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COMPLICATIONS IN MICROVASCULAR
FREE FLAP SURGERY
MARK D. DELACURE, MD

The avoidance of complications in the performance of microvascular free tissue transfer begins in the
conceptualization of both the ablative and reconstructive phases of a procedure. Even the most experienced
microvascular surgeon will encounter a broad range of complex clinical and technical issues, both predictable and
otherwise, that he or she will also come to recognize, pre-empt, and compensate for, in acquiring true expertise. The
appropriate application of microneurovascular free tissue transfer techniques has allowed ablative surgeons to more
radically (and often more effectively) resect advanced-stage and recurrent malignant disease. As such, the indications
for this technique have broadened and our already complex technical tasks are being further tested as we refine and
reapply the state-of-the-art. The ability to minimize and avoid complications is a critical part of advancing this
technique, which has made one of the most profound contributions to patient care of any in the modern era of
reconstructive surgery.

The avoidance of complications in the performance of
microvascular free tissue transfer begins in the conceptual-
ization of both the ablative and reconstructive phases of
the procedure. Minor modifications in the conduct of neck
dissection, in particular, may profoundly influence the
range of options available to the reconstructive team in
terms of recipient vessels and pedicle geometry while not
compromising the oncologic effectiveness of the resective
procedure. These considerations are compounded in reop-
erative cases.
Command of anatomical aspects of donor site anatomy
can only be acquired through experience and cannot be
substituted by even the most detailed and colorful atlas or
videotape, informative weekend course, recent cadaver
dissection, or successful rat femoral vein anastomosis. The
widespread availability of surgeons who are experienced
in microneurovascular reconstruction across many special-
ties should provide the patient with competent and highly
experienced technicians with seasoned clinical and techni-
cal skills that can only be acquired through performance.
However, even the most seasoned microvascular surgeon
will encounter a broad range of complex clinical and
technical challenges, both predictable and otherwise, that
he or she will also come to recognize, pre-empt, and
compensate for in the process of acquiring expertise. This
is nowhere more common than in the previously treated
patient (surgery, in particular--but also radiation), where
From the Surgery Institute of Reconstructive Plastic Surgery, New York,
NY.
Address reprint requests to Mark D. DeLacure, MD, FACS, Surgery
Institute of Reconstructive Surgery, Suite 711,550 1st Ave, New York, NY
10016.
Copyright 2000 by W.B. Saunders Company
1043-1810/00/1103-0006510.00/0
doi:10.1053/otot.2000.18235
expertise, experience, and creativity meet their most criti-
cal test.
The appropriate application of microneurovascular free
tissue transfer techniques has allowed ablative surgeons to
more radically (and often more effectively) resect advanced-
stage and recurrent malignant disease. As such, the indica-
tions for this technique have broadened and we are no
longer obligated by the historical paradigm of the recon-
structive ladder, applying more conservative techniques
that have an almost certain likelihood of at least partial
failure and inadequate suitability to task. The increased
complexity of such resections has provided an additional
challenge to the microsurgeon at a time when mere flap
survival is considered a "soft endpoint" and where form
and function are increasingly measured in the context of
functional outcomes analysis and cost containment. The
individual surgeon's already complex technical tasks are
being further tested as the field as a whole redefines what
is current state-of-the-art technology in reconstructive
head and neck surgery. The ability to minimize morbidity
and avoid complications is a critical part of advancing this
technique, which has made one of the most profound
contributions to patient care of any in the m o d e m era of
reconstructive surgery.
PEDICLE SELECTION AND GEOMETRY
The need for vein grafting, with its attendant increase in
complexity and potential for anastomotic complication,
should be a rare event in contemporary head and neck
reconstruction, even with the emerging indications of total
bilateral maxillary and high central midfacial applications.
Strategies to minimize this need are also discussed in the
section on flap design.
The dictum to "make m i c r o s u r g e r y , macrosurgery'" does
not infer that one should routinely perform anastomoses to
the external carotid artery simply because it is the largest

178 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 11, NO 3 (SEPT), 2000: PP 178-183
caliber recipient artery generally available in the neighbor-
hood. This concept is largely a carryover from the early
days of reconstructive microsurgery, ie, the groin flap era
where donor blood vessels were on the order of l m m or
less and the vascular anatomy of contemporary flap donor
sites had yet to be defined. Despite the possibilities of
partial or brief cross-clamping of the common carotid
artery in patients without atherosclerotic disease, the
greatest risk of this arrangement is not to the flap but lies in
the possibility of stroke a n d / o r death through the propaga-
tion of retrograde thrombosis should the arterial anastomo-
sis fail. The risk of anastomotic disruption with life-
threatening hemorrhage is also greater in this context. In
this circumstance, the anastomosis must be resected to
obtain vascular control, thereby sacrificing the flap. Use of
the external carotid may unnecessarily compromise blood
flow to other residual ipsilateral structures and tissues and
may eliminate the future option of high-dose intrarterial
chemotherapy. Although end-to-side configurations may
appear to circumvent this issue they are, in my opinion,
unnecessarily complex and maintain the risk of thrombosis
and retrograde propagation into the common and internal
systems in the event of failure. Additionally, the high
inflow rate provided by this hookup may result in an
engorged flap having high-capacitance physiology that
cannot be met on the venous outflow side, with subsequent
progressive flap failure attributable to distal vascular
failure despite spectacular inflow. The internal carotid
artery should never be considered as a potential donor
vessel in my opinion, regardless of the youthfulness of the
patient or the results of neurovascular testing and cerebral
angiography. The possibilities of delayed stroke, propa-
gated thrombosis, embolic phenomena, and fatal disrup-
tion prohibitively mitigate against its use.
Arterial anastomoses should generally be done to
branches of the external carotid system, which are almost
always several millimeters in diameter and of sufficient
length and quality to allow satisfactory technical anastomo-
sis even in previously irradiated and reoperative situa-
tions. I have encountered, with some frequency, rosetting
the intima. In this circumstance, absolute attention to detail
and handsewn technique are a must. In this instance,
mechanical anastomotic devices are not technical options.
End-to-side arterial anastomoses are usually unneces-
sary in either primary or delayed reconstruction and are of
somewhat increased complexity in execution. There is not
convincing evidence from either clinical or laboratory
studies that this hookup is more or less effective than its
end-to-end counterpart. Vessel caliber discrepancy may
often be compensated for by telescoping techniques of
anastomosis as long as blood flow is prograde from small
to large vessel.
A basic principle of pedicle geometry selection is that of
temporary flap insetting (suture, staple, or osteosynthesis)
and ranging the head from side-to-side, in neck flexion and
extension, and through complete mandibular excursion
(where applicable), to facilitate appropriate choice of ves-
sel length. These maneuvers will minimize tension, redun-
dancy, and kinking as well as misspent effort in adventitial
clearance, which tends to be focused on the pedicle ends
that have been selected for maximal length at the donor
site, but which commonly exceed requirements once trans-
ferred to the head. This will furthermore decrease ischemic
time through appropriately focusing pedicle dissecting
efforts. Dividends also include a reduced need to revise
anastomotic configurations that are deemed too redundant
MARK D. DELACURE
only when anastomoses a n d / o r insetting are completed
and such possibilities theretofore unrecognized or, more
seriously, in a return to the operating theater after accept-
ing a marginal configuration that later becomes chal-
lenged, unreliable, or fails.
In cases where there are no apparent available donor
vessels from the ipsilateral external carotid system, the
transverse cervical artery (subclavian system) may often be
found undisturbed in the supraclavicular fossa, even in
previously operated necks. Although a review of the
previous operative report may provide explicit informa-
tion regarding the management of this pedicle in the lower
neck, it is more commonly--not specifically--mentioned
and requires direct identification at reoperative explora-
tion. A contingency plan in the event that this pedicle is
determined to be unavailable must be a part of the
preoperative conceptualization of the reconstructive proce-
dure. When identified, additional length can be recruited
by following the vessels into the region of the brachial
plexus. This anatomy has been well covered by Netterville
et aU
A recent work has elucidated the role of retrograde
perfusion in donor vessel selection that may be of particu-
lar use in reoperative or irradiated cases where recurrent
tumor approximates the carotid bifurcation area and elimi-
nates otherwise plentiful donor vessel choices. I have
found the superior thyroid artery in its relatively straight
segment course along the posterior border of the thyroid
cartilage to be useful for this purpose. Perfusion, therefore,
takes place through the inferior thyroid artery and contra-
lateral arteries, through the thyroid gland, and into the
superior thyroid vessel where pulsatile retrograde flow
may successfully support a flap.
Another way to support a flap without contralateral
anastomosis or interpositional vein grafting may be termed
"pedicle transport." This uncommon procedure involves
hooking up a flap to a pedicle, which is provided by a
regionally available flap (eg, pectoralis major--thoracoac-
romial branch) pedicle, and is transported into the opera-
tire field. This will usually eliminate the use of the flap,
which may have been otherwise based upon the pedicle
used to support the free flap. A more commonly described
vein option involves the cephalic vein, which can be
dissected from the arm and transposed into the neck for
anastomosis there.
The routine sacrifice of the external jugular vein robs the
reconstructive team of a recipient vein of significant caliber
or of a graft conduit that is readily present in the operative
field. This is as commonly the result of inexpert hands at
the opening neck incision as it is of intentional sacrifice at
the neck base, when it is encountered there.
MECHANICAL ANASTOMOSIS
The mechanical microvascular anastomotic coupling de-
vice has increased the efficiency and reliability of microvas-
cular anastomosis and has been shown to be an effective
adjunct, when selectively applied, to traditional hand-
sewn suture techniques in a variety of head and neck
contexts. 2 This holds true in a large experience including
both arteries and veins, end-to-end and end-to-side configu-
rations, irradiated vessels, and a variety of flaps. 3 The
apparent simplicity of such devices can not substitute for
expertise in traditional suture techniques that are not
uncommonly necessary in unfavorable situations such as
significant vessel mismatch, small caliber, endothelial roset-
179
ting, and nonpliability. Clinical judgment honed through
experience is particularly necessary on the arterial side.
The release of a 3-mm implant later this year should
simplify the venous side in certain reconstructions where
vessel pleating techniques have previously been required
and are used only by an experienced few. At the other
extreme, in a broad experience encompassing almost every
imaginable contingency, most surgeons have found little
use for the 1.5-mm implant despite reports of laboratory
and clinical success. Those who have experienced disrup-
tion of implant rings after apparent nominal coupling
should adopt the routine of gently and evenly (circumfer-
entially) squeezing the rings with the heel of a mosquito
clamp upon terminal release of the vessels. If done too
vigorously or asymmetrically, this tweak may torque the
anastomosis unfavorably.
FLAP DESIGN AND DONOR SITE
COMPLICATIONS
With few exceptions, the majority of ablative head and
neck defects can be managed with the appropriate choice
and design of just 5 free flap donor sites (fibula, jejunum,
latissimus dorsi, radial forearm, rectus abdominis). The
need to extend beyond this nucleus should be rare and
based upon special patient-related circumstances and per-
sonal preference and experience (eg, iliac crest, lateral
thigh flap, lateral arm flap). The renewed interest in
multiple simultaneous free flap transfer has yet to be
proven superior and significantly increases the potential
for operative complications. Such combination procedures
should be restricted to highly selected cases.
Defect: Flap of choice:
Anterior composite oromandib- Fibula
ular defect
Cervical esophagus/pharynx Jejunum
Scalp ___calvarium Latissimus dorsi
Major glossectomy Radial forearm
Major craniofacial defect Rectus abdominus
All of these basic flaps are characterized by predictable
anatomy, relatively large caliber donor vessels, and rela-
tively long pedicle length. Specialized application may call
for other donor sites that have evolved as flaps of choice
for particular problems, ie, serratus, gracilis, or pectoralis
minor for facial paralysis, and parascapular for microso-
mia or contour deficiencies. In expert hands, even the most
common complications are rare and have been well de-
scribed. Conservative management of minor functional
and wound healing problems is usually sufficient in such
instances.
LATISSIMUS DORSI
For the latissimus donor site, recurrent seroma formation
(treated with aspiration as occasion requires) and broad-
ened scar and wound dehiscence (where taken as a
myocutaneous flap) are most frequent. Although repeated
aspiration will usually be adequate in time, sclerosing
agents or opening and packing the wound are rare solu-
tions. Because of its specific use in large surface area
wounds, partial split thickness skin graft (STSG) take is
common and can be maximized through the use of wet-
moist dressing changes after initial graft adherence (3-5
days).
180
RADIAL FOREARM
The radial forearm site should generally be without sacri-
fice or damage to the superficial branch of the radial nerve,
which can form painful neuromas that are triggered on
contact of this area during activities of daily work and
living. Partial or total loss of STSGs at the donor site can be
minimized through preservation of the paratenon, meticu-
lous graft placement, adequate bolstering, and stable
splinting. We are exploring the use of acellular dermal
allografts and STSG composites in an effort to further
minimize this problem and to optimize function and
aesthetics at this site. Frank tendon exposure should be
managed through wet-dry dressing changes to maintain
tissue hydration and allow stabilization of surrounding
soft tissues and progression of marginal granulation tissue
that may subsequently be skin grafted. Tendon resection
(palmaris longus) may ultimately be required. Involve-
ment of other principal tendons (flexor carpi radialis,
brachioradialis) are much less common as they are situated
at the margins of a properly designed flap and are usually
easily covered through advancing skin margins or through
myodesis of forearm muscles over them. The skin-grafted
surface area can be minimized through maneuvers that
slightly advance and tack down residual skin margins,
thereby minimizing the donor site defect--usually about
10% to 25% overall. Radial forearm flaps incorporating
bone are accompanied by the risk of radius fracture, which
is minimized through careful attention to percentage of
bone harvested (30%-40% recommended) and through
appropriate casting technique (including elbow joint--
long arm spica) and duration of casting during the healing
phase. 4 The bone obtained with this flap is generally
inadequate for osseointegrated implant placement and
masticatory function, particularly given the excellent alter-
natives available. 5
FIBULA
Wound healing complications in the lower extremity do-
nor site are more common, most often involving distal
peroneus longus tendon exposure or partial STSG take,
both of which are managed conservatively. Although we
most commonly incorporate the entire flexor hallucis
longus muscle with these flaps, I have yet to observe
significant inability to elevate the great toe as a result of
this. Physical therapy should minimize morbidity and
maximize function. Appropriate splinting technique should
avoid pressure sores in dependent areas. Retention of
about 6 cm of proximal and distal bone should ensure knee
and ankle joint stability. Harvest of this flap in growing
children should include orthopedic fusion of the distal
fibula to the tibia in order to avoid the development of
varus deformities with bone growth. The decision to
perform preoperative imaging studies is now believed to
be optional for most in the presence of a normal distal
pedal pulse examination. This does not, however, disclose
the presence of tibial-peroneal trunk trifurcation involve-
ment by atherosclerotic disease. This may be significant in
arteriopaths, diabetics, hypertensives, and the like, in
which case, diagnostic imaging studies may facilitate the
choice of left versus right side donor site regardless of the
distal examination. The selective use of magnetic reso-
nance angiography or traditional contrast angiography
may be rationally applied to individuals with these comor-
bid conditions. One should be familiar with the vascular
COMPLICATIONS IN MICROVASCULAR FREE FLAP SURGERY
anomaly of peroneal arteria magna. 6 Anecdotal reports of
leg loss, major nerve paralysis, or vascular accident should
not be experienced with true command of the anatomy and
a broad experience in application of this flap. Pedicle
lengthening procedures particular to the fibula involve
distal fasciocutaneous paddle design (which is also where
the highest density of septocutaneous perforators are
located) and proximal subperiosteal bone resection. In
general, the failure of one fibula free flap is an indication to
perform a second, contralateral fibula free flap, where
possible, as the indications for its ~pplication in the first
place remain unchanged despite the previous failure. This
approach is taken notwithstanding the significant addi-
tional morbidity, particularly when not performed in a
delayed setting but during the same hospitalization.
JEJUNUM
It is fortunate that many complications related to this flap
are strictly within the purview of the gastrointestinal
surgeon and will remain so. Laparoscopic harvest tech-
niques promise to minimize the morbidity and complica-
tions attendant to coeliotomy. Although it is possible to
perform intrathoracic distal anastomosis through thora-
cotomy, the complication of anastomotic leak is usually life
threatening. It is the responsibility of the multidisciplinary
team to avoid such contingencies at all costs. The knowl-
edge of submucosal metastases, synchronous second pri-
mary esophageal disease, and the ability to predict, through
experience, the distal margin of resection, particularly in
previously treated cases, should minimize errors in resect-
ing disease. The jejunal flap permits easy distal anastomo-
sis above the thoracic inlet and superior mediastinum.
Automatic end-to-end-anastomosis-type stapling devices
are not an adequate solution in the event of far distal
anastomosis for technical reasons. The most common
problem in the application of the segmental jejunum is not
microvascular anastomotic, but anastomotic, attributable
to circumferential cicatricial stricture. This occurs despite a
number of well-diagrammed castellating and Z-plasty
designs available. This phenomenon is most common at
the distal anastomosis and is generally treated with bougie
dilation. The transposed flap can be irradiated to usual
therapeutic doses. Gastric transposition reconstruction re-
mains a viable alternative option, avoids some of the
potential complications attendant to microsurgical recon-
struction, offers not 2 but 1 potential site for mucosal
stricture, and, by design, does not have inferior margin
considerations (ie, is coupled with total pull-through esoph-
agectomy). The gastric pull-up persists as an important
option, although it has limited ability to be transposed
above the tongue base level--not an issue in the free tissue
transfer. Expanded application of the antimesenterically
opened flap as a resurfacing option remains underused.
RECTUS ABDOMINUS
Common problems attendant to this flap is the occurrence
of herniation or the more common phenomenon of fascial
attenuation and bulging. The need to repair such defects
should be rare (ie, < 10%) and the routine use of implant
materials (ie, Marlex mesh [Davol, Inc, Cranston, RID
should be unnecessary given muscle and fascial-sparing
techniques of flap harvest. This is as equally true of
extended quadripod designs as it is of smaller vertical
MARK D. DELACURE
designs, as the fascial and muscle components removed
are identical for both.
MICROVASCULAR FREE FLAP FAILURE IS NOT
AN ALL-OR-NONE P H E N O M E N O N m W H E N
DISASTER STRIKES
The worst possible complications observable in the tech-
nique of free tissue transfer include (1) failure to capture
intended tissues in pedicle territory, (2) avulsion of the flap
from the donor site, and (3) mechanical engagement of the
pedicle by powered instruments (eg, drill or saw). The first
is the only absolutely irreversible error of the 3 complica-
tions, the result requiring one to seek a second donor site
(usually contralateral). As a veteran instructor of several
training programs at the resident and fellow level, I have
experienced both of the latter near-catastrophes and have
successfully reversed the otherwise complete loss of such
mishandled flaps. Principles of trauma surgery, where the
zone of injury concept is applied at the pedicle level and
creative compensation for being short-changed in terms of
vessel length, are required. In the second event, and more
rarely the third, traditional administration of bolus dose
heparin before clamping the flap pedicle is impossible, and
the best one may do is to immediately transition to cold
ischemia. This will increase tissue tolerance during the
period of no blood flow as recipient vessel microsurgery
has not yet prepared the field for flap transfer that must
take sudden priority over all other procedures in progress.
It is possible that, in cases of relatively late venous
thrombosis (ie, 3 days and out), the flap remains ad-
equately arterialized, maintaining adequate inflow signal
and clinical characteristics while venous outflow is main-
tained via numerous microvessels established by that time
over the peripheral surface of the flap. This has been the
only plausible explanation for several flaps I have ob-
served where clear flap viability has been maintained as
evidenced by active bleeding in the context of apparent
complete and long-standing vein thrombosis.
PERIOPERATIVE PHARMACOLOGY AND
THERAPEUTICS
The wide variance of opinion and practice regarding how
to optimally manage postoperative free tissue transfers to
the head and neck region incorporates as much voodoo
medicine as pharmacology. Intraoperative management
incorporates topical papaverine or lidocaine as a smooth
muscle vasoplegic. Bolus IV heparin 1,000 to 2,000 units is
given before vascular pedicle clamping and again just
before clamp release and reperfusion of the flap. Often, an
infusion of 10% low molecular weight dextran-40 is admin-
istered at 25 m L / h o u r for platelet effects. This is an
optional step and may be wisely avoided in patients with
marginally compensated cardiovascular status. Flash pul-
monary edema and headaches have been attributed to this
drug. Acting on the same target--but through a separate
mechanism--is aspirin, which is also given by some as a
suppository then enterally thereafter for about 2 months
postoperative. Cases involving interposition vein grafts,
prolonged ischemia times, and those salvaged after re-
exploration are often run on low-dose heparin at about
500U/hour intravenously. Despite the plethora of agents
and mechanisms of action, it is rare to have problems
caused by hematoma or ongoing blood loss at the recipient
181
site in the head and neck. The use of active suction drains
temporarily internally fixated away from the anastomosis
and vessels is an important pre-emptive maneuver in the
avoidance of related problems. There are advocates of
calcium channel blockers in selected clinical situations. The
use of intravenous nitroglycerine infusion is discouraged
because of the possibility of actually shunting peripheral
blood flow away from the flap. Topical dimethyl sulfoxide
(free radical scavenger with good tissue penetration),
steroids (membrane stabilization), and nitroglycerin paste
(vasodilation) are of distinctly unproven benefit in human
clinical situations. One should probably not attribute flap
difficulty to perioperative cigarette smoking except for
donor site complications. The effect at the anastomotic
level is probably not measurable, diminished 02 carrying
capacity, vasoconstriction, and blood pressure elevation
notwithstanding.
MONITORING CONSIDERATIONS
It is likely true that the real benefit of monitoring protocols
and technology is not the apparent sophistication in
monitoring blood flow but the imposed schedule of actu-
ally observing the flap clinically. There is simply no
substitute for clinical experience and judgment in this area;
ultimately false alarms have been sounded equally from
$15,000 implantable Dopplers and $400 percutaneous Dopp-
ler units. Clinical parameters of color, warmth, turgor, and
capillary refill remain gold standards of flap monitoring. I
have never been a fan of flap pricking and defend this in an
analogy to the conversion of first to third degree burns by
infection and desiccation. Providing a route of ingress for
bacteria in the setting of oral sepsis and a potentially
marginal flap has been an avoidable mechanism of evalua-
tion except in unusual circumstances. Surface temperature
thermistor probes have been inched unrecognized toward
warm air Bair Hugger blankets (Augustine Medical Inc,
Eden Prairie, MN) by physician and intensive care unit
staff alike giving the illusion of normal and unchanged
temperature difference--the flap nonperfused all the while.
A shifting or even loss of signal 2 to 3 days out may take
place as a result flap settling during edema resolution or
may, in fact, represent a real crisis. All of the technology in
the world will not distinguish among the 2 possibilities.
Enthusiasm for re-exploration must be carefully bal-
anced against the real likelihood of actually doing no good
at all or even causing harm tQ either the flap or the patient
beyond about 3 days postoperative. Typically, the soft
tissues are at the height of their edema and are nonpliable,
requiring additional reconstruction in order to achieve
closure without tension. Microvascular anastomoses are
invariably covered in congealed, organized clot a n d / o r
fibrin at that point. The likelihood of success in this setting
is, in m y opinion, severely diminished. More acute catastro-
phes must be dealt with by revision anastomosis, Fogarty
catheter embolectomy, or intravascular injection of strepto-
kinase or tissue plasminogen activator. 7
THE SPECIAL CASE OF BONE-CONTAINING
FREE FLAPS
True expertise in clinical microsurgery involves a clear
understanding of microvascular anatomy and physiology
of blood flow at the capillary and cellular level, in addition
to the mastery of anastomotic technique and donor site
182
anatomy. Nowhere is this more true than in flaps involving
the transfer of bone. The fibula free flap involves some of
the most fascinating surgically induced physiology in
contemporary surgery. Normally perfused via its medul-
lary vessel entering the bone at the junction of its proximal
and middle thirds, blood flow to the medullary cavity and
about two thirds of the cortices is centrifugal in direction,
with minor periosteal flow contribution. Once the bone is
osteotomized, the normal supply is interrupted and the
flap is perfused solely by the periosteal route, which is
preserved through the preservation of a several millimeter
cuff of muscle on the bone, underlining the absolute
importance of attention to detail in flap dissection tech-
nique. Physiologic blood flow is reversed in this situation
to centripetal and may be confirmed clinically by medul-
lary bleeding at the distal-most aspect of the multiply
osteotomized bone.
It is for the above reason that a thrombosed fibula flap
cannot be thought of as the equivalent of a nonvascular-
ized bone graft because the cuff of attached necrotic soft
tissue actually acts as a barrier to the ingrowth of cells from
the surrounding tissues. Similarly, burying such a flap with
another transposed flap (eg, pectoralis) is nearly always
condemned to failure unless, perhaps, the skeletal compo-
nent is removed, stripped of its attached soft tissues, and
then replated as a nonvascularized bone graft. 8
OSTEOSYNTHESIS
The proliferation of plating systems for osteosynthesis and
increasingly superficial understanding of biomechanics
and design has resulted in general lack of consensus and
misapplication of hardware in bone-containing free flaps.
This has intensified, rather than diminished, in recent
years. The earliest reports of free fibula series9 transplanted
almost as much hardware as bone and soft tissue. The
alternative iliac crest flap was most commonly coupled
with large reconstruction plates, which, in combination,
often resulted in a prognathic skeletal profile. Both made
subsequent placement of osseointegrated implants more
difficult. Segment-to-segment shaping, cortical thickness,
and sequential osteotomy fixation has been a distinct
advantage of the fibula flap in the recreation of the
subtleties of lower skeletal form and, for this, a variety of
mini-plating systems (2.0-2.7mm) and designs have been
applied. Although it was intuitive that after the segmental
resection of bone and muscle attachments, enough mastica-
tory force could not be generated to actually fracture
contemporary titanium plating systems, clinical experi-
ence has proven otherwise in the case of most 2.0-mm
systems. The potentially favorable physiologic principle of
stress transference (versus stress shielding) must be bal-
anced by adequate internal fixation to ensure ultimate
bony union at osteotomy sites and to avoid such plate
fracture. Our own techniques have evolved to the rela-
tively minimalist use of 2.4-ram systems in osteotomy sites
in one plane, and 2.7-mm systems at points of juncture
between flap and the residual mandible remnant. Here,
screws are placed bicortically into the native side but may
otherwise be monocortical. Radiographic assessment of
union is assessed quarterly and monitored on a clinical
basis. Attributable in part to plate failure are nonanatomic
skeletal reconstruction, failure to achieve bony union, the
need to place osseointegrated dental implants, and recur-
rent disease. A range of orthognathic type reoperative
COMPLICATIONS IN MICROVASCULAR FREE FLAP SURGERY
p r o c e d u r e s h a v e b e e n safely p e r f o r m e d o n p r e v i o u s fibula
transfers. N e v e r t h e l e s s the best time to " g e t it right,"
p a r t i c u l a r l y at the skeletal level, is at the time of initial flap
placement.
THE ELDERLY PATIENT
I n general, patients w h o are c a n d i d a t e s for resection of
m a l i g n a n t tissue are also c a n d i d a t e s for m i c r o v a s c u l a r free
tissue transfer reconstruction. Indeed, literature exists attest-
i n g to the feasibility a n d safety of these techniques in the
elderly p o p u l a t i o n . A g e in a n d of itself is n o t a contraindica-
tion to the use of m i c r o v a s c u l a r technique. The i m p o r t a n c e
of p r e o p e r a t i v e e v a l u a t i o n a n d o p t i m i z a t i o n , w h e r e p o s -
sible, is h e i g h t e n e d . It is the responsibility of all i n v o l v e d to
m i n i m i z e time u n d e r general anesthesia b y a m a s s i n g the
m o s t experienced technical t e a m available, active p r e o p e r a -
tive c o m m u n i c a t i o n w i t h accurate p r e d i c t i o n of the defect
to be created, anticipation of the reconstructive require-
ments, a n d facilitation of an efficient s i m u l t a n e o u s 2-team
approach.
MARK D. DELACURE
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