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COMPLICATIONS IN MICROVASCULAR
FREE FLAP SURGERY
MARK D. DELACURE, MD
The avoidance of complications in the performance of microvascular free tissue transfer begins in the
conceptualization of both the ablative and reconstructive phases of a procedure. Even the most experienced
microvascular surgeon will encounter a broad range of complex clinical and technical issues, both predictable and
otherwise, that he or she will also come to recognize, pre-empt, and compensate for, in acquiring true expertise. The
appropriate application of microneurovascular free tissue transfer techniques has allowed ablative surgeons to more
radically (and often more effectively) resect advanced-stage and recurrent malignant disease. As such, the indications
for this technique have broadened and our already complex technical tasks are being further tested as we refine and
reapply the state-of-the-art. The ability to minimize and avoid complications is a critical part of advancing this
technique, which has made one of the most profound contributions to patient care of any in the modern era of
reconstructive surgery.
The avoidance of complications in the performance of expertise, experience, and creativity meet their most criti-
microvascular free tissue transfer begins in the conceptual- cal test.
ization of both the ablative and reconstructive phases of The appropriate application of microneurovascular free
the procedure. Minor modifications in the conduct of neck tissue transfer techniques has allowed ablative surgeons to
dissection, in particular, may profoundly influence the more radically (and often more effectively) resect advanced-
range of options available to the reconstructive team in stage and recurrent malignant disease. As such, the indica-
terms of recipient vessels and pedicle geometry while not tions for this technique have broadened and we are no
compromising the oncologic effectiveness of the resective longer obligated by the historical paradigm of the recon-
procedure. These considerations are compounded in reop- structive ladder, applying more conservative techniques
erative cases. that have an almost certain likelihood of at least partial
Command of anatomical aspects of donor site anatomy failure and inadequate suitability to task. The increased
can only be acquired through experience and cannot be complexity of such resections has provided an additional
substituted by even the most detailed and colorful atlas or challenge to the microsurgeon at a time when mere flap
videotape, informative weekend course, recent cadaver survival is considered a "soft endpoint" and where form
dissection, or successful rat femoral vein anastomosis. The and function are increasingly measured in the context of
widespread availability of surgeons who are experienced functional outcomes analysis and cost containment. The
in microneurovascular reconstruction across many special- individual surgeon's already complex technical tasks are
ties should provide the patient with competent and highly being further tested as the field as a whole redefines what
experienced technicians with seasoned clinical and techni- is current state-of-the-art technology in reconstructive
cal skills that can only be acquired through performance. head and neck surgery. The ability to minimize morbidity
However, even the most seasoned microvascular surgeon and avoid complications is a critical part of advancing this
will encounter a broad range of complex clinical and technique, which has made one of the most profound
technical challenges, both predictable and otherwise, that contributions to patient care of any in the m o d e m era of
he or she will also come to recognize, pre-empt, and reconstructive surgery.
compensate for in the process of acquiring expertise. This
is nowhere more common than in the previously treated
patient (surgery, in particular--but also radiation), where PEDICLE SELECTION AND GEOMETRY
The need for vein grafting, with its attendant increase in
complexity and potential for anastomotic complication,
should be a rare event in contemporary head and neck
From the Surgery Institute of Reconstructive Plastic Surgery, New York, reconstruction, even with the emerging indications of total
NY.
bilateral maxillary and high central midfacial applications.
Address reprint requests to Mark D. DeLacure, MD, FACS, Surgery
Institute of Reconstructive Surgery, Suite 711,550 1st Ave, New York, NY Strategies to minimize this need are also discussed in the
10016. section on flap design.
Copyright 2000 by W.B. Saunders Company The dictum to "make m i c r o s u r g e r y , macrosurgery'" does
1043-1810/00/1103-0006510.00/0 not infer that one should routinely perform anastomoses to
doi:10.1053/otot.2000.18235 the external carotid artery simply because it is the largest
178 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 11, NO 3 (SEPT), 2000: PP 178-183
caliber recipient artery generally available in the neighbor- only when anastomoses a n d / o r insetting are completed
hood. This concept is largely a carryover from the early and such possibilities theretofore unrecognized or, more
days of reconstructive microsurgery, ie, the groin flap era seriously, in a return to the operating theater after accept-
where donor blood vessels were on the order of l m m or ing a marginal configuration that later becomes chal-
less and the vascular anatomy of contemporary flap donor lenged, unreliable, or fails.
sites had yet to be defined. Despite the possibilities of In cases where there are no apparent available donor
partial or brief cross-clamping of the common carotid vessels from the ipsilateral external carotid system, the
artery in patients without atherosclerotic disease, the transverse cervical artery (subclavian system) may often be
greatest risk of this arrangement is not to the flap but lies in found undisturbed in the supraclavicular fossa, even in
the possibility of stroke a n d / o r death through the propaga- previously operated necks. Although a review of the
tion of retrograde thrombosis should the arterial anastomo- previous operative report may provide explicit informa-
sis fail. The risk of anastomotic disruption with life- tion regarding the management of this pedicle in the lower
threatening hemorrhage is also greater in this context. In neck, it is more commonly--not specifically--mentioned
this circumstance, the anastomosis must be resected to and requires direct identification at reoperative explora-
obtain vascular control, thereby sacrificing the flap. Use of tion. A contingency plan in the event that this pedicle is
the external carotid may unnecessarily compromise blood determined to be unavailable must be a part of the
flow to other residual ipsilateral structures and tissues and preoperative conceptualization of the reconstructive proce-
may eliminate the future option of high-dose intrarterial dure. When identified, additional length can be recruited
chemotherapy. Although end-to-side configurations may by following the vessels into the region of the brachial
appear to circumvent this issue they are, in my opinion, plexus. This anatomy has been well covered by Netterville
unnecessarily complex and maintain the risk of thrombosis et aU
and retrograde propagation into the common and internal A recent work has elucidated the role of retrograde
systems in the event of failure. Additionally, the high perfusion in donor vessel selection that may be of particu-
inflow rate provided by this hookup may result in an lar use in reoperative or irradiated cases where recurrent
engorged flap having high-capacitance physiology that tumor approximates the carotid bifurcation area and elimi-
cannot be met on the venous outflow side, with subsequent nates otherwise plentiful donor vessel choices. I have
found the superior thyroid artery in its relatively straight
progressive flap failure attributable to distal vascular
segment course along the posterior border of the thyroid
failure despite spectacular inflow. The internal carotid
cartilage to be useful for this purpose. Perfusion, therefore,
artery should never be considered as a potential donor
takes place through the inferior thyroid artery and contra-
vessel in my opinion, regardless of the youthfulness of the
lateral arteries, through the thyroid gland, and into the
patient or the results of neurovascular testing and cerebral superior thyroid vessel where pulsatile retrograde flow
angiography. The possibilities of delayed stroke, propa- may successfully support a flap.
gated thrombosis, embolic phenomena, and fatal disrup- Another way to support a flap without contralateral
tion prohibitively mitigate against its use. anastomosis or interpositional vein grafting may be termed
Arterial anastomoses should generally be done to "pedicle transport." This uncommon procedure involves
branches of the external carotid system, which are almost hooking up a flap to a pedicle, which is provided by a
always several millimeters in diameter and of sufficient regionally available flap (eg, pectoralis major--thoracoac-
length and quality to allow satisfactory technical anastomo- romial branch) pedicle, and is transported into the opera-
sis even in previously irradiated and reoperative situa- tire field. This will usually eliminate the use of the flap,
tions. I have encountered, with some frequency, rosetting which may have been otherwise based upon the pedicle
the intima. In this circumstance, absolute attention to detail used to support the free flap. A more commonly described
and handsewn technique are a must. In this instance, vein option involves the cephalic vein, which can be
mechanical anastomotic devices are not technical options. dissected from the arm and transposed into the neck for
End-to-side arterial anastomoses are usually unneces- anastomosis there.
sary in either primary or delayed reconstruction and are of The routine sacrifice of the external jugular vein robs the
somewhat increased complexity in execution. There is not reconstructive team of a recipient vein of significant caliber
convincing evidence from either clinical or laboratory or of a graft conduit that is readily present in the operative
studies that this hookup is more or less effective than its field. This is as commonly the result of inexpert hands at
end-to-end counterpart. Vessel caliber discrepancy may the opening neck incision as it is of intentional sacrifice at
often be compensated for by telescoping techniques of the neck base, when it is encountered there.
anastomosis as long as blood flow is prograde from small
to large vessel.
A basic principle of pedicle geometry selection is that of MECHANICAL ANASTOMOSIS
temporary flap insetting (suture, staple, or osteosynthesis)
and ranging the head from side-to-side, in neck flexion and The mechanical microvascular anastomotic coupling de-
extension, and through complete mandibular excursion vice has increased the efficiency and reliability of microvas-
(where applicable), to facilitate appropriate choice of ves- cular anastomosis and has been shown to be an effective
sel length. These maneuvers will minimize tension, redun- adjunct, when selectively applied, to traditional hand-
dancy, and kinking as well as misspent effort in adventitial sewn suture techniques in a variety of head and neck
clearance, which tends to be focused on the pedicle ends contexts. 2 This holds true in a large experience including
that have been selected for maximal length at the donor both arteries and veins, end-to-end and end-to-side configu-
site, but which commonly exceed requirements once trans- rations, irradiated vessels, and a variety of flaps. 3 The
ferred to the head. This will furthermore decrease ischemic apparent simplicity of such devices can not substitute for
time through appropriately focusing pedicle dissecting expertise in traditional suture techniques that are not
efforts. Dividends also include a reduced need to revise uncommonly necessary in unfavorable situations such as
anastomotic configurations that are deemed too redundant significant vessel mismatch, small caliber, endothelial roset-