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Regional and Free Flaps


Key Points

  • 1.

    Every reconstructive plan should be tailored to the individual patient, taking into consideration not only the unique defect but also other perioperative and patient factors.

  • 2.

    The ideal plan for one patient may not work for another.

  • 3.

    Before surgery, always consider patient comorbidities (heart/lung disease, perioperative risk) and optimize patients for healing (diabetes control, thyroid-stimulating hormone [TSH], nutrition [albumin/pre-albumin], cessation of nicotine use, and psychosocial support).

  • 4.

    When deciding on a reconstructive plan, always consider previous surgeries that the patient has had, donor site morbidity, and the patient’s lifestyle and hobbies, in addition to general flap characteristics.

  • 5.

    In general, both regional pedicled and free tissue flaps are very reliable and allow successful reconstruction of complex defects in the head and neck.

  • 6.

    Remember that defect reconstruction does not have to occur at the time of injury; some cases may be better served with a delayed reconstruction, either all together or in part.

  • 7.

    When choosing a flap, consider donor site morbidity, tissue type the flap provides and tissue type being reconstructed, bulk of the flap, and pedicle length.

  • 8.

    When evaluating the defect, consider whether it should be altered or expanded for an improved cosmetic outcome and consider nearby features that are important not to distort or alter (e.g., facial subunits).

  • 9.

    Not every large defect is best served with regional/free flap reconstruction, and not every small defect is best served with local tissue rearrangement.

  • 10.

    Even if a defect could be closed with local tissue rearrangement, a regional or free flap may be preferable if it can:

    • a.

      prevent distortion of facial features

    • b.

      prevent undesirable tissue tethering or deformity

    • c.

      allow easier healing by transferring well-vascularized, nonirradiated tissue into a wound.

Pearls

  • 1.

    Free flaps

    • Advantages

      • Maximally versatile positioning, minimal bulk around the pedicle, osteocutaneous reconstruction, minimal distortion of surrounding features and tissues, reliable

    • Disadvantages

      • Operative time, time in hospital, microsurgical training, possible second surgical team

  • 1.

    Regional pedicled flaps

    • Advantages

      • Shorter operating times, no microsurgical training necessary, can be used in vessel-depleted areas, reliable

    • Disadvantages

      • Limited position and reach given pedicled base, cosmetically undesirable bulk around the pedicle, few-to-no options for osteocutaneous reconstruction

  • 3.

    Remember to evaluate if a patient needs a temporary tracheostomy or feeding tube.

Questions

1

What is a regional or regional pedicled flap?

A regional flap is any group of tissue that is nourished by a named artery that can be surgically separated from its surrounding tissue and rotated, transposed, or interpolated into a new position. A regional flap remains pedicled at its base around the vessel(s) that provide(s) its nutrition.

2

What are common regional flaps in head-and-neck reconstruction?

Pectoralis, deltopectoral, sternocleidomastoid (SCM), supraclavicular, trapezius, paramedian forehead, nasolabial, latissimusdorsi, submental, temporoparietofascial (TPF), abbe, temporalis ( Table 68.1 ).

Table 68.1
Common Regional Flaps for Head and Neck Reconstruction
NAME AND TYPE PEDICLE CHARACTERISTICS AND USES
Pectoralis major (myocutaneous, myofascial) Thoracoacromial artery
  • -

    Simple harvest with or without skin

  • -

    Can easily reach the neck, occasionally reach the lower face

  • -

    Can be very bulky

  • -

    Shearing of skin paddle during harvest may lead to damage of perforating vessels and partial flap loss

  • -

    Can disfigure the breast and be aesthetically undesirable, especially for women

  • -

    Can be harvested with rib cartilage or bone for osteocutaneous reconstruction (but rib viability is often unreliable)

Deltopectoral (fasciocutaneous) Internal mammary artery, perforating branches (2nd and 3rd)
  • -

    Simple harvest

  • -

    Often used for cutaneous defects of the lower neck

  • -

    May require a skin graft for donor site closure

  • -

    Can be prone to distal-tip necrosis, especially when extended over the deltoid

Latissimus dorsi (myocutaneous, myofascial) Thoracodorsal artery
  • -

    Used for large cutaneous defects of the face, neck, and scalp

  • -

    Used for smile reanimation

  • -

    Can be harvested with the patient in a supine or prone position

  • -

    Can be very bulky if harvested with skin or thin and pliable if only muscle is harvested

  • -

    Can be pedicled or free

  • -

    Can have relatively small-caliber pedicle vessels

Trapezius (myocutaneous, myofascial) Transverse cervical artery
  • -

    Used for cutaneous defects of the posterior and lateral neck or lower face

  • -

    Can be harvested off the transverse or descending branches

  • -

    May have a short arc of rotation and variable vascular anatomy

  • -

    May need lateral decubitus positioning or intraoperative position changes for harvest and inset

Supraclavicular (fasciocutaneous) Supraclavicular artery
  • -

    Used for cutaneous defects of the neck and lower face

  • -

    In some cases can reach the oral tongue, buccal mucosa, and soft palate

  • -

    Has excellent color match for facial defects

  • -

    Can be prone to distal tip necrosis

Temporoparietal fascia (fascia only) Superficial temporal artery
  • -

    Used in facial and skull base defects and microtia repair

  • -

    Very thin, durable, and highly vascular

  • -

    Harvest can risk damage to the frontal branch of the facial nerve and alopecia from hair follicle damage

Temporalis (myofascial) Deep temporal artery
  • -

    Used for facial and skull base defects

  • -

    Very robust, durable, reliable

  • -

    Carries a risk of aesthetic deformity from temporal wasting

Abbe (myocutaneous) Labial artery
  • -

    Full-thickness lip reconstruction

Nasolabial (fasciocutaneous) Angular artery
  • -

    Used for cutaneous defects of the nose or cheek and oral cavity defects of the buccal mucosa and lips

Inferior turbinate (mucosal) Angular artery (anteriorly), branches of the sphenopalatine artery (posteriorly)
  • -

    Used for intranasal and septal defects

  • -

    Can be anteriorly or posteriorly based

Paramedian forehead (fasciocutaneous) Supratrochlear artery
  • -

    Nasal reconstruction

Submental (myocutaneous) Submental artery
  • -

    Oral cavity defects

  • -

    Risk of failure to remove malignant cells when used for reconstruction of defects from oral cavity cancer resection

Sternocleidomastoid (myofascial, myocutaneous) Occipital artery (superior third), superior thyroid artery (middle third), transverse cervical artery (inferior third)
- 2 of 3 vessels need to be preserved
  • -

    Can be pedicled superiorly or inferiorly

  • -

    Used for oral and pharyngeal defects and cutaneous defects of the neck and face

  • -

    Can have poor viability of the skin flap due to variable vessel anatomy

  • -

    Donor site contour abnormality

Latissimus dorsi (myofascial, myocutaneous) Thoracodorsal artery and vein
  • -

    Used for neck and lower face defects

  • -

    May require intraoperative position changes

3

What are the advantages of regional flap reconstruction?

  • Does not require microsurgical anastomosis or training for use

  • Can provide a large amount of tissue for reconstruction

  • Can provide an optimal match of skin tone and texture

  • Can be used in a vessel-depleted neck that lacks suitable local vessels required for free flap anastomosis

  • Often completed with shorter operating/anesthesia times than free flaps

4

What are disadvantages of regional flap reconstruction?

  • This can result in undesirable donor site morbidity and scarring. For example, a pectoralis myocutaneous or myofascial regional flap distorts the breast, which may be concerning, particularly for female patients.

  • Can have bulkiness at the pedicle with an undesirable cosmetic outcome

  • Are more at risk for distal tip necrosis from poor perfusion

  • Are limited in their positioning and reach, given that they are reliant on their pedicled base

5

What is a free flap, aka free tissue transfer?

A free flap is any group of tissue that is nourished by a named artery and can be harvested, its artery and vein ligated, for transfer to a completely separate part of the body. The artery and vein(s) supplying a free flap are cut, thus making the tissue completely free from any attachments. The artery and vein require anastomosis to local vessels in the area of transfer to reestablish nutritional inflow and outflow and flap survival.

6

What are common free flaps used in head and neck reconstruction?

Radial forearm, fibula, anterolateral thigh (ALT), rectus abdominis, latissimus dorsi, scapula/parascapular, lateral arm, jejunum, gracilis, sternohyoid/omohyoid ( Table 68.2 ).

Table 68.2
Common Microvascular Free Flaps for Head and Neck Reconstruction
NAME AND TYPE PEDICLE CHARACTERISTICS and USES
Radial forearm (fasciocutaneous, osteocutaneous) Radial artery, venae comitantes ± cephalic vein
  • -

    Thin and pliable with a long pedicle

  • -

    Versatile, with numerous uses including oral cavity, tongue, palate, face, pharynx, and larynx

  • -

    Often good color match for head and neck defects

  • -

    Need for donor site skin graft

  • -

    Rare risk of hand ischemia

Anterolateral thigh (myocutaneous, septocutaneous) Descending branch of lateral circumflex femoral artery, venae comitantes
  • -

    Pliable with a long pedicle

  • -

    Large surface area

  • -

    Versatile

  • -

    Very bulky in some patients, thin in others

  • -

    Variable pedicle course can make harvest challenging

Rectus abdominis (myocutaneous, myofascial) Deep inferior epigastric artery and vein
  • -

    Often very bulky

  • -

    Used when reconstruction requires tissue volume (such as total glossectomy and skull base defects)

  • -

    Risk of abdominal hernia

Fibula (osteocutaneous – can be harvested with or without a skin paddle) Peroneal artery and vein
  • -

    Most common flap used for osteocutaneous reconstruction (mandibular and maxillary repair)

  • -

    Risk of ankle pain and instability

  • -

    Risk of foot ischemia

Scapular/parascapular (fasciocutaneous, osteocutaneous) Circumflex scapular artery and vein
  • -

    Harvest can include muscle, skin, and bone

  • -

    Flexibility for 3D reconstruction

  • -

    Used for closing large, complex midface and oromandibular defects or when fibular harvest is contraindicated

  • -

    Lateral decubitus positioning during surgery (risk of brachial plexus injury)

  • -

    Risk of shoulder weakness

  • -

    Can be combined with latissimus dorsi harvest for a mega flap

  • -

    Can be harvested as a chimeric flap with separate skin paddles

Lateral arm (fasciocutaneous) Profunda brachii artery, venae comitantes
  • -

    Thickness depends on patient BMI

  • -

    Used for oropharyngeal and cutaneous defects

  • -

    Can have a small-caliber pedicle

  • -

    Risk of radial nerve palsy

Latissimus dorsi (myofascial, myocutaneous) Thoracodorsal artery and vein
  • -

    Used for skull base and scalp defects, facial reanimation

  • -

    Useful for large, thin defects

  • -

    May require intraoperative position changes

Jejunum (enteral) Branches of the superior mesenteric artery and vein
  • -

    Used for circumferential pharyngoesophageal defects

  • -

    Peristalsis affects swallowing

  • -

    Production of succus entericus can cause dysgeusia and interfere with voice rehabilitation

  • -

    Tolerates a shorter ischemia time (2 h)

Gracilis (myofascial) Adductor artery and venae comitantes, obturator nerve
  • -

    Facial reanimation

  • -

    Can add unnatural bulk to the face

Sternohyoid/omohyoid (myofascial) Superior thyroid artery, middle thyroid vein, ansa cervicales
  • -

    Facial reanimation

  • -

    Fast twitch, synchronous smile rehabilitation

  • -

    Adds minimal bulk to the face

7

What are the advantages of free flap reconstruction?

  • Maximally versatile in terms of positioning, tissue bulk, tissue pliability/quality given the many donor options

  • Can achieve excellent cosmetic and functional results

  • Generally very reliable

  • Does not have a bulky pedicle

  • Variability of donor site and donor site morbidity

8

What are the disadvantages of free flap reconstruction?

  • Requires microsurgical vessel anastomosis

  • Often requires longer operating room/anesthesia times

  • May require a second surgical team

  • Often requires longer stays in the ICU and longer stays in the hospital after surgery

9

What does it mean for a flap to be called fasciocutaneous, myocutaneous, myofascial, or osteocutaneous?

These terms refer to the different tissue types transferred. A fasciocutaneous flap includes transfer of skin and underlying fascia. A myocutaneous flap includes transfer of skin and muscle. Similarly, a myofascial flap includes transfer of muscle with its fascia but no cutaneous components. An osteocutaneous flap includes skin and bone. While different flaps can include multiple angiosomes, perforators, or branching vessels that supply subsections of the overall flap, all tissue transferred is based on a single, dominant arteriovenous pedicle.

10

What is a perforator flap?

A perforator flap is one based on a perforating artery or an artery that travels through fascial planes to supply tissue. An ALT, for example, is a type of perforator flap, as the vessels supplying the skin perforate through the underlying muscle and fascia.

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