Revascularized Tissue Transfers of the Head and Neck

1. Revascularized Tissue Transfers of the Head and Neck Russell D. Briggs, M.D. Karen H. Calhoun, M.D.

2. History Early 1900�s Alexis Carrel 1950�s Jacobsen and Suarez-- first anastomoses in animal 1957 Som and Seidenberg� first free tissue transfer in humans 1972 Daniels and Taylor� �free flap�

3. History 1974 Baker and Panje� first free flap in for head and neck cancer reconstruction 1980�s osteocutaneous flaps popularized 1987 osseointegrated implants popularized 1990 sensate flaps popularized

4. 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

5. 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

6. Disadvantages of Free Tissue Transfer Technically demanding Increased operating room time Increased flap failure rate Functional disability at donor site

7. Preoperative Planning Patient selection Age Diabetes Arteriosclerosis Tobacco use Collagen vascular disease Coagulopathies Hypercoagulable states

8. Preoperative Planning Donor site selection Functional and aesthetic needs Degree of bulk Need for carotid coverage Surface area of defect External vs. internal lining Need for bone History of donor site abuse

9. Intraoperative Management Operating microscope, instruments, sutures Irrigation supplies Anticoagulants and volume expanders No pressors Patency assessment (15-20 minutes) Pulsation Doppler

10. 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

11. Postoperative Management Inspection and prick test Arterial vs. venous insufficiency Pharmacotherapy Heparin, dextran, aspirin

12. Postoperative Management Temperature measurements SPECT scanning Infrared spectroscopy Transcutaneous and intravascular devices Technicium scanning

13. Reconstructive Planning Must consider all options for particular defect and patient Options Secondary intent Primary closure Skin grafts Local flaps Myocutaneous flaps Free flaps

14. Oral Cavity and Oropharynx Reconstruction Thin pliable mucosa Possibilities Radial Forearm Scapular/Parascapular Lateral Arm Gastric Mucosa

15. Radial Forearm Free Flap Venous Source Deep venous commitantes and/or cephalic vein Arterial source Radial artery

16. Radial Forearm Free Flap Advantages Thin 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

17. Radial Forearm Free Flap