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Common Free Flaps
Synopsis
Free tissue transfer (“free flap”) reconstruction is commonly used to address defects of the body after trauma or tumor resection. A wide variety of tissue flaps exist, and flap selection should be based on requirements for coverage at the recipient site. Flaps can be designed to include skin, fat, fascia, muscle, bone, tendon, nerve, and various combinations of these tissue types. Successful flap reconstruction relies on thorough pre-operative patient assessment, wound management, understanding of flap anatomy, meticulous microsurgical technique, and vigilant post-operative flap monitoring. A comprehensive review of every flap described in the literature is beyond the scope of this chapter. Instead, we focus on 5 common free flaps that can be used for virtually any defect of the body and that should be part of the armamentarium of a reconstructive plastic surgeon. These are the radial forearm, anterolateral thigh, fibula, latissimus dorsi, and rectus abdominis flaps. Step-by-step guides to harvesting each flap are outlined and illustrated by clinical photographs. A description of microsurgical anastomosis technique is accompanied by a video demonstrating the procedure ( ). Finally, recommendations for post-operative care, including identification and management of complications, are provided.
Clinical Issues
Radial Forearm Flap
The radial forearm free flap (RFFF) is a thin fasciocutaneous flap with a well-defined and large vascular pedicle. Common applications include head and neck reconstruction for defects involving partial tongue, buccal mucosa, maxilla, lower lip, or hypopharynx/pharynx. The radial forearm may also be designed and harvested as an osteocutaneous flap including unicortical radius, or as a fascia-only flap. The pedicled or “reverse” radial forearm flap is used for ipsilateral arm or hand reconstruction.
Anterolateral Thigh Flap
The anterolateral thigh (ALT) flap is a versatile flap that may be used for any defect in the body that requires soft tissue reconstruction with skin, fascia, and/or muscle. Common applications include head and neck reconstruction of larger cutaneous defects or of partial/total pharyngeal defects, where the flap may be tubed to restore alimentary tract continuity. The ALT is also useful for reconstruction of the upper or lower extremity, chest or abdominal wall, and pelvis/perineum. In many cases, the ALT flap has been used instead of the radial forearm flap for reconstruction because of a more favorable scar on the thigh than on the forearm. However, thigh tissues are usually thicker than those of the forearm, so the surgeon must choose which flap to use based upon tissue requirements.
Fibula Flap
The most common application of the free fibula flap is mandibular reconstruction after destruction/loss of the mandible after trauma or tumor excision. For head and neck tumors that involve bone and soft tissue, the free fibula osteocutaneous flap is ideal, where both bone and skin are used to reconstruct the defect. The flap may also be used to reconstruct bony defects of the midface, femur, tibia, humerus, or radius. For patients with peripheral vascular disease of the lower extremities, the fibula flap may be contraindicated, because it requires harvest of the peroneal artery. Careful pre-operative evaluation of the leg by clinical examination or by imaging is recommended to ensure that the patient has normal three-vessel anatomy and perfusion.
Latissimus Dorsi Flap
The latissimus dorsi (LD) flap may be designed as a total muscle flap, partial muscle flap based on either the transverse or descending branches of the thoracodorsal artery, or myocutaneous (muscle and skin) flap. This flap is useful for any defect in the body that requires coverage with a large, broad area or volume of tissue. Common applications include scalp reconstruction and reconstruction of the upper or lower extremities. Functional restoration of the upper extremity can be achieved with an innervated muscle flap. When used as a pedicled flap, the latissimus is very useful for breast reconstruction or for defects of the chest wall, back, or spine.
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