Free Flap for Head and Neck Reconstruction

Dr. Nathan Chen

Dr. Jeffery Jorgensen
Oct. 10, 2012
 History
Seidenberg and colleagues 1959: free jejunal flap for cervical
esophageal reconstruction
Mongrel dogs
NPO 5-7 days
No leak or stenosis
First Otolaryngologists to report the use of free tissue transfer for
the reconstruction of the oral cavity in 1976
Taylor and associates reported the first vascularized bone graft using
a fibula for reconstruction of long bone injuries in 1975
Hidalgo adapted the osteocutaneous fibula flap for mandibular
reconstruction in 1989.

Seidenberg B, Rosenak SS, Hurwitt ES, et al: Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 1959; 149:162.
Cummings CW, Flint PW, Haughy BH, Robbins KT, Thomas JR, Harker LA, Richardson MA, Schuller DE. Otolaryngology: Head & Neck Surgery, 4th ed. 2005.
 Why free flap
Advantages Disadvantages
Versatility in tissue (skin, muscle, bone, Increased technical difficulty (additional
nerves) and in orientation
training required)
Restoration of shape, function, and sensation
Single operation for complex reconstructions Two surgical teams required (surgeons and
Multiple potential donor sites available nurses)
Simultaneous resection and flap harvest Expensive instrumentation
possible
Donor sites out of field of prior treatment Longer operation times
Extensive amounts of tissue available for More intensive postoperative management
large or massive defects Donor site morbidity
Postoperative irradiation tolerance
Independent blood supply for compromised
tissue beds
Improved function and cosmesis
Dental rehabilitation possible Cummings CW, Flint PW, Haughy BH, Robbins KT, Thomas JR, Harker LA,
High success rates (>90%), including for Richardson MA, Schuller DE. Otolaryngology: Head & Neck Surgery, 4th
ed. 2005.
bony reconstruction
Only available option for some patients
 Common indications for free flaps
Composite defects of the oral cavity
Total or near-total pharyngoesophageal defects
Extensive skull base defects
Extensive scalp defects
Massive defects not readily addressed with
other techniques
Lack of other reconstructive options (failures
or patient limitations)
Salvage surgery for chemoradiation failures
 Donor sites

Cummings CW, Flint PW, Haughy BH, Robbins KT, Thomas JR, Harker LA, Richardson MA, Schuller DE. Otolaryngology: Head & Neck
Surgery, 4th ed. 2005.
 Flap selection
Skin and soft tissue volume, bulk, and color
Pedicle length and vessel caliber
Innervation capacity (sensory / motor)
Bone quality, quantity, and availability
Donor site location to allow concurrent resection
and harvest
Donor site morbidity (dysfunction, cosmetic
deformity)
 Radial forearm flap
Versatile
Large thin and pliable skin, potentially sensate
Long vascular pedicle, good caliber vessels
(up to 20 cm, 2-2.5 mm)
OC, BOT, pharynx, soft palate, skull base
Functional adynamic funnel for pharyngo-
esophageal defect (better tracheoesophageal
speech)
 Radial forearm flap
Advantages
Easy positioning
Can be harvested concurrently
Potential for sensate flap
Thin, pliable skin with long,
large pedicle
Potential for unusual shapes
Potential for vascularized bone
Highly tolerant of radiation
therapy
Acceptable functional
morbidity at donor site
Disadvantages
Loss of hand
Poorly aesthetic donor site
Requires skin graft
Limited amount of bone
Potential for pathologic
fractures
Loss of hand function
(supination, wrist flexion,
grip, pinch)
 1.
2.
4. Radial recurrent a
5. Common
interosseous a
6.
7. Pronator teres
8.
9. Palmaris longus
10. Flexor digitorum
superficialis
11. Bicipital
aponeurosis
12. Flexor carpi ulnaris

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Radial a.
2.
4. Radial recurrent a
5. Common
interosseous a
6.
7. Pronator teres
8.
9. Palmaris longus
10. Flexor digitorum
superficialis
11. Bicipital
aponeurosis
12. Flexor carpi ulnaris

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Radial a.
2. Ulnar a.
4. Radial recurrent a
5. Common
interosseous a
6.
7. Pronator teres
8.
9. Palmaris longus
10. Flexor digitorum
superficialis
11. Bicipital
aponeurosis
12. Flexor carpi ulnaris

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Radial a.
2. Ulnar a.
4. Radial recurrent a.
5. Common
interosseous a
6.
7. Pronator teres
8.
9. Palmaris longus
10. Flexor digitorum
superficialis
11. Bicipital
aponeurosis
12. Flexor carpi ulnaris

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Radial a.
2. Ulnar a.
4. Radial recurrent a
5. Common
interosseous a
6. Brachioradialis
7. Pronator teres
8.
9. Palmaris longus
10. Flexor digitorum
superficialis
11. Bicipital
aponeurosis
12. Flexor carpi ulnaris

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Radial a.
2. Ulnar a.
4. Radial recurrent a
5. Common
interosseous a
6. Brachioradialis
7. Pronator teres
8. Flexor carpi radialis
9. Palmaris longus
10. Flexor digitorum
superficialis
11. Bicipital
aponeurosis
12. Flexor carpi ulnaris

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 Radial forearm
Artery?

Vein?

Nerve?

 Radial forearm
Artery?
Radial a.
Vein?

Nerve?

 Radial forearm
Artery?
Radial a.
Vein?
Venae comitantes / cephalic vein
Nerve?

 Radial forearm
Artery?
Radial a.
Vein?
Venae comitantes / cephalic vein
Nerve?
Medial / lateral antebrachial cutaneous nerves
 Radial forearm
Tourniquet
ID subfascial plane
Elevated to lateral border of FCR and medial border of BR.
Pedicle is identified distally btwn these tendons and ligated.
Follow the pedicle along the undersurface of the BR.
Tiny perforating vessels to the radius are identified and
cauterized or clipped
OR
If bone is harvested, the distal perforators are preserved and
followed to the radius. Do not shear the vessels from the bone
during harvest.
The pedicle can be followed to the antecubital fossa.
The cephalic vein is identified proximally. The LABC is
identified in proximity. Further dissection between the FCR
and BR allows for complete elevation and skeletonization of
the pedicle.
Pedicle is ligated proximally, and the flap is inset in the defect.
Donor site defect closed with STSG

Netter FH. Atlas of Human Anatomy 2nd Ed. 1997

 Radial forearm osteocutaneous
Reconstruction of limited mandibular defects and maxillofacial
defects
Perforators in the intermuscular septum
10-12 cm of bone
Thickness limited to 40% of circumference of radius (monocortical)
Concern of bone quality and pathologic fracture of radius bone
(23% risk)
Prophylactic internal fixation of the radius eliminates the risk

Werle AH, Tsue TT, Toby EB, et al: Osteocutaneous radial forearm free flap: I
ts use without significant donor site morbidity. Otolaryngol Head Neck Surg
2000; 123:711-717.
 Anterolateral thigh
More bulk than radial forearm
Large skin pedicle (up to 25 cm wide x 40 cm), sensate
Long pedicle (14-16 cm, 2-2.5 mm)
OC, pharyngeal, maxilla defects
Min donor site morbidity, 1o closure
Not affected by PVD
2 team

Disadvantage
Variable pedicle
Subcutaneous fat difficult dissection
Morbidity related to vastus lateralis injury
 Anterolateral thigh
Descending or transverse br. of
lateral circumflex femoral artery
(btwn rectus femoris & vastus
lateralis)
Venae comitantes
Lateral femoral cutaneous n.
 Anterolateral thigh
Cutaneous blood supply
Septocutaneous
Musculocutaneous (thru vastus l)
84% incidence
57% - myocutaneous from
descending br of LCFA
27% - myocutaneous from
transverse br. of LCFA
11% - septocutaneous from
descending br. of LCFA
5% - septocutaneous from
transverse br. of LCFA
 Anterolateral thigh
Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and
neck reconstruction. Head Neck. 2004 Sep;26(9):759-69.
 Intraoral ALT vs. RF
10 ALT vs.10 RF: no functional difference in
speech or swallow

Farace F, Fois VE, Manconi A, Puddu A, Stomeo F, Tullio A, Meloni F, Pisanu G, Rubino C. Free anterolateral thigh flap versus free forearm flap: Functional results in oral reconstruction.J Plast
Reconstr Aesthet Surg. 2007;60(6):583-7. Epub 2007 Jan 24.
 Advanced Tongue Cancer
Reconstruction: Functional Outcome
Chien CY, Su CY, Hwang CF, Chuang HC, Jeng SF, Chen YC. Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: functional outcomes. Eur J Surg Oncol.
2006 Apr;32(3):353-7. Epub 2006 Feb 7.

Farace F. J Plast Reconstr Aesth Surg 2007

 Pharyngectomy
Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope. 2006 Feb;116(2):173-81.
Unpopular in U.S.
Why?
 Unpopular in U.S.

 Anterolateral thigh
Yu P. Head Neck 2004
 Fibular osteocutaneous
Mainstay for mandibular reconstruction
Moderate amount of skin, potentially sensate (1o closure
possible), larger & 3-layer defects require another flap
Up to 25 cm of bone
Bone stock to support dental implantation
Septocutaneous or musculocutaneous perforators (variable
inclusion of soleus m)
Pre-op confirmation of 3-vessel flow
(angiography gold standard - spasms)

Galler RM, Sontagg HK. Bone Graft Harvest. Barrow Quarterly. 2003;19(4):
www.thebarrow.org/.../Vol_19_No_4_2003/158516.
 1. Popliteal a
2. Posterior tibial a.
Fibular osteocutaneous 3.
4.
7.
8. Popliteal m.
9. Tibial posterior m.
10.
11. Flexor digiorum longus m.
12. Peroneus longus

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Popliteal a
2. Posterior tibial a.
Fibular osteocutaneous 3. Peroneal a.
4.
7.
8. Popliteal m.
9. Tibial posterior m.
10.
11. Flexor digiorum longus m.
12. Peroneus longus

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Popliteal a
2. Posterior tibial a.
Fibular osteocutaneous
3. Peroneal a.
4. Ant Tibial a.
7.
8. Popliteal m.
9. Tibial posterior m.
10.
11. Flexor digiorum longus m.
12. Peroneus longus

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Popliteal a
2. Posterior tibial a.
Fibular osteocutaneous 3. Peroneal a.
4. Ant Tibial a.
7. Flexor hallucis longus m.
8. Popliteal m.
9. Tibial posterior m.
10.
11. Flexor digiorum longus m.
12. Peroneus longus

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 1. Popliteal a
2. Posterior tibial a.
Fibular osteocutaneous 3. Peroneal a.
4. Ant Tibial a.
7. Flexor hallucis longus m.
8. Popliteal m.
9. Tibial posterior m.
10. Soleus m.
11. Flexor digiorum longus m.
12. Peroneus longus

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 Fibular osteocutaneous
Artery?

Vein?

Nerve?
.
 Fibular osteocutaneous
Artery?
Peroneal a.
Vein?

Nerve?

Strauch B, Yu HL Atlas of Microvascular Surgery 2nd Ed. 2006

 Fibular osteocutaneous
Artery?
Peroneal a.
Vein?

Nerve?

Bailey BJ et al. Head and neck surgery-Otolaryngology, 3rd ed. 2001

 Fibular osteocutaneous
Artery?
Peroneal a.
Vein?
Peroneal v.
Nerve?
 Fibular osteocutaneous
Artery?
Peroneal a.
Vein?
Peroneal v.
Nerve?
Lateral sural cutaneous n.
 Fibular osteocutaneous
Doppler to ID perforating vessels in the septum.
Skin flap designed to incorporate at least one vessel.
ID intermuscular septum by palpation and anatomic landmarks.
Skin incision
Proximal and distal extensions allow for bone harvest and pedicle
dissection. The anterior portion of the skin paddle is dissected.
The peroneus longus is reflected anteriorly
ID the fibula
ID the posterior crural septum (avoid injury to the perforators).
Once visualized, the septum is examined for perforators. Further
dissection anteriorly around the fibula is performed, transecting
the extensor hallucis longus.
ID the thick interosseous septum.
Posterior dissection to free up the skin paddle from the soleus and
gastrocnemius,
ID the setum from its posterior aspect.
 Fibular osteocutaneous
Bony cuts are made with an oscillating saw. The bone is
pulled laterally as the interosseous membrane is transected.
The chevron-shaped tibialis posterior is transected carefully
with bipolar scissors. Just underneath this muscle lies the
pedicle, which is identified distally and ligated.
The flexor hallucis longus and soleus muscles must be
transected. Dissection is continued proximally to the posterior
tibial bifurcation. The anterior and posterior tibial pulses are
palpated prior to transecting the peroneal vessels.
The length of bone needed for reconstruction is measured.
Proximal elevation of periosteum along the fibula allows
sizing of the bone and lengthening of the pedicle. Some
surgeons prefer to contour the bone while the flap is still
vascularized in the leg while others prefer to transect the
pedicle at this time and perform osteotomies on a back table.
1o closure if the defect is small or no skin was harvested,
otherwise STSG
Apply posterior leg splint
The bone is plated and inset into the defect following
osteotomies. The pedicle is positioned along the lingual aspect
of the flap, and the skin paddle is adjusted.
 Fibular osteocutaneous
Advantages Disadvantages
Mandible reconstruction 2 flaps required for large
(near total) skin defects
Osseointegrated implant Pain on ambulation donor
site morbidity
Skin loss in 5-10% flaps
Contraindications
h/o leg trauma/surgery
Venous stasis
 Rectus abdominis
Advantages Disadvantages
Bulky Poor color match
Good for skull base defects, Ptoptic
total glossectomy Risk of ventral hernias
Long pedicle, large caliber
vessels
Min donor site morbidity
Easy harvest
 Rectus abdominis
Artery?
Deep superior / inferior epigastric a.
Vein?
Deep superior / inferior epigastric a.
Nerve?
Lower intercostal n.

 Rectus abdominis

Microanastomoses techniques
 Microanastomoses techniques
Interrupted
Continuous
Locking continuous
Interrupted horizontal mattress
suture
Continuous horizontal mattress
Spiral anastomosis
Sleeve anastomosis

Alghoul MS, Gordon CR, Yetman R, Buncke GM, Siemionow M, Afifi AM, Moon WK. From simple interrupted to complex spiral: a systematic review of various suture techniques for
microvascular anastomoses. Microsurgery. 2011 Jan;31(1):72-80. doi: 10.1002/micr.20813. Epub 2010 Nov 28.
 Interrupted vs. continuous
Multiple studies in 1960s 1-4
Simple interrupted superior to continuous
Concern of purse string
Reduced patency was attributed to
Lumen stenosis
Decreased vessel compliance
Decreased pulsatility
Little and Salerno 1978: similar patency rates
with both techniques, less OP time with
continuous

1. Cobbett J. Small vessel anastomosis: A comparison of suture techniques. Br J Plast Surg 1967;20:1620.
2. Jenkins JD. Repair of small vessels. Br J Surg 1967;54:558560.
3. Case MD, Schwartz SL. Consistent patency of 1.5 mm arterial anastomoses. Surgical Forum 1965;13:220.
4. Jacobson JH, Suarez EL. Microvascular surgery. Dis Chest 1962;41:220.
5. Little JR, Salerno TA. Continuous suturing for microvascular anastomosis. J Neurosurg 1978;48:10421045.
 Interrupted vs. continuous

Alghoul MS, Gordon CR, Yetman R, Buncke GM, Siemionow M, Afifi AM, Moon WK. From simple interrupted to complex spiral: a systematic review of various
suture techniques for microvascular anastomoses. Microsurgery. 2011 Jan;31(1):72-80. doi: 10.1002/micr.20813. Epub 2010 Nov 28.
 Interrupted vs. continuous
Memorial Sloan Kettering Hospital
200 free flaps performed using the continuous
suture technique in both the arterial and venous
anastomoses and reported an overall 97.5% flap
survival
Re-exploration rate 6.5%
Minor complication 16.5%
Major complication 15.1%

Cordeiro PG, Santamaria E. Experience with the continuous suture microvascular anastomosis in 200 consecutive free flaps. Ann Plast Surg 1998;40:16.
 Continuous locking and spiral
interrupted
Minimizes purse-stringing
Allows visualization of lumen during
the last passes
Comparable patency to simple
interrupted, but shorter opeartive
time

Cordeiro PG, Santamaria E. Experience with the continuous suture microvascular anastomosis in 200 consecutive free flaps. Ann Plast Surg
1998;40:16.
 Sleeve anastomosis
Shorter operative time
No need to flip to suture posterior wall
Proximal vessel < distal vessel
Patency rates reported to be equal
to interrupted suture technique
Higher likelihood of stenosis if vessels
are similar size

Cordeiro PG, Santamaria E. Experience with the continuous suture microvascular anastomosis in 200 consecutive free flaps. Ann Plast Surg 1998;40:16.
 Leeches
Enzyme secreted?

Bacteria transmitted?

Prophylactic abx coverage?

 Leeches
Enzyme secreted?
Hirudin
Bacteria transmitted?

Prophylactic abx coverage?

 Leeches
Enzyme secreted?
Hirudin
Bacteria transmitted?
Aeromonas hydrophila (GNR)
Prophylactic abx coverage?

 Leeches
Enzyme secreted?
Hirudin
Bacteria transmitted
Aeromonas hydrophila (GNR)
Prophylactic abx coverage
Beta-lactamase-resistant (fluoroquinolone, third
generation cephalosporin, or TMP-SMX)

 References
Seidenberg B,Rosenak SS,Hurwitt ES,et al:Immediate reconstruction of the cervical esophagus by a revascularizedisolated
jejunalsegment. Ann Surg1959;149:162.
Cummings CW, Flint PW, HaughyBH, Robbins KT, Thomas JR, HarkerLA, Richardson MA, SchullerDE. Otolaryngology: Head &
Neck Surgery, 4th ed. 2005.
Bailey BJ et al. Head and neck surgery-Otolaryngology, 3rd ed. 2001
StrauchB, Yu HL Atlas of MicrovascularSurgery 2nd ed. 2006
Netter FH. Atlas of Human Anatomy 2ndEd. 1997
WerleAH,TsueTT,TobyEB,et al:Osteocutaneousradial forearm free flap: Itsuse without significant donor site morbidity.OtolaryngolHead
Neck Surg2000;123:711-717.
Farace F, Fois VE, Manconi A, Puddu A, Stomeo F, Tullio A, Meloni F, Pisanu G, Rubino C. Free anterolateral thigh flap versus free
forearm flap: Functional results in oral reconstruction.J Plast Reconstr Aesthet Surg. 2007;60(6):583-7. Epub 2007 Jan 24
Chien CY, Su CY, Hwang CF, Chuang HC, Jeng SF, Chen YC. Ablation of advanced tongue or base of tongue cancer and reconstruction
with free flap: functional outcomes. Eur J Surg Oncol. 2006 Apr;32(3):353-7. Epub 2006 Feb 7.
Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects.
Laryngoscope. 2006 Feb;116(2):173-81.
Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head
Neck. 2004 Sep;26(9):759-69.
GallerRM, SontaggHK. Bone Graft Harvest. Barrow Quarterly. 2003;19(4): www.thebarrow.org/.../Vol_19_No_4_2003/158516
AlghoulMS, Gordon CR, YetmanR, BunckeGM, SiemionowM, AfifiAM, Moon WK. From simple interrupted to complex spiral: a
systematic review of various suture techniques for microvascularanastomoses. Microsurgery. 2011 Jan;31(1):72-80. doi:
10.1002/micr.20813. Epub2010 Nov 28.
Cobbett J. Small vessel anastomosis: A comparison of suture techniques. Br J PlastSurg1967;20:1620.
Jenkins JD. Repair of small vessels. Br J Surg1967;54:558560.
Case MD, Schwartz SL. Consistent patency of 1.5 mm arterial anastomoses. Surgical Forum 1965;13:220.
Jacobson JH, Suarez EL. Microvascularsurgery. DisChest 1962;41:220.
Little JR, Salerno TA. Continuous suturing for microvascularanastomosis. J Neurosurg1978;48:10421045.
CordeiroPG, SantamariaE. Experience with the continuous suture microvascularanastomosisin 200 consecutive free flaps. Ann
PlastSurg1998;40:16.