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Free Flap Reconstruction in Head and Neck PowerPoint Presentation

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Free Flap Reconstruction of Head and Neck Defects Parag Parikh, MD UC-Irvine April 7, 2004
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Introduction Prior to 3 Decades Ago Majority of Head and Neck Defects closed with Local Tissue Local Skin Flaps from other sites to the H/N Forehead Flap…Indians then McGregor in 1963 1965 Bakamjian…Deltopectoral Flap Limited Reach
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Introduction Early 1900’s Alexis Carrel Free tissue transfer in animals (jejunum to neck) 1950’s Jacobsen and Suarez-- first anastomoses in animal 1959 Seidenberg– free jejunum segments to repair pharyngoesophageal defects 1973 Daniels and Taylor– “free flap” First free cutaneous flap
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History 1976 Baker and Panje– first free flap in head and neck cancer reconstruction Groin pedicled on the circumflex iliac artery Other cutaneous flaps Axillary Dorsalis pedis
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Introduction Free flaps grew out of favor in the late 1970s to early 80s Few donor sites Inconsistent small pedicles Technically difficult High morbidity
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Introduction Pedicled flaps grew in favor (70s and 80s) 1976 – Tansini – Latissimus dorsi Pectoralis major Trapezius Sternocleidomastoid 1979 – Ariyan – harvest rib with PMC 1979 – Demergasso and Piazza – harvest spine of the scapula with trapezius flap
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Regional Flaps Advantages/Uses: Bulky Quick and easy to harvest Single stage Minimal donor site morbidity Required one surgical team Large Tongue Base/TG Defects Carotid Coverage Disadvantages: Bulky Downward Pull of Flap Atrophy Arc of Rotation Limiting Distal Flap Necrosis
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Free Tissue Transfer 1979 – Taylor et al. – iliac crest composite flap 1980 – dos Santos et al. – scapular cutaneous flap 1981 – Yang et al. – radial forearm free flap 1982 – Nassif et al. – parascapular cutaneous flap 1982 – Song et al. – lateral arm fasciocutaneous flap 1983 – Baek et al. – lateral cutaneous thigh flap 1985 – Drever et al. – rectus Abdominis myocutaneous flap 1986 – scapular osseocutaneous flap
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Advantages of Free Tissue Transfer Two team approach Improved vascularity and wound healing Low rate of resorption Defect size little consequence Potential for sensory and motor innervation Permits use of osseointegrated implants
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Advantages of Free Tissue Transfer Wide variety of available tissue types Large amount of composite tissue Tailored to match defect Wide range of skin characteristics More efficient use of harvested tissue Immediate reconstruction
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Disadvantages of Free Tissue Transfer Technically demanding Increased operating room time Increased flap failure rate Functional disability at donor site
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Preoperative Planning Amount and type of tissue required Bone, soft tissue bulk, external vs. internal lining Anticipated functional gains History of previous surgery or injury around the donor site Donor morbidity Patient positioning and donor location Operative time Need for carotid coverage Patient factors General medical status Wishes and expectations
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Preoperative Planning Patient selection Age Diabetes Arteriosclerosis/Cardiac Tobacco use Collagen vascular disease Coagulopathies Hypercoagulable states
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Reconstructive Planning Must consider all options for particular defect and patient Options Secondary intent Primary closure Skin grafts Local flaps Myocutaneous flaps Free flaps
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Fasciocutaneous Free Flaps Radial forearm Lateral arm Lateral thigh
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Radial Forearm Free Flap Arterial source Radial artery Venous Source Paired vena commitantes and/or cephalic vein
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Radial Forearm Free Flap Forearm Radial a. w/ vena commitantes Lateral intermusc-ular septum Antebrachial cutaneous n.
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Radial Forearm Free Flap Advantages Thin, pliable skin with long, large pedicle Easy positioning Potential for sensate flap Potential for unusual shapes Potential for vascularized bone Ease of preoperative evaluation Disadvantages Loss of hand Poorly aesthetic donor site Requires skin graft Potential for pathologic fractures Loss of hand function
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Radial Forearm Free Flap Choose the nondominant hand No venous access in the chosen donor arm Avoid raising the flap over the ulnar artery Volar splint X 2 weeks 10-15 degrees of extension
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Lateral Arm Free Flap Arterial supply Posterior radial collateral artery from profunda brachii artery Venous supply Vena commitantes in spiral groove of humerus
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Lateral Arm Free Flap Advantages Low donor site morbidity (vertical scar) Easy positioning Potential for sensory innervation via posterior cutaneous nerve Disadvantages Short and smaller caliber artery (1.55 mm, up to 8-10 cm) Longer dissection than RFFF Thicker subcutaneous tissue Pressure dressing Risk to radial n.
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Lateral Thigh Free Flap Arterial supply is from third perforator of profunda femoris artery Venous output from associated vena commitantes
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Lateral Thigh Free Flap Advantages Large amount of thin, hairless skin Low donor site morbidity (primary closure) Easy positioning Sensation potential with lateral femoral cutaneous nerve Disadvantages Difficult dissection Retraction of vastus lateralis Short, variable pedicle 15 cm, 2-4mm
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Muscle and Musculocutaneous Free Flaps Rectus abdominis Latissimus dorsi
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Rectus Abdominus Free Flap Arterial supply based on deep inferior epigastric artery Venous supply form vena commitantes joining external iliac vein
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Rectus Abdominis Free Flap Versatility of the inf epig. a. Periumbilical perforators A. Transverse B. Extended C. Extended Less muscle D. Longitudinal Thick E. Subarcuate Thinner
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Rectus Abdominus Free Flap Advantages Easy positioning and harvest Constant anatomy Long (8-10 cm) and large caliber vessel (avg 3.4 mm) Donor site closed primarily Large flap obtained Anterior rectus sheath durable Disadvantages Often bulky No sensation potential Potential for hernia formation if dissection below arcuate line
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Rectus Abdominis Free Flap Preoperative evaluation Previous abdominal surgery Presence of umbilical hernia Presence of rectus diastasis
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Latissimus Dorsi Free Flap Arterial supply based on thoracodorsal artery Venous drainage from thoracodorsal vein Motor nerve innervation potential with thoracodorsal nerve
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Latissimus Dorsi Free Flap Advantages Large flap with long pedicle ( artery 2-3 mm, vein 3-5 mm, length: 7-10 cm) 2nd largest skin paddle Possibility for “axillary megaflap” Multiple skin paddles Low donor site morbidity Possibility of muscle reinnervation via thoracodorsal nerve Disadvantages Difficult positioning and two team harvest Postoperative seroma formation Bulky flap Unable to tube
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Composite Free Flaps Radial forearm Fibula Scapular/Parascapular Ilium
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Fibular Free Flap Arterial supply – peroneal artery Dual supply Endosteal Periosteal Venous supply – vena commitantes
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Fibular Free Flap Advantages Longest and strongest bone stock (25 cm of bone) Pedicle 12 cm Can be a sensate flap Lateral sural n. Low donor site morbidity Easy positioning Excellent periosteal blood supply (contouring) Support osseointegrated implants Disadvantages High incidence of peripheral vascular disease Small cutaneous paddle Decreased ankle strength and toe flexion Small risk chronic ankle pain Requires invasive study for preop. evaluation
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Fibula Free Flap Fibula is outlined Skin paddle centered over junction of middle and distal third to encompass dominant septoperforators
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Fibula Free Flap Leave 6 cm of proximal and distal fibula
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Fibula Free Flap Aberrations in blood supply (10%) Peripheral vascular disease
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Iliac Crest Free Flap Arterial supply from deep circumflex iliac artery Venous supply deep circumflex vein
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Iliac Crest Free Flap Advantages Thick bone stock Easy positioning Defect closed primarily Minimal donor deformity Support osseointegrated implants Disadvantages Bulky soft tissue component Poor reliability of skin paddle Pelvic pain and risk for hernia formation Decreased postop ambulation Risk to peritoneum
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Iliac Crest Free Flap Most commonly used for mandibular defects in the head and neck best for angle/body defects can be used for symphyseal and parasymphyseal defects
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Iliac Crest Free Flap
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Iliac Crest Free Flap Skin paddle based on cutaneous perforators must be made large enough to incorporate perforators has poor mobility Can be improved by placing the paddle more cephalad
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Iliac Crest Free Flap Postoperative care Progressive mobilization Assisted ambulation POD # 3 or 4 Stair climbing 3 weeks
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Scapular/Parascapular Free Flap Arterial supply Circumflex scapular Venous Supply Vena commitantes
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Scapular/Parascapular Free Flap Advantages Large skin paddle Easy to harvest Low donor site morbidity (closes primarily) Availability for bone Disadvantages Thick skin Difficult positioning
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Jejunum Free Flap Seidenberg (1959) - First case report in a human Roberts and Douglas (1961) – first patient to survive Primarily use for reconstruction of pharyngoesophageal defects
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Jejunum Free Flap Arterial supply from portion of superior mesenteric arterial arcade (2nd or 3rd arcade) Venous supply from venous branches along arcade
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Jejunum Free Flap Advantages Tubular Mucosal surface may help with lubrication Minimal donor defect Disadvantages Bowel or pharynx fistulas Need for laparotomy Gen. Surg. team No neovascularization Reverse peristalsis Poor TE speech Short pedicle Difficult in obese persons
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Jejunum Free Flap Contraindications Ascites History of extensive abdominal surgery Involvement of the thoracic esophagus H/o of intestinal disease (Crohn's)
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Intraoperative Management Operating microscope, instruments, sutures Irrigation supplies Anticoagulants and volume expanders No pressors Patency assessment (15-20 minutes) Pulsation Doppler
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Postoperative Management Skilled nursing important No pressure on pedicle (no ties on neck) Eliminate cooling of flap Keep head in neutral position No pressors– keep BP stable Hematocrit important Frequent inspections and doppler pedicle
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Postoperative Management Inspection and prick test Arterial vs. venous insufficiency Pharmacotherapy Heparin, dextran, aspirin
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Oral Cavity and Oropharynx Reconstruction Thin pliable mucosa Possibilities Radial Forearm Scapular/Parascapular Lateral Arm Lateral thigh
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Tongue Reconstruction Reconstruction aimed at preserving what has not been resected Less than 1/3-1/2– primary closure vs. STSG Over ½--consider free free flap if expected contracture makes speech/bolus transit difficult (sensate) Anterior 2/3–consider coned RFFF (sensate
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Tongue Reconstruction For tongue base and total glossectomy defects—need adequate oral mound to approximate with palate for speech and bolus transit May consider rectus abdominus and latissimus dorsi free flaps
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Hypopharynx and Cervical Esophageal Reconstruction Must be prepared for possibility of complete circumferential pharyngeal defect Over 3 cm remains– primary closure Less than 3 cm—pec flap vs. RFFF Total loss above thoracic inlet– tubed pec flap, RFFF, scapular FF, lateral thigh free flap, or free jejunum flap Total loss below thoracic inlet– gastric pull-up
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Mandibular Reconstruction Loss of anterior mandibular arch Loss of chin/lip support Sensory loss Malocclusion Retrognathia Lack of oral competence/eating/speaking Consider osteocutaneous free flaps-- fibula, iliac crest, scapula, radius
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Mandibular Reconstruction Loss of lateral mandible Concavity of cheek Mandible rotation to defect side with cross bite Remnant rotation superiorly and medially Mental nerve loss Easier for patient to adjust Consider osteocutaneous free flap
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