Microvascular Flaps Brian B. Burkey and John R. Coleman, Jr. surgeons witnessed a tremendous evolution inthe recon- struction of postsurgical, traumatic, and congenital de- fects, The era of microvascular reconstruction became evident inthe early 1970s, Refinements in technique, donor sites, and surgical skills have led to the widespread use of free-tissue transfer. Most patient series reporied in the last3 years detail a success rate of 95% or greater, and most major medical cen- ters have either head and neck surgeons, plastic surgeons, or both who are well versed in multiple lap options to recon- struct head and neck defects. ‘The purpose of this chapter isto provide the reader with an overview of microvascular freetissue transfer. We will is- «cuss surgical technique, flap monitoring, and management of flap failure. We will then examine 10 donor sites that are com- ‘monly used, discussing the anatomy, surgical technique, and advantages and disadvantages of each flap. The chapter will conclude witha review of functional sites in the head and neck and the different flaps that might be used in each location. I: the latter half of the twentieth century, head and neck PERIOPERATIVE MANAGEMENT Surgical Technique To achieve a successful transfer of free tissue, the microvas- cular surgeon must use meticulous technique to ensure appropriate harvest of the flap, handling and preparation of the vessels, anastomosis of the vessels, and insettng of the flap with attention to vessel, geometry Flap Harvest Successful transfer of free tissue begins with the flap harvest A deéailed knowledge of the anatomy and elevation planes, allows an efficient and safe harvest, The surgeon must respect the location of the vascular pedicle and protect the pedicle during the harvest. It is imperative to avoid separating the pedicle from the tissue to be transferred, All branches and perforators not included with the flap should be separated from the pedicle at the greatest distance possible. Surgical clips, bipolar electrocautery, and surgical ties are all accept- able options depending on the vessel size. Unipolar cautery should always be avoided in close proximity to the pedicle Alter the pedicle has been dissected a sulficient distance to create adequate pedicle length, the lap vessels canbe dividled and the flap taken to a back table for vessel preparation, Vessel Preparation The back table allows the microvascular surgeon the oppor- tunity to prepare the flap and its vessels for transfer. At this point, the flap is flushed with heparinized saline to remove blood and. thrombogenic precursors. The appropriate ‘microvascular instruments to ensure gentle handling of the flap should be used. Typically, an operating microscope is used for illumination and magnification (4 to 16 times). Some surgeons use high-power loupe magnification and have demonstrated equal success rates. Jewelers forceps, straight and curved microscissors,a vessel dilator, and a curved-nee- dle holder are essential to the next stages of the transfer ig, 47-1), The interior ofthe vessels should never be han- led directly "The loose layers of the adventitia are removed from the ends of the vessels for an appropriate distance to allow for the anastomosis. This dissection is most easily accomplished with the surgeon and the assistant grasping the vessel at 180-degree apposite points to create traction and ‘open space for the dissection. The artery and vein(s) should also be separated from one another so that good vessel geom- etry and spacing can be obtained during anastomosis. Anastomosis After an analogous cleaning of the adventitia is accomplished ‘on the recipient vessels in the neck, the anastomosis of the ves- sels can be performed. Typically, arterial anastomoses are end- to-end and venous anastomoses are accomplished either end- to-end or end-to-side. Its important to choose appropriate recipient vessels when multiple vessels are available. Vessels for anastomosis should be of similar caliber, and inflow and outflow vessels should exhibit brisk bleeding, Unfortunately, this sa luxury that the microvascular surgeon does not always have, Ifa lumen size mismatch beyond 2:1 exists, the surgeon can fish-mouth the smaller vessel and take unequal bites to achieve adequate approximation.” Te end-to-side anastomo- sis can alo be used for lage-vessel mismatch (Fig 47-2). Most ‘microvascular surgeons prefer to use an end-to-side anasto- ‘mosis forthe donor vein(s) o the internal jugular vein; Ueda et al demonstrated no statistical difference in vessel thrombosis ‘when comparing the end-io-side anastomosis to the jugular ‘vein with end-fo-end venous anastomoses! The traditional technique for the anastomosis involves the use of interrupted stitches with9-0 or smaller nylon; however, an equivalent rate of vessel patency has been reported with contimuous-suture fechnique® The continuous-suture technique 567568 _ Reconstaucrive SuRCERY OF THE FACE AND NECK Figure 47-2 Anastomoses fora lateral arm flap showing an arterial end-to-end anastomosis and a venous end-to-side anastomosis (tothe internal jugular vein). allows fora faster anastomosis and is particularly helpful with ‘vessel size mismatch. The disadvantage of the continuous tech- nique is the potential narrowing atthe anastomosis ofthe ves- sel lumen, Framed clamps are commonly used for end-to-end anastomoses, whereas end-to-side anastomoses are generally done free-hand. Other authors have examined the use of anas- tomotic devices in head and neck free-tissue transfer” They have found the devices to be safe and effective, witha similar thrombosis rate. Shindo noted that the only failures that ‘occurred in her series were with the arterial anastomosis; there- fore, her group recommends the ring anastomotic device for igure #7 The basic microvascular equipment tray, including straight and curved scissors eweler’s forceps, vessel dilator, vessel clamps, and vessel approximators, ‘venous anastomoses only. The advantages of the device were decreased operative lime and the ability to perform the anas- tomosis even when exposure was not ideal [No matter the technique chosen for vessel anastomosis, the microvascular surgeon mistensure that the intimal layers of the vessels are well approximated and that the sutures are placed in sucha fashion as to prevent damage to the endothe- lium and thrombosis formation. Another common mistake is “pack-walling’ of the vessel. This occurs when the back wall of the vessels is incorporated in a stitch that reapproximates the front wall. This mistake is prevented by always having direct visualization of the needle as it passes through the tis- sue and inspecting the anastomosis carefully after the first half ofthe vessel is completed. Vessel Geometry Vessel geometry refers to the orientation of the anastomotic vessels. Although this appears to be a simple concept, suc- cess or failure of the flap often hinges on the orientation of the pedicle It is essential that the pedicle be anastomosed in a tension-free environment, allowing sufficient length to cre- ate gentle curves rather than tight turns that can potentially kink It is preferable for the anastomosis to sit down in the neck rather than rice up immediately under the skin. With ‘bone flaps, the surgeon must decide whether to take the pedi- cle over or under the bone segment as undue pressure can be paced on the pedicle by a tight tunnel under the bone or by external compression over the bone. At each step in the reconstruction, the surgeon should check the orientation of the vessels and the external forces that can be placed on them; often, this attention to detail and a simple tacking suture ‘where needed can help ensure a successful transfer. Flap Monitoring After the vessels have been anastomosed lap monitoring or perfusion begin. Immediately inthe operating room, most Surgeons rely on direct examination of te fap. Bleeding from the cat edgesof the fap, capillary rellon the skin page dle if one is avaliable, flap warmth, and ultrasonic Dopplersignals directly over the vessels all indicate a successful anas- tomosis and a well-perfused flap. When the flap has been inset and the case completed, the choice of flap monitoring is, surgeon-dependent, and often varies with the type and loca- tion of lap. An ideal technique for postoperative monitoring of all laps has not yet been described” An ideal technique ‘would be safe, inexpensive, effective with 100% sensitivity and specificity, reproducible, noninvasive, easly interpreted by nursing staf and physicians alike, and provide continuous ‘monitoring with instantaneous notification of changes in the vvessel dynamics!” ‘The number of techniques that have been discussed in the literature is significant and continues to grow as new dlevices and ideas are created. Techniques typically rely on assessment of a monitoring segment," vascular perfusion (©, Doppler ultrasonography, laser Doppler flowmety)/* tissue perfusion (eg, oxygen tension,” photoplethysmo- graphy)!" or tissue metabolism (e.g, hydrogen clearance.!* Each technique has positives and negatives. Despite all ofthe technology available, the vast majority of microvascular reconstructive surgeons employ clinical assessment as theit ‘monitoring method of choice. At our institution we rely on clinical assessment (capil- lary refill, bleeding, temperature) of all flaps with cutaneous paddles or monitoring segments and Doppler ultrasono- graphic signals over the monitoring segment, For the frst 72 hours the flap is checked every hour by nursing staff. They assess the color, warm, capillary refill, and Doppler signal of the flap as possible based on location. [Fa change occurs, the surgeon repeats the previous assessment and also per forms a needlestick exam. If an unsatisfactory change has ‘occurred, the patient is scheduled for urgent exploration. Ifa hematoma is suspected as the cause of flap failure the wound. is opened at the bedside and the patient taken to the operat ing room as soon as possible, After 72 hours, lap monitoring is reduced to every 4 hours for 2 days and then every Shours, until discharge. On the assessment examination described previously, a normal examination would find the flap to have a pink color, bbe warm to the touch, have capillary refill of to 3 seconds, and have strong arterial and venous Doppler signals. A pin- prick would produce bright red blood within several seconds of removal of the 20-gauge needle. Arterial insufficiency is characterized by a skin paddle with a pale or bluish hue, a flap that is cool to the touch, capillary refill that is prolonged to greater than $ seconds if it can be detected, and a pinprick that reveals dark blood, which takes a long time to reach the surface if ever. The hallmarks of venous insufficiency are a congested blue flap, brisk capillary refill that retums almost as soon as the finger or instrument is removed, and dark blood that appears right after the needle has been removed. Inboth cases, urgent surgical exploration is required. Flap Failure ‘The success of free-tissue transfer has reached the level that ‘most large series report a success rate of 95 to 98% Failure due to salvageable vessel thrombosis has been found to occur carly in the postoperative course. In the M. D. Anderson data, thrombosis ofthe vein (64%) wag more common overall than. thrombosis of the artery (20%%)." The vast majority (00% of Microvascutar Fars 569 the arterial anastomoses that failed did so within the first 24 hours, whereas most venous failures presented later. All sal- ‘vageable thromboses occurred within the frst 3 days following surgery. Multiple factors have been examined to determine if they affect flap survival" Although studies differ on which factors most important, one can say that detailed attention to the flap choice (attempting to avoid vein grafts), lap harvest, ‘vessel geometry, vessel anastomosis, and postoperative mon- itoring can lead to high success rates. entification ofa problem and swift, effective correction of the problem can lead to flap salvage when flap failure is imminent, The goal of the microvascular surgeon is to limit the ischemia time that the tissue experiences. After a certain time, the flap becomes unsalvageable due to the “no-reflow phenomenon! This phenomenon represents the point at ‘which the microvascularity of the flap suffers such damage from the ischemia thatthe vessels can only exist in a throm bbosed state. The endothelium of the microvascular circula- tion has been damaged and depleted of its energy reservoir, and despite reperfusion ofthe larger vessels, the injury can- not be overcome and thrombosis reversed. The exact amount time before the no-reflow phenomenon becomes evident is unknown. The microvascular surgeon must rely, then, on carly identification of problem and rapid correction to pre- vent flap failure. Salvage rates after early detection range from 69 to 100%6in the literature!" Tolessen the likelihood of vessel thrombosis, many sur- goons use an anticoagulant regimen perioperatively. Although the benefit of this has never been proven in ‘microvascular reconstruction, it has been shown to be of value in reimplantation and traumatic amputations”** Agents commonly employed include aspirin, dextran, heparin, and prednisone. These medications work primarily t0 pre- vent platelet deposition and clot formation. Currently, we use aspirin beginning on postoperative day 1 and continding for 3 weeks in all free-tissue transfer patients. We also frequently use dexiran-40 for up to 48 hours. The decision to use dex- tran isbased on flap and patient characteristics. We use dextran ‘when the flap has smaller vessels, the anastomoses are diffi- cult, or the flow though the donor vessels is not as brisk as desired. We avoid dextran or limit the length of its use in patients with poor heart function and functional anemia. The ‘volume expansion effect of dextran can lead to pulmonary edema and falling hematocrit, MICROVASCULAR FLAPS USED IN HEAD AND NECK RECONSTRUCTION Fascial and Fasciocutaneous Flaps Radial Forearm Free Flap ‘The radial forearm free flap was first described in 1978 by Goufan, Baoqui, and Yuzhi* Iss popularity since its inteo- duction has soared, and it is mow considered the workhorse flap in head and neck reconstruction. The applications for the radial forearm free flap are diverse and commonly include reconstructions of the oral cavity/oropharynx, hhypopharyna, total pharyngoesophagus, external skin and scalp, and skull base?