Cervicofacial Transposition Flaps

History of present illness

• a.

  The extent and complexity of the defect requiring reconstruction must be determined.

  • 1)

    Ideally defects should be reconstructed with like tissue. If a defect involves a loss of cutaneous tissue, it is ideally reconstructed with cutaneous tissue of similar color, thickness, and texture.

  • 2)

    Similarly, if the defect includes multiple tissue types such as epithelium and muscle, a flap including tissue of similar thickness and tissue type is ideally used for reconstruction.

• b.

  Current function and future functional needs should be elicited.

  • 1)

    Preoperative swallowing and breathing should be evaluated.

  • 2)

    Possible need for postoperative airway protection (tracheostomy) and nutritional support (nasogastric feeding tube) should be considered.

Past medical history

• a.

  Prior treatment in the head and neck region

  • 1)

    Prior head or neck surgery may affect the viability of regional reconstructive options.

  • 2)

    Prior radiation may affect postoperative healing and flap viability.

• b.

  Medical illnesses that may affect flap viability and reconstructive outcomes

  • 1)

    Diabetes, especially if poorly controlled, can affect healing outcomes and flap viability.

  • 2)

    Peripheral vascular disease may affect flap viability.

  • 3)

    Coagulopathies may affect postoperative bleeding or coagulation.

  • 4)

    Tobacco abuse/nicotine exposure is associated with arterial constriction and vascular insufficiency. It should be avoided in the perioperative period.

• c.

  Family medical history

  • 1)

    Coagulopathies can promote postoperative bleeding or coagulation and thus flap viability.

• d.

  Medications

  • 1)

    Consideration of risks/benefits to discontinuing any drugs that would increase the risk of bleeding. Development of a hematoma can threaten flap viability.

Examination of the face

• a.

  The face should be carefully evaluated for any scars or evidence of prior surgical intervention, as this could disrupt blood flow for a cervicofacial advancement flap. The size of the defect should be measured to make sure that the planned flap is large enough to cover the defect.

Examination of the neck

• a.

  The neck should be carefully evaluated for any scars or evidence of prior surgical intervention that may affect blood flow.

• b.

  In planning a submental island flap, the amount of submental skin redundancy must be measured via the “pinch test,” with the patient in mild neck extension to ensure adequate flap volume while sparing enough tissue for closure of the primary donor site without restricting head elevation.

Doppler examination

• a.

  A preoperative Doppler exam ination is required for the supraclavicular artery flap to identify and trace the vascular pedicle from the supraclavicular fossa over the clavicle and onto the deltoid region of the shoulder. This can be done either in the office or on the day of surgery.

• b.

  The site of Doppler signals should be marked with a marking pen to facilitate future identification.

Computed tomography (CT) scan with contrast: Although not required for flap planning, this may be useful to evaluate the vascular system within the neck if prior surgery has been performed. It can help in surgical planning to establish that the vessels of the flap pedicle are intact.

CT angiography (CTA) or formal angiography: Although rarely needed, an angiogram may be useful if there is concern regarding the presence of the flap’s pedicle vessels.

General anesthesia

• a.

  This is the most commonly used anesthetic approach because the flap is often harvested concurrently with tumor resection.

• b.

  General anesthesia is helpful in procedures that require dissection of the vascular pedicle, since this calls for meticulous care.

• c.

  Use of a paralytic is at the discretion of the surgeon depending on the nerves at risk.

The patient is positioned supine.

Placement of a shoulder roll or extension of the neck away from the side of operation may be beneficial during early flap elevation.

• a.

  At the end of the surgery, if the closure is under tension, consider removing all rolls and rotating the patient back to neutral position to reduce tension and aid in primary closure.

Their use depends on the defect to be reconstructed and the associated risk factors.

Monitoring of the facial nerve is recommended when its branches are at risk.

Standard head and neck set

Bipolar cautery

Sterile Doppler

Spy fluorescent angiography—allows for the prediction of flap viability after harvesting

Flap viability: Because of the random pattern of the flap, it is at increased risk for vascular insufficiency, especially at its distal and peripheral edges.

Bleeding: The development of a hematoma in the wound can compromise the flap’s viability owing to compression of the pedicle.

• a.

  Meticulous hemostasis should be established at the time of closure.

• b.

  Suction drains should be placed whenever possible owing to the significant dead space created during flap elevation and risk of hematoma formation.

Injury to the cranial nerves

• a.

  Branches of the facial nerve are at risk most noticeably in raising of the cervicofacial and submental island flaps. Nerves should be identified and protected during primary flap elevation.

• b.

  The accessory nerve is at risk during elevation and rotation of the sternocleidomastoid muscle flap. It should be identified, dissected free of the muscle, and preserved during flap elevation/rotation.