Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

Defects in the head and neck resulting from the extirpation of malignant tumors frequently lead to disabling functional and cosmetic deformities. In the past, extensive surgical resections were restricted by the patient's inability to tolerate the morbidity of the resultant deformity. With the advent of microvascular free tissue transfer techniques, immediate restoration of form and function became possible. It also allowed a far greater freedom in the selection of tissue that could be used in the reconstruction. In addition, revascularized flaps are not dependent upon the vascularity of the tissues to which they are transferred, so they are particularly useful in the previously irradiated patient. Finally, the donor site morbidity is generally well tolerated.

The goal of free tissue transfer in the head and neck cancer patient is to perform the ablative procedure and the reconstruction as a single stage operation so as to restore a functionally and aesthetically acceptable state as soon as possible. This is an important consideration, given the often limited life expectancy of these patients. However, it is also important not to sacrifice the oncologic principles of the operation in order to perform the reconstruction, and a prolonged free flap procedure with its attendant morbidity should not be performed if a simple skin graft, local flap, or prosthesis will suffice.

In addition to the increased length of operation, several other potential disadvantages of free flap reconstruction exist. Two surgical teams are necessary, special training is required, and the ablative procedure itself can limit the availability of recipient vessels. Also, as with any large flap reconstruction, tumor recurrences can be obscured.

The absolute indications for performing microvascular free tissue transfer are for the reconstruction of anterior mandibular, circumferential pharyngeal, or extensive soft tissue defects. It should also be considered in any situation that can be reconstructed with a regional flap, since recent studies have shown that free flap reconstructions tend to have a lower rate of complications, a better aesthetic and functional outcome, and less donor site deformity than regional flap reconstructions. A microvascular free flap is also preferable to other methods of reconstruction in the irradiated patient.

Selection of the donor tissue is clearly dependent upon the defect that is to be reconstructed. The factors that must be taken into account include the size of the defect, the type of tissue required, the extent of bony requirement, the need for innervation, and the resultant donor deformity. The donor tissue should be of sufficient bulk and pliability to facilitate reestablishing contour and function. In addition, the status of the donor tissues should be taken into consideration. It is important to assess the regional vascular status and take into account previous surgery or trauma, body habitus, and the patient's overall medical condition.

The free flaps frequently used in head and neck surgery include the iliac crest-internal oblique osseomyocutaneous, rectus abdominis, latissimus dorsi, fibular, radial forearm, and jejunal flaps. The iliac crest-internal oblique osseomyocutaneous flap in an excellent composite free flap for oromandibular reconstruction. It provides a large amount of bone, up to 16 cm, that can be contoured to reconstruct the anterior mandibular arch as well as the ramus and condyle. It is a tripartite flap, consisting of iliac crest, internal oblique and skin, and it is supplied by the deep circumflex iliac artery and vein. The internal oblique provides well vascularized tissue, which, when lined with a skin graft, can reconstruct the lingual and buccal sulci and preserve the mobility of the residual tongue. The skin paddle can restore external defects and act as an external monitor of the flap's viability postoperatively. Because the skin retains its anatomic relationship to the bone, it retains its vascularity. The patient can also be positioned so that the flap can be harvested simultaneously with the head and neck resection, thereby decreasing the time of operation. This composite flap is also good for oromandibular reconstruction because the iliac crest will withstand placement of osseointegrated implants.

The disadvantages are that the harvesting and placement of the flap require a great deal of skill, and, because the skin paddle relies on musculocutaneous perforators for its vascularity, its ability to be rotated is limited. The skin paddle is also a poor color match in the head and neck. Other disadvantages of this flap are that the patients often have significant postoperative hip pain and weakness, and late ventral hernias may develop.

The rectus abdominis myocutaneous flap is an extremely versatile flap that can provide the entire length of the muscle form the xiphoid to the pubis and also provides the largest skin paddle of all the free flaps. Its bulk and pliability make it particularly useful for reconstructing orbitomaxillary and glossectomy defects. In addition, the deep inferior epigastric artery and vein are long, large caliber vessels that facilitate the microvascular anastomosis. It is also relatively easy to harvest, and the supine positioning of the patient allows a two team approach.

An obvious disadvantage of this flap is that is does not provide any bone. Also, depending on the patient's body habitus, it may be too thick. This problem can be circumvented by either harvesting the muscle alone or harvesting different thicknesses of subcutaneous tissue and then applying a skin graft. Another disadvantage is that removal of the rectus abdominis muscle may predispose to ventral hernia formation.

The latissimus dorsi is also a bulky myocutaneous flap that can be used to reconstruct large defects of the face, neck, oral cavity, and skull base. The thoracodorsal artery, which is a branch of the subscapular artery, and its accompanying thoracodorsal vein, provide a very long pedicle. Another advantage is that the donor defect is generally well tolerated. When harvested along with the thoracodorsal nerve, reinnervation of the muscle is also possible. While the reinnervation may only prevent atrophy of the muscle, this serves to maintain its bulk, which is a particular advantage when reconstructing total glossectomy defects.

On the other hand, a bulky flap can be a disadvantage is some patients, and patient positioning prevents a two team approach, prolonging the operative time.

The fibular free flap is useful for reconstructing segmental mandibular defects. It is a strong, tubular bone that is capable of maintaining osseointegrated implants for dental rehabilitation. Its long length can be used to reconstruct any sized mandibular defect, and it has a long vascular pedicle. Moreover, the course of the supplying peroneal vessels parallels that of the bone, so multiple osteotomies for contouring the bone do not jeopardize its blood supply. The donor site is also far away from the head and neck region and makes the two team approach easy. In addition, donor site morbidity is minimal and is usually limited to local sensory loss and weakness of dorsiflexion of the great toe.

However, this flap provides very limited soft tissue, and the septocutaneous blood supply is often variable and has been considered inadequate to support a skin paddle for intraoral placement.

The radial forearm fasciocutaneous flap is frequently used for intraoral soft tissue reconstruction. It is easy to harvest, it has a long vascular pedicle, and it provides a thin, pliable flap that is well-suited for reconstructing intraoral defects. It is supplied by the radial artery and drained by the paired venae comitantes. When harvested along with the medial and lateral antebrachial nerves, it becomes a sensate flap, and reestablishing sensation may be important in improving postoperative function. The radial bone may be included, but its length is limited, it is difficult to contour, and the donor defect is unsightly. In addition, loss of a portion of radius predisposes to pathologic fractures.

Total reconstruction of the hypopharynx and cervical esophagus has always been a surgical challenge. Prior to free jejunal transfer, reconstruction after total laryngopharyngectomy was accomplished with such techniques as deltopectoral or myocutaneous flaps. These flaps had a high rate of functional failure and usually resulted in lengthy hospitalizations. On the other hand, the jejunal interposition graft is ideal for reconstructing circumferential defects of the pharynx and cervical esophagus. The jejunum is of comparable size to the esophagus, and the harvest and microvascular anastomosis are fairly easily accomplished. these patients are usually eating by postoperative day 7 to 10. Other advantages are that tracheojejunal speech can be accomplished, and these grafts can be irradiated without significantly increasing the rate of complications.

The disadvantages are that a laparotomy is required for harvesting, and the jejunum does not tolerate ischemia well. The graft also relies entirely on its vascular pedicle for its blood supply, since the serosa appears to prevent the neovascularization from the recipient bed as occurs with other types of free flaps. Therefore, disruption of the vascular pedicle even 1 to 2 years later can lead to late graft failure.

Postoperatively, intensive monitoring of the vascular status of the flap is crucial for a successful outcome. The only way to salvage a compromised flap is to recognize immediately that the flap circulation is in jeopardy and then promptly intervene to reestablish its circulation.

The primary cause of flap failure is thrombosis at the anastomotic site. Early postoperative failure is hopefully noticed intraoperatively and is often the result of technical problems with the anastomosis or problems with the geometry of the vascular pedicle, such as mismatch in the artery sizes. Vasospasm and hypotension also play a role in causing ischemia of the flap. It is very important to avoid the use of vasoconstricting drugs, to keep the patient warm, and to monitor the volume status.

Failure within the first 24 to 72 hours is most often the result of venous congestion from compression, for example, by a hematoma. Drains are therefore crucial to prevent the formation of fluid collections. Failure beyond 72 hours is rare and may be secondary to infection or compression of the vascular pedicle.

The most important method of monitoring the flap is clinically. The flap should be pink and blanch with pressure; it should not be white or blue. Capillary refill should be less than 2 seconds, and the flap should be soft. A firm or tense flap suggests venous congestion. Last, it is important to survey the patient's general status, looking for hypotension, checking drain function, and watching for signs of bleeding and hematoma formation.

There are several mechanical ways of monitoring the circulation of the flap. The Doppler ultrasound is commonly used. The arterial phase of the Doppler signal has a crisp, biaphasic quality, whereas the venous phase consists of a triphasic hum.

In summary, microvascular free flaps are playing an increasingly larger role in the reconstruction of head and neck defects after ablative surgery. However, free tissue transfer as yet has no impact on the overall survival or on local or regional recurrences. The goal of the reconstruction is to provide better functional and cosmetic results, thereby improving the quality of the patient's remaining period of life.

Case Presentation

A 67-year-old black man developed a left scalp mass one year prior to presentation. The mass progressively enlarged, and he noticed a 15 pound weight loss. He had no other medical problems. On examination, an 8 x 8 cm, fungating, ulcerated scalp mass that was fixed in the left parieto-occipital region was present. No other skin lesions were found, and there was no lymphadenopathy. The remainder of the head and neck examination was unremarkable. A biopsy of the lesion was suggestive of malignant tricholemmal tumor. CT scanning of the head demonstrated a left parietal scalp mass that extended to, but did not invade, the calvarium. A metastatic evaluation was negative.

The patient underwent wide local excision of the scalp lesion with resection of the outer table of the calvarium. A 13 x 16 cm defect resulted, which was reconstructed with a free latissimus dorsi muscle flap and a split thickness skin graft. An end-to-end anastomosis was performed between the facial and thoracodorsal arteries, and an end-to-side anastomosis was performed between the thoracodorsal and internal jugular veins. The ischemia time was 2 hours 12 minutes. His postoperative course was uncomplicated, and he maintained a strong pulse in his graft as monitored by Doppler ultrasound. His was discharged to his home on postoperative day 14 and is currently doing well. The final pathology of the mass revealed a basal cell carcinoma and the margins were free of tumor.

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