Principles of Microvascular Free Tissue Transfer For Soft Tissue Reconstruction of the Oral Cavity, Pharynx and Larynx

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Principles of Microvascular Free Tissue Transfer For Soft Tissue Reconstruction of the Oral Cavity, Pharynx and Larynx

Head and Neck Surgery
Author Credentials 

Kelly Michele Malloy, MD
Associate Professor; Director, Head and Neck Surgical Oncology and Microvascular Reconstruction Fellowship
Department of Otolaryngology- Head and Neck Surgery 
University of Michigan
Ann Arbor, MI
kellymal@med.umich.edu

Module Summary

Head and neck ablative surgery imparts significant functional and cosmetic impact on patients. Sot tissue free flap reconstruction provides reliable replacement tissues to reconstruct these complicated defects. An understanding of the tissue characteristics and function of the resected organs is essential to proper flap selection and design. Moreover, head and neck surgical wounds can often be complicated by contamination and fistula due to their location within the aerodigestive tract. This module provides the basic anatomy, physiology, pros, cons and complications of soft tissue free flap harvest and reconstruction from which a deeper understanding of complex mucosal and cutaneous head and neck reconstruction can be developed.

Module Learning Objectives 
  1. Name the most common free flaps used in mucosal head and neck reconstruction, including the vascular anatomy and the tissue qualities that each flap provides. 
  2. Apply the appropriate soft tissue flap reconstruction to common mucosal head and neck defects.
  3. Diagnose flap-related complications, including vascular compromise, donor site morbidity, and functional consequences. 
     

Embryology

Learning Objectives 

Name the congenital anomalies that may impact soft tissue flap harvest

  1. Radial artery anomalies
  2. Congenital absence of palmaris longus tendon
References 
  1. Porter CJ, Mellow CG. Anatomically aberrant forearm arteries: an absent radial artery with co-dominant median and ulnar arteries. Br J Plast Surg. 2001;54:727-8. [EBM Level 5]
  2. Carroll CM, Pathak I, Irish J, Neligan PC, Gullane PJ. Reconstruction of total lower lip and chin defects using the composite radial forearm--palmaris longus tendon free flap. Arch Facial Plast Surg. 2000 Jan-Mar;2(1):53-6. [EBM Level 4]

Anatomy

Learning Objectives 
  1. Catalogue the available soft tissue flap armamentarium with respect to:
    • Flap soft tissue characteristics: bulk, pliability and epithelial lining
    • Neurovascular anatomy
    • Pedicle length
    • Donor site morbidity
    • Availability of a source for nerve grafting
    • Simultaneous two-team harvest
    • Free versus pedicled flap opportunities
  2. Describe the angiosome principle:
    • Primary angiosome
    • Angiosome once removed
    • Angiosome twice removed
    • Choke vessel connections between angiosomes
  3. Classify soft tissue flaps by tissue type:
    • Fascial and fasciocutaneous
    • Myogenous and myocutaneous
    • Enteric
  4. Analyze common defects of the head and neck anatomy with respect to the specific tissue and functions affected:
    • Oral cavity: glossectomy, floor of mouth, buccal mucosa
    • Oropharyngeal
    • Laryngeal, hypopharyngeal and cervical esophagus
    • Cervical soft tissue
    • Scalp
    • Facial tissues (e.g. major lip, nasal, cheek defects)
References 
  1. Urken ML, Cheney ML, Blackwell KE, Harris JR, Hadlock TA, Futran N. Regional and Free Flaps for Head and Neck Reconstruction: Flap Harvest and Inseting. 2nd ed. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2012.
  2. Urken ML. Multidisciplinary Head and Neck Reconstruction: A Defect-Oriented Approach. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2009.
  3. Neligan PC and Wei FC. Microsurgical Reconstruction of the Head and Neck. New York: Thieme; 2009. 
  4. Genden EM. Reconstruction of the Head and Neck: A Defect-Oriented Approach. New York: Thieme; 2012.

Pathogenesis

Learning Objectives 
  1. Anticipate surgical defects based on pre-operative physical exam and imaging characteristics.
  2. Explain general reconstructive goals for head and neck defects, including functional restoration, durability, optimal aesthetics, limited donor site morbidity, and quality of life enhancement.
  3. Indicate how these goals are accomplished by various reconstructive approaches.
  4. Describe the reconstructive ladder for the following defects:
    • Oral cavity
      • Partial glossectomy
      • Hemiglossectomy
      • Total/subtotal glossectomy 
      • Floor of mouth defect without bone resection
      • Palate defects
      • Buccal/cheek defects
      • Subtotal lip defects
    • Oropharyngeal
    • Total laryngectomy with and without external skin loss
    • Laryngopharyngectomy
    • Total parotidectomy defect with or without facial nerve resection
    • Orbital extenteration, soft tissue only
    • Resection of anterior skull base
References 

Urken ML. Multidisciplinary Head and Neck Reconstruction: A Defect-Oriented Approach. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2009.
Genden EM. Reconstruction of the Head and Neck: A Defect-Oriented Approach. New York: Thieme; 2012.

Basic Science

Learning Objectives 
  1. Discuss the general principles of sound microsurgical technique
    • Specialized training
    • Microsurgical preparation of donor and recipient vessels
    • End-to-end and end-to-side anastomoses
    • Management of vessel caliber mismatch
    • Pedicle geometry
    • Indications for vein grafts
  2. Distinguish the different elements that contribute to flap vessel thrombosis
    • Clotting factors
    • Platelets
    • Pedicle kinking or tension
    • Wound contamination from fistula/infection
  3. Explain the concept of ischemia-reperfusion injury and understand the relevance to reconstruction with microvascular free tissue transfer
References 
  1. Esclamado RM, Carroll WR. The pathogenesis of vascular thrombosis and its impact in microvascular surgery. Head Neck. 1999 Jul;21(4):355-62.
  2. Carroll WR, Esclamado RM. Ischemia/reperfusion injury in microvascular surgery. Head Neck. 2000 Oct;22(7):700-13.

Genetics

Learning Objectives 

Understand how genetic clotting disorders can affect free flap management 

  • Hypercoagulable disorders:
    • Proteins C & S deficiencies
    • Factor V Leiden mutation
    • Antiphospholipid antibody syndrome
    • Anticardiolipin antibody syndrome
    • Prothrombin gene mutation
    • Hyperhomocysteinemia
    • Factor VIII elevation
    • Essential thrombocytosis
References 
  1. Wang TY, Serletti JM, Cuker A, McGrath J, Low DW, Kovach SJ, Wu LC. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg. 2012 Feb;129(2):443-53. [EBM Level 4]

Patient Evaluation

Learning Objectives 
  1. Assess patient’s overall health, functional status, comorbidities
    • Tolerance of a long anesthetic event
    • Tolerance of donor site morbidity
    • Vascular health
    • Prothombotic states
    • Dental status and goals for dental rehabilitation
  2. Identify appropriate pre-operative evaluations to assess candidacy for specific free flap donor sites
    • Radial forearm flap: 
      • Allen’s test
      • Ultrasound with digital pressures
    • Rectus abdominus flap:
      • Previous abdominal surgery, hernia, diastasis recti
    • All fasciocutaneous donor sites:
      • Assess potential flap thickness and pliability with respect to body habitus
  3. Explain the importance of nutrition and identify methods to optimize prior to advanced reconstructive surgery.
  4. Predict and prepare for wound healing issues related to previous head and neck radiation, including the impact of radiation-related hypothyroidism
References 
  1. Benatar MJ, Dassonville O, Chamorey E, Poissonnet G, Ettaiche M, Pierre CS, Benezery K, Hechema R, Demard F, Santini J, Bozec A. Impact of preoperative radiotherapy on head and neck free flap reconstruction: a report on 429 cases. J Plast Reconstr Aesthet Surg. 2013 Apr;66(4):478-82 [EBM Level 4].
  2. Lo SL, Yen YH, Lee PJ, Liu CC, Pu CM. Factors Influencing Postoperative Complications in Reconstructive Microsurgery for Head and Neck Cancer. J Oral Maxillofac Surg. 2017  [EBM Level 4]
  3. Rosko AJ, Birkeland AC, Bellile E, Kovatch KJ, Miller AL, Jaffe CC, Shuman AG, Chinn SB, Stucken CL, Malloy KM, Moyer JS, Casper KA, Prince MEP, Bradford CR, Wolf GT, Chepeha DB, Spector ME. Hypothyroidism and Wound Healing After Salvage Laryngectomy. Ann Surg Oncol. 2017 Dec 20. Epub ahead of print. [EBM Level 4]
  4. Dort JC, Farwell DG, Findlay M, Huber GF, Kerr P, Shea-Budgell MA, Simon C, Uppington J, Zygun D, Ljungqvist O, Harris J. Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society. JAMA Otolaryngol Head Neck Surg. 2017 Mar 1;143(3):292-303. [EBM Level 4]

Measurement of Functional Status

Learning Objectives 

Assess patient’s functional age and comorbidity risk using tools such as the American Society of Anesthesiologists (ASA) score, rather than simple chronologic age, when considering microvascular surgery.

References 
  1. Jubbal KT, Zavlin D, Suliman A. The effect of age on microsurgical free flap outcomes: An analysis of 5,951 cases. Microsurgery. 2017 Nov;37(8):858-864. [EBM Level 4]
  2. Ehrl D, Heidekrueger PI, Ninkovic M, Broer PN. Effect of Preoperative Medical Status on Microsurgical Free Flap Reconstructions: A Matched Cohort Analysis of 969 Cases. J Reconstr Microsurg. 2018 Mar;34(3):170-175 [EBM Level 4]

Imaging

Learning Objectives 
  1. Order and interpret appropriate preoperative imaging to assist with operative planning and flap selection:
    • Vascular studies
      • CTA/MRA/ultrasound Doppler studies for arterial assessments
    • CT neck with contrast
      • Anticipate soft tissue defect based on primary tumor extension
      • Assess for bony involvement by tumor and need to reconsider bone flap
      • Assess vessels for microvascular anastomosis, particularly in revision surgery and/or vasculopathic patients
  2. Interpret appropriate postoperative imaging to assist with functional rehabilitation
    • Video fluoroscopic swallowing study (VFSS)/modified barium swallow (MBS)
  3. Assess for tongue, pharyngeal and esophageal function following flap reconstruction of the upper aerodigestive tract
  4. Guide rehabilitation therapy and assess response
     
References 
  1. Dziegielewski PT, Ho ML, Rieger J, Singh P, Langille M, Harris JR, Seikaly H. Total glossectomy with laryngeal preservation and free flap reconstruction: objective functional outcomes and systematic review of the literature. Laryngoscope. 2013 Jan;123(1):140-5 [EBM Level 4]
  2. Rieger JM, Zalmanowitz JG, Li SY, Sytsanko A, Harris J, Williams D, Seikaly H. Functional outcomes after surgical reconstruction of the base of tongue using the radial forearm free flap in patients with oropharyngeal carcinoma. Head Neck. 2007 Nov;29(11):1024-32. [EBM Level 4]

Treatment

Learning Objectives 

Select appropriate soft tissue flap reconstruction for various head and neck defects:

  • Pharyngoesophageal: 
    • Anterolateral thigh 
    • Radial forearm
    • Gastro-omental
    • Jejunum
  • Oropharynx: 
    • Radial forearm
    • Gastro-omental
    • Lateral arm
    • Anterolateral thigh
  • Partial and hemiglossectomy: 
    • Radial forearm
    • Ulnar
    • Anterolateral thigh
    • Scapular/parascapular
    • Lateral arm
  • Near total/total glossectomy: 
    • Anterolateral thigh
    • Rectus abdominis
    • Latissimus dorsi
  • Lateral skull base/skull base: 
    • Radial forearm
    • Anterolateral thigh
    • Latissimus dorsi
    • Omentum
  • Anterior skullbase: 
    • Anterolateral thigh
    • Radial forearm
    • Temporoparietal
  • Large surface defect (e.g. scalp):
    • Latissimus dorsi
      • Myocutaneous or muscle alone with split thickness skin graft
    • Anterolateral thigh
    • Omentum
References 
  1. Chepeha DB, Sacco AG, Erickson VR, Lyden T, Haxer M, Moyer J, Teknos TN, Prince ME, Eisbruch A, Bradford CR, Wolf GT. Oropharyngoplasty with template-based reconstruction of oropharynx defects. Arch Otolaryngol Head Neck Surg. 2009 Sep;135(9):887-94 [EBM Level 4]
  2. Chepeha DB, Teknos TN, Shargorodsky J, Sacco AG, Lyden T, Prince ME, Bradford CR, Wolf GT. Rectangle tongue template for reconstruction of the hemiglossectomy defect. Arch Otolaryngol Head Neck Surg. 2008 Sep;134(9):993-8 [EBM Level 4]
  3. Lin DT, Yarlagadda BB, Sethi RK, Feng AL, Shnayder Y, Ledgerwood LG, Diaz JA, Sinha P, Hanasono MM, Yu P, Skoracki RJ, Lian TS, Patel UA, Leibowitz J, Purdy N, Starmer H, Richmon JD. Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy. JAMA Otolaryngol Head Neck Surg. 2015 Sep;141(9):797-803 [EBM Level 4]
  4. Chang EI, Yu P, Skoracki RJ, Liu J, Hanasono MM. Comprehensive analysis of functional outcomes and survival after microvascular reconstruction of glossectomy defects. Ann Surg Oncol. 2015 Sep;22(9):3061-9 [EBM Level 4]
  5. Selber JC, Xue A, Liu J, Hanasono MM, Skoracki RJ, Chang EI, Yu P. Pharyngoesophageal reconstruction outcomes following 349 cases. J Reconstr Microsurg. 2014 Nov;30(9):641-54 [EBM Level 4]
  6. Patel RS, Makitie AA, Goldstein DP, Gullane PJ, Brown D, Irish J, Gilbert RW. Morbidity and functional outcomes following gastro-omental free flap reconstruction of circumferential pharyngeal defects. Head Neck. 2009 May;31(5):655-63. [EBM Level 4]

Pharmacology

Learning Objectives 

Determine the role of antithrombotic therapy in free tissue transplantation

  • Routine prophylaxis has no demonstrated benefit, but may be utilized as per surgeon preference
  • Use of various agents is common in cases of flap compromise
    • Aspirin
    • Heparin
    • Medicinal leeches
References 
  1. Lighthall JG, Cain R, Ghanem TA, Wax MK. Effect of postoperative aspirin on outcomes in microvascular free tissue transfer surgery. Otolaryngol Head Neck Surg. 2013 Jan;148(1):40-6. (EBM Level 4]
  2. Reiter M, Kapsreiter M, Betz CS, Harréus U. Perioperative management of antithrombotic medication in head and neck reconstruction-a retrospective analysis of 137 patients. Am J Otolaryngol. 2012 Nov-Dec;33(6):693-6.
  3. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN. Leech therapy for patients with surgically unsalvageable venous obstruction after revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg. 2002 Aug;128(8):960-5.

Surgical Therapies

Learning Objectives 
  1. Describe the relevant anatomy, including the arterial, venous and potential nerve supply or each of the following fascial/fasciocutaneous/myocutaneous free flaps 
    • Radial forearm free flap 
    • Ulnar forearm free flap 
    • Lateral arm flap
    • Anterolateral thigh flap 
    • Lateral thigh flap
    • Temporoparietal fascial flap
    • Rectus abdominis flap
    • Latissimus dorsi flap
    • Scapular/parascapular flap 
    • Jejunal free flap
    • Gastro-omental free flap
  2. Compare and contrast the above flaps with respect to quality of soft tissue (pliability, bulk), pedicle length, and donor site morbidity.
References 
  1. Urken ML, Cheney ML, Blackwell KE, Harris JR, Hadlock TA, Futran N. Regional and Free Flaps for Head and Neck Reconstruction: Flap Harvest and Inseting. 2nd ed. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2012.

Rehabilitation

Learning Objectives 

Anticipate and diagnose pertinent rehabilitative issues in patients undergoing soft tissue flap reconstruction 

  • Operative morbidity at the head and neck reconstructive site
    • Poor articulation
      • Loss of tongue protrusion and premaxillary contact
      • Loss of tongue volume
      • Worse if defect involves tongue tip
    • Dysphonia/aphonia
      • Voice restoration (tracheoesophageal puncture)
    • Dysphagia
      • Oral incompetence
      • Poor oral phase of swallow
        • Inability to clear floor of mouth sulci
        • Inability to obliterate the oral cavity
        • Velopharyngeal insufficiency
        • Poor laryngeal elevation and pharyngeal phase
        • Pharyngoesophageal stricture
        • Aspiration as possible consequence of above
    • Pain
  • Donor site morbidity
    • Ambulation rehabilitation for thigh donor sites
    • Shoulder rehabilitation for scapular and latissimus donor sites
    • Ambulation and postoperative pulmonary toilet for rectus and latissimus donor sites
    • Tendon exposure, loss of grip strength, cold intolerance for forearm donor sites
    • Pain
  • Rehabilitative services
    • Speech pathology
    • Swallow therapy
    • Physical therapy
    • Occupational therapy
    • Oral surgery and prosthedontics
    • Anesthesia/pain services
References 
  1. Sethi RKV, Deschler DG. National trends in primary tracheoesophageal puncture after total laryngectomy. Laryngoscope. 2017 Dec 27. [EBM Level 4]

Case Studies

  1. 64-year-old man with recurrent T3N0M0 SCC of right piriform sinus; had chemoradiation 18 months ago. Continues to smoke, poorly controlled diabetic.
    • Will require total laryngopharyngectomy (TLP).
    • Options include tubed radial forearm flap, anterolateral thigh flap, gastro-omental flap or jejunal free flap.
    • In patients who are “low risk” for salivary fistula:
      • Primary TLP, or previous radiation only
      • Body habitus is main selection factor:
        • Anterolateral thigh tubed flap if BMI is within normal
        • Radial forearm tubed flap if BMI is high
    • In “high risk” patients:
      • Chemoradiation failure, hyperfractionated radiation, previous tracheostomy, anticipated loss of anterior neck skin
      • Consider gastro-omental flap as the omentum provides support/replacement of skin while isolating great vessels from potential fistula
  2. 40-year-old man with newly diagnosed T2N1M0 SCC right oral tongue. Works as a carpenter, nonsmoker. Body habitus is stocky, but concerned about manual dexterity given his profession. Right-hand dominant.
    • Will require hemiglossectomy, extending to tongue tip and margin will include ipsilateral floor of mouth.
    • Anterolateral thigh, radial forearm, and scapular/parascapular flaps are all feasible.
    • Must assess donor sites for skin and soft tissue volume, pliability and discuss donor site morbidity frankly with these patients
    • Left (nondominant) radial forearm flap selected for rectangle tongue reconstruction.
  3. 62-year-old woman with advanced sinonasal carcinoma with extensive skull-base and unilateral orbital involvement.
    • Will require craniofacial resection with orbital exenteration and excision of facial skin. Skull-base and dural reconstruction will be critical.
    • Myocutaneous flap with long pedicle desired. 
    • Best options include rectus abdominis and latissimus dorsi. 
References 
  1. Patel RS, Goldstein DP, Brown D, Irish J, Gullane PJ, Gilbert RW. Circumferential pharyngeal reconstruction: history, critical analysis of techniques, and current therapeutic recommendations. Head Neck. 2010 Jan;32(1):109-20 [EBM Level 5]
  2. Chepeha DB, Spector ME, Chinn SB, Casper KA, Chanowski EJ, Moyer JS, Morrison R, Carvill E, Lyden TH. Hemiglossectomy tongue reconstruction: Modeling of elevation, protrusion, and functional outcome using receiver operator characteristic curve. Head Neck. 2016 Jul;38(7):1066-73 [EBM Level 4]

Complications

Learning Objectives 
  1. Recognize flap compromise and intervene for salvage
  2. Manage wound complications at both the transplant and donor sites
    • Flap vascular compromise
      • Arterial insufficiency from spasm or clot
        • Cool, pale skin paddle with slow or no capillary refill
        • No blood on pinprick
      • Venous compression or thrombosis
        • Blue or purple skin paddle; tense, turgid flap with flash capillary refill
        • Fast, dark blood on pinprick
      • Both situations mandate return to the OR 
    • Defect site
      • Hematoma/seroma
      • Fistula
      • Partial flap loss
      • Complete flap loss
    • Flap monitoring techniques
      • Direct tissue observation, including pinprick
      • External tissue monitoring island for buried flaps
      • Doppler signal over pedicle and/or perforator
      • Implanted Doppler probes on pedicle
    • Donor site
      • Hematoma/seroma
      • Wound dehiscence
      • Tendon exposure – forearm flaps
      • Neuropraxia – radial forearm
      • Abdominal hernia - rectus
      • Compartment syndrome – thigh flaps
References 
  1. Urken ML, Cheney ML, Blackwell KE, Harris JR, Hadlock TA, Futran N. Regional and Free Flaps for Head and Neck Reconstruction: Flap Harvest and Inseting. 2nd ed. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2012.
  2. Urken ML. Multidisciplinary Head and Neck Reconstruction: A Defect-Oriented Approach. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2009.
  3. Neligan PC and Wei FC. Microsurgical Reconstruction of the Head and Neck. New York: Thieme; 2009. 
  4. Genden EM. Reconstruction of the Head and Neck: A Defect-Oriented Approach. New York: Thieme; 2012.
     

Review

References 
  1. Name six soft tissue flaps commonly used in head and neck reconstruction, and give an appropriate example of their use for each.
  2. Name the primary vascular pedicle for each of the above.
  3. List the advantages and disadvantages of each donor site.
  4. Give 2 examples of how to reconstruct a hemiglossectomy defect.
  5. Give 2 examples of how to reconstruct a total laryngopharyngectomy defect.
  6. Describe the angiosome principle and how it relates to free flap design.
Resources 

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