Deep inferior epigastric artery perforated rectus abdominis free flap for head and neck reconstruction

The deep inferior epigastric artery perforated rectus abdominis (DIEAP-ra) free flap is a modification of the classic myocutaneous DIEA free flap in which only fasciocutaneous tissue is harvested based on the paraumbilical perforators of the medial row. The aim of this retrospective study is to describe our experience with this reconstructive technique in head and neck surgery. Between 2004 and 2009, 24 patients affected by oncologic maxillofacial, skull base, oral, and oropharyngeal defects were submitted to reconstruction with DIEAP-ra. After harvesting the DIEAP-ra, the longitudinally split muscular belly was sutured and the anterior rectus sheath closed with a nonabsorbable mattress suture without inlay mesh interposition. Surgical defects encompassed half of the hard palate in ten patients, orbit and part of the cranial vault in one, radical extended parotidectomy in four, subtotal glossectomy in seven, and total glossectomy in two cases. The only complete flap necrosis (4%) developed as a consequence of an orocutaneous fistula and required a second latissimus dorsi free flap. Another case (4%) developed a partial necrosis for oropharyngeal fistula after total glossectomy that healed after transposition of a pedicled myofascial pectoralis major. Two patients (8%) presented a minor salivary fistula that healed by medication alone. No major complication of the donor site was observed. DIEAP-ra is a valid alternative to the DIEA free flap when applied to complex maxillofacial or tongue major defects. Its greatest advantages are the reduced donor site morbidity and a more adjustable thickness of the skin paddle, particularly in females and obese patients.     

Orbital exenteration reconstruction with rectus abdominis microvascular free flap

OBJECTIVES: To determine the course of reconstructive treatment and outcomes with use of the rectus abdominis free flap after orbital exenteration with or without total maxillectomy. STUDY DESIGN: Retrospective chart review of treatment and outcomes of patients who had rectus abdominis free-tissue transfer for orbital exenteration with or without total maxillectomy at the Mayo Clinic between 1994 and 2004. METHODS: Charts of patients who had rectus abdominis free flap reconstruction after orbital exenteration were retrospectively reviewed and the surgical technique evaluated. An explanation of the surgical technique for rectus abdominis free-tissue transfer to the orbital cavity is provided, along with a discussion of the advantages and disadvantages of this reconstructive method. RESULTS: Twelve of 13 patients who underwent reconstruction with rectus abdominis free-tissue transfer had a successful outcome (flap viability 92%). Cosmetic results were acceptable both to patients and to surgeons. CONCLUSIONS: Rectus abdominis microvascular free-tissue transfer for repair of orbital exenteration defects is a safe and reliable alternative to the use of the temporalis or the pectoralis major muscle as a pedicle flap; it provides a larger volume of well-vascularized tissue and greater placement flexibility without associated orientation problems; and the long vascular pedicle facilitates the use of multiple donor vessels within the head and neck, which is an advantage in previously irradiated patients. Postoperative care and the donor site defect are well tolerated. The flap allows reliable obturation of the oral maxillectomy defect, and it negates the need for cavity care in these patients.     

Lateral arm free flap in head and neck reconstruction.

The lateral arm fasciocutaneous free flap is a versatile donor site of sensate soft tissue for reconstruction and augmentation of the head and neck. The lateral arm flap can be quickly harvested without interference to the head and neck team and with minimal morbidity to the patient. For these reasons, this flap has become our soft-tissue flap of choice.     

The free scapular flap for head and neck reconstruction

The free scapular flap is a versatile flap for soft tissue and bony reconstruction of the head and neck. It has a very reliable blood supply and is easy to harvest. In this paper, we present our cumulative experience with the use of five cutaneous flaps and 31 osteocutaneous flaps.     

The ulnar fasciocutaneous free flap in head and neck reconstruction

OBJECTIVES/HYPOTHESIS: The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction. STUDY DESIGN: Prospective consecutive case series. METHODS: Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue transfer using the ulnar fasciocutaneous free flap. The male-to-female ratio was 3:1. RESULTS: Defects were located in the oral cavity (14), oropharynx (12), neck skin (1), and soft tissue of the lateral skull (3). The average size of the skin paddle that was transferred was 7 x 10 cm (range, 3 x 5 to 9 x 12 cm). The mean area of tissue that was transferred was 70 cm2 (range, 15-108 cm2). Vessel sizes were somewhat smaller than the comparable radial forearm. One patient had complete loss of the skin graft on the donor site. There were no median nerve or other wound-healing problems. Two flaps were lost in the postoperative period. Indications for use of the ulnar fasciocutaneous free flap were failed Allen's test (23), use of a less hairy part of the forearm (3), and surgical preference (4). CONCLUSIONS: The ulnar fasciocutaneous free flap has all of the tissue characteristics of the radial forearm flap. When a radial forearm flap cannot be used and forearm skin is desired, consideration of an ulnar fasciocutaneous free flap should be undertaken.     

The combined latissimus dorsi-scapular free flap in head and neck reconstruction.

Microvascular free tissue transfer techniques offer great versatility in the selection of tissue for reconstruction of head and neck defects. The system of flaps based on the subscapular artery and vein provides the widest array of composite free flaps. The possible flaps that can be harvested based on this single vascular pedicle include the scapular and parascapular skin flaps, the serratus anterior and latissimus dorsi muscle flaps, and the lateral scapular bone flap. In addition, a segment of vascularized rib can be transferred with the serratus anterior and latissimus dorsi muscles. Large cutaneous defects can be resurfaced by combining the latissimus dorsi and scapular flaps. Another advantage of this combined flap is the independent vascular pedicles of its components, which allow freedom in orientation of the various tissue segments. Thus, the combined flap can be helpful in reconstructing complex three-dimensional composite defects of the head and neck. In addition, by reinnervating the muscle portions of this flap, bulk can be preserved and an improved functional reconstruction of the oral cavity achieved. A review of the literature shows three previous reports utilizing this combination of flaps in five patients. We report the use of the combined latissimus dorsi-scapular free flap in six patients to reconstruct massive composite defects of the oral cavity, midface, and scalp. There was one flap failure, which was successfully reconstructed with the contralateral latissimus dorsi-scapular flap. The anatomy of this flap is reviewed, and the indications for its application are discussed.     

The cutaneous scapular free flap in head and neck reconstruction

Successful surgical reconstruction of complicated soft-tissue defects of the head and neck region has been greatly enhanced by free-revascularized tissue transfers. The scapular free flap has become a favored reconstructive option in our department and has been reported previously for one-stage mandibular reconstruction. This flap can also be transferred as a cutaneous free flap. We present our clinical experience with the fasciocutaneous scapular free flap and review the anatomy, surgical technique, and utility of this versatile flap.     

Lateral thigh free flap for head and neck reconstruction.

OBJECTIVES: To present the technique of lateral thigh free flap reconstruction in the head and neck and review the use of this procedure in 58 head and neck defect reconstructions. STUDY DESIGN: Retrospective review in the setting of a tertiary, referral, and academic center. METHODS: Retrospective review of patient records in cases of lateral thigh free flap reconstruction for head and neck defects. Records were reviewed for patient age, gender, pathologic findings, type of reconstruction (pharyngoesophageal, glossectomy, oropharyngeal, or external soft tissue defects), recipient and donor-site complications, and flap failure. RESULTS: Fifty-eight patients underwent lateral thigh flap reconstruction from 1984 to 1997. Patient age ranged from 10 to 76 years. Thirty-nine patients were men, and 19 were women. Forty-three flaps were used for pharyngoesophageal reconstruction, nine for glossectomy defects, two for oropharyngeal defects, and four for external, soft tissue defects. All resections were for squamous cell carcinoma, except one case of recurrent hemangiopericytoma. One flap failure occurred from venous thrombosis (1.7%). Forty-two of 43 pharyngoesophageal defects were successfully reconstructed (97.6%). Five temporary salivary leaks were noted, but no frank fistulas occurred. One fistula occurred in the oropharyngeal reconstruction group. Four minor donor-site complications were noted (6.9%). CONCLUSION: This series demonstrates the low donor-site morbidity, as well as the reliability and versatility, of the lateral thigh free flap for head and neck reconstruction.     

Microvascular free flap reconstruction for head and neck defects

In a three-year period, 53 microvascular free-tissue grafts were performed on 51 patients to repair defects following major head and neck ablative surgery or trauma. The vast majority were done at the time of tumor resection. The remainder were done as secondary operations after resection or injury. The choice of free flap was dictated by the reconstructive needs of the patient and donor site availability. Fifty-two (98%) of 53 free-tissue transfers were successful with one failure resulting from venous thrombosis. Complications were noted in 16 of 53 flaps. The majority of these complications were in flaps used to replace bony defects or oropharyngeal resections. Although free flaps may appear to be more risky than traditional forms of reconstruction, they offer the surgeon a greater spectrum of reconstructive options. Limitations of the use of free flaps result only from lack of technical skills and specialized equipment.     

Perioperative cardiac complications in patients undergoing head and neck free flap reconstruction

Background

Limited data exists on cardiac complications following head and neck free flaps.

Gracilis free flap in head and neck reconstruction beyond facial palsy reanimation

IntroductionThe gracilis muscle free flap has gained popularity in head and neck reconstruction due to minimal donor-site morbidity, reliable vascular pedicle, strong muscular component, and possibility to perform nerve coaptation. However, almost all the existing evidence in the literature is related to its use for facial palsy reanimation. The aim of this study was therefore to review and provide a comprehensive summary of all the possible indications and outcomes of this versatile free flap in head neck reconstructive surgery.Materials and methodsA systematic review of the literature was conducted including articles from 1970 to 2019. All articles were examined and described.ResultsTwenty-seven papers published between 1994 and 2019 were identified for analysis. The evidence highlights the use of the gracilis muscle free flap for parotid, forehead and midface defects, oral tongue, oral sphincter, lower and upper lip, cheek, and oral commissure defects, among others, as the most common defects reconstructed.ConclusionThis flap represents an easy to harvest and versatile free flap with low donor-site morbidity and multiple proven uses in head & neck reconstruction. We therefore encourage reconstructive surgeons to include this flap in their armoury, either as a first or as a second-line option.     

Preoperative low-molecular weight heparin chemoprophylaxis in head and neck free flap reconstruction

BackgroundThe safety of presurgical thromboprophylaxis using low molecular weight heparin (LMWH) has not been well described in head and neck oncologic surgery with free tissue transfer (HNS-FTT).MethodsRetrospective chart review of HNS-FTT patients receiving versus not receiving presurgical subcutaneous enoxaparin (Px-LMWH) was performed. Outcomes included estimated blood loss (EBL), hematoma, flap compromise, DVT or pulmonary embolus (PE). Fisher's exact test and Wilcoxon Rank Sum test were performed to compare groups. Odds ratios and associated 95 % confidence intervals were provided as appropriate.Results43 of 128 patients (34 %) received Px-LMWH. There was no significant difference in EBL, hematoma, or flap complications between groups. Patients without Px-LMWH had higher rates of DVT and PE, although the difference did not reach statistical significance (p = 1.00, 0.095, respectively).ConclusionPresurgical Px-LMWH can be used in major head and neck reconstructive surgery without increased intraoperative blood loss or postoperative complications. Larger studies will need to be done to determine the impact of Px-LMWH on DVT and PE in this patient population.Level of evidence3.     

The superior trapezius myocutaneous flap in head and neck reconstruction.

The superior trapezius myocutaneous flap, based on the paraspinous perforating branches of the intercostal vessels, is generally not a first-line choice for reconstruction of head and neck defects. However, after wound breakdown following radical neck dissection and radiation therapy, the superior trapezius flap is extremely reliable for coverage of exposed major neck vessels. The flap was used in 30 patients undergoing lateral neck reconstruction. All 30 patients had undergone prior neck dissection and all but two had undergone prior radiation therapy. There were no flap failures. The superior trapezius flap is unique among other regional myocutaneous flaps presently in use in that it has a superiorly based pedicle, which reduces the problem of gravitational pull on the suture lines of severely unfavorable recipient beds. Another advantage of using the denervated muscle of this flap is that it imposes no additional functional loss. The deficiencies of this flap are primarily related to its limited arc of rotation, thereby precluding its use when resurfacing defects that extend beyond the midline of the neck. The reliability of the superior trapezius flap after neck dissection can be explained by the angiosome concept. Based on that concept, previous ligation of the transverse cervical vessels during a neck dissection serves to simultaneously stage this flap, thereby improving its reliability and potential surface area available.     

The radial forearm flap in head and neck reconstruction

The radial forearm flap has proven to be a very reliable and versatile technique for reconstructing head and neck defects. It is of particular value where segmental defects in the mandible and intraoral mucosa exist, and in reconstructing defects within radiated tissue. The skin of the flap drapes well over the radial bone to allow denture fitting. The radial bone provides an adequate bony strut to allow essentially normal mandibular function. In a previously radiated bed, the flap (from a non-irradiated area) has the virtue of being highly vascular, thus benefiting wound healing. The lack of bulk in the flap prevents separation at the site of inset as wound healing occurs. It is a one-stage reconstruction, and since the donor site is on the upper extremity, early patient mobilization is possible. The donor defect is cosmetically acceptable, and since it lies against the body in the position of rest, it is not frequently exposed. The osseous portion of the flap in a postmenopausal woman should be approached with caution and patients should be warned of the risk of radius fracture. This flap is capable of providing tissue for reconstruction of the head and neck and should be considered for closure of all major defects, particularly those with bone defects or in defects created postirradiation.