorly based nasolabial flap or bilateral flaps
as needed for lower lip reconstruction.

Nasal Reconstruction:

Nose being the most centrally placed organ of the face has always been a
challenge for reconstruction. Nasal reconstruction originated almost 3000
years ago in India, where midforehead flaps were developed to reconstruct
noses. Nasal amputation was a form of punishment for various crimes from
theft to adultery, and this practice gave rise to the need for reconstruction. A
seventh century CE Indian medical document, the Sushruta Samita, described
the approach. In the 15th century, Antonio Branca of Italy discovered an
Arabic translation of the Sushruta Samita and was the first to perform a similar
procedure outside of India. In Europe, Italian surgeons used a pedicled flap
from the medial surface of the upper arm for nasal reconstruction until J.C.
Carpue, in the late 18th century, found a description of the Indian techniques.
Carpue first practiced these techniques on cadavers and later applied them to
live patients, eventually publishing his results. His use of the forehead flap
subsequently spread across Europe and America, revolutionizing nasal
reconstruction. Carpue's basic techniques laid the foundation for modern nasal
reconstruction for the next century. Kazanjian advanced the development of the
forehead flap by advocating primary closure of the forehead donor site. These
techniques were modified further and popularized by Millard in the 1960s and
1970s. He used a characteristic gull-wing design with lateral extensions for
alar reconstruction and extended the pedicle incisions below the brow to
provide greater flap length. Burget and Menick made significant contributions
to the forehead flap by emphasizing aggressive thinning of the skin paddle,
narrowing the pedicle base for easier rotation and length, and modifying
defects to follow aesthetic subunits of the nose. The midline forehead flap is
based on a narrow pedicle centered on the medial brow area, often capturing
the proximal supratrochlear artery with a skin paddle positioned in the precise
center of the forehead. An advantage of this flap is that the donor site scar is in
a more aesthetic midline position, consistent with principles of facial aesthetic
units.

Nasal defects may be classified as small and superficial or large and deep. A
small superficial lesion is less than 1.5 cm, with an intact underlying cartilage
framework. If a vascularized bed of perichondrium or periosteum is present, a
skin graft may be placed or the defect resurfaced with a local nasal flap. If the
defect is greater than 1.5 cm, not enough residual adjacent skin is present over
the nose to spread over the entire nasal surface without distorting the tip or
alar rims. A large deep defect is greater than 1. 5 cm or requires the
replacement of a cartilage framework or lining. A regional flap from the
forehead or cheek is employed for nasal resurfacing.
Most often, a failure in reconstruction results from a shortage of lining, even
though it is normally hidden from view. If the defect is full-thickness, the lining
chosen for replacement must be vascular enough to support primary cartilage
grafts, supple enough to conform to the proper shape, and thin enough that it
neither stuffs the airways nor distorts the external shape.

SPECIFIC FREE FLAPS FOR SPECIFIC NEEDS:

MUSCULAR NEEDS

Pectoralis Minor
Blood supply: Pectoral Branch of Thoracoacromial artery
Nerve: Medial pectoral nerve.
Anatomy: A flat triangular muscle lying just under pec major that attaches to
ribs 2-5 and coracoid process
Advantages:
Minimal to no post-operative disability
Size, shape, lack of bulk good for facial soft-tissue and reanimation procedures
Good reinnervation potential
Can be used as a composite graft when includes underlying rib
Disadvantages:
Short vascular pedicle (usually < 3 cm)
Sometimes not enough bulk

OSTEOCUTAN EOUS
Iliac Crest
Blood supply: Deep circumflex iliac artery (DCIA) and vein
Nerve: None
Anatomy: Osteocutaneous flap utilizing the iliac crest and overlying skin
Advantages:
Reliable flap
Good for large bony defects
Minimal donor deformities
Defect closed primarily
Disadvantages:
Risk of damage to femoral nerve, iliac vessels, peritoneum and bowel
Difficult to elevate and find vessels
Painful site of healing and long scar

Fibula
Blood Supply: Endosteal and periosteal branches of the peroneal artery and
vein
Nerve: None
Anatomy: Up to 25 cm of fibular bone accompanied by overlying skin
Advantages:
Minimal donor site morbidity
Excellent periosteal supply allows the use of osteotomies to shape the graft
Two-team approach possible
Disadvantages:
Variability of the septocutaneous perforators to the skin may limit viability
Questionable osseointegration

Scapula Flap
Blood supply: Subscapular artery and subsequent circumflex scapular branch
with the venous drainage being the vena comitantes.
Nerve: none
Anatomy: Thin pliable flap mostly skin and subcutaneous tissue (with bone if
desired) 6 x 8 cm width by 10 to 18 cm length
Advantages:
Long vascular pedicle (6-8 cm)
Large, thin, pliable fasciocutaneous flap
Two bone segments available with independent pedicles by harvesting the
angular branch of the thoracodorsal artery
Composite flap with each component having an independent vascular supply
Can include lat. dorsi muscle in flap
Very reliable
Donor site closes primarily
Disadvantages:
Patient must be in the lateral decubitus
The shoulder must be immobilized for 4-5 days
Some potential for post-operative shoulder dysfunction

FASCIOCUTANEOUS

Radial Forearm Flap

Blood supply: Radial artery and vena comitantes
Nerve: Medial and lateral cutaneous sensory nerves
Anatomy: Fairly thin flap along anterior forearm, can include bone
Advantages:
Ease of pre-operative evaluation
Easy to harvest
Reliable blood supply
Good source for mandible when bone is taken
Preop tissue expansion for larger
Disadvantages:
Vascular supply to hand at
Postoperative dysfunction from tendinous
Usually requires skin graft for closure
Significant risk of pathologic fractures with bone

Lateral Thigh
Blood Supply: Septocutaneous branches of the 3rd perforator of the profunda
femoris system and associated vena comitantes
Nerve: Lateral femoral cutaneous nerve
Anatomy: Fasciocutaneous tissues of the lateral thigh
Advantages:
Thin pliable flap for intraoral and pharyngeal reconstructions
Reinnervation possible for sensate flaps
Two-team approach
Primary closure
Disadvantages: Anomalous vasculature may require intraoperative
modifications

MUSCULOCUTANEOUS

Latissimus Dorsi
Blood supply: Two major branches off the thoracodorsal, the interior
longitudinal and posterior transverse branch (the posterior transverse branch
is vital to flap survival)
Nerve: Thoracodorsal nerve (runs in neurovascular bundle)
Anatomy: Very large triangular muscle
Advantages:
Large amount of tissue (25 x 35 cm) available
Easily closed donor defect with minimal morbidity
Long vascular pedicle possible
Very reliable flap
Disadvantages:
Requires patient in lateral decubitus position.
Sometimes flap too bulky

Inferior Rectus Abdominis

Blood supply: Inferior epigastric artery.
Nerve: none
Anatomy: Large flat musculocutaneous flap
Advantages:
Large flaps
Long, reliable vascular pedicle
Can be closed primarily with minimal donor defect
Disadvantages:
Often bulky
Possible hernia formation

HOLLOW VISCUS

Jejunum
Blood supply: Vascular arcade based on the superior mesenteric artery and
vein
Nerve: None
Anatomy: Second loop of jejunum most reliable (1.5 to 2 feet beyond ligament
of Treitz)
Advantages:
Minimal donor defect (often none noticeable).
Most physiologic choice for pharyngoesophageal reconstruction.
Disadvantages:
Bowel or pharynx fistulas.
Need for abdominal procedure