Int. J. Oral Maxillofac. Surg.

2007; 36: 450–452

doi:10.1016/j.ijom.2006.12.007, available online at http://www.sciencedirect.com

Technical Note
Head and Neck Oncology

Debulking of free N. C. Tan1,2, E. Cigna1, P. Varkey1,

Y.-T. Liu1
1
Department of Plastic and Reconstructive

myocutaneous flaps for head Surgery, E-Da Hospital/I-Shou University,

Yan-Chau Shiang, Taiwan; 2Department of
Surgery, Changi General Hospital, Singapore

and neck reconstruction using

§
an arthroscopic shaver
N. C. Tan, E. Cigna, P. Varkey, Y.-T. Liu: Debulking of free myocutaneous flaps for
head and neck reconstruction using an arthroscopic shaver. Int. J. Oral Maxillofac.
Surg. 2007; 36: 450–452. # 2006 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Most reconstructive surgeons prefer a myocutaneous free flap for head and
neck reconstruction due to its bulk and superiority in bacterial suppression. To
obtain proper symmetry and contouring in the head and neck region, ancillary
procedures usually have to be performed. Eleven head and neck cancer patients
underwent resection and reconstruction with myocutaneous flaps that resulted in
unacceptable facial contouring. Delayed flap debulking with an arthroscopic shaver
was performed. All 11 patients were satisfied with their facial contouring and
symmetry after one session of debulking. There were no complications such as flap
necrosis, seroma or haematoma. This novel technique done under local anaesthesia
is effective for debulking myocutaneous free flaps and removing fibrotic tissues. It is Accepted for publication 7 December 2006
simple, safe and produces a reliable and satisfactory outcome. Available online 8 February 2007

Microsurgery has further refined head and
neck reconstruction by providing an
increased repertoire of flaps and tissues that
facilitate one-stage repair. After extirpation
of malignant disease in the head and neck
region, the importance of form as well as
function should not be overlooked when
planning the reconstructive stage. Myocu-
taneous flaps are the coverage method of
choice in head and neck reconstruction due
to their bulk and superiority in bacterial
§
Presented at the Annual Meeting of the
Plastic Surgical Association, 26 November
2005, Kaohsiung, Taiwan, ROC.
suppression2. The drawback of being bulky
is that it causes contouring problems. Con-
ventionally, surgical excision of the sub-
cutaneous fat or liposuction (suction
assisted, ultrasound, laser or power assisted
systems) is used to debulk the flap4–6,9.
Surgical excision, the most commonly used
procedure, may cause partial or total flap
failure if the pedicle or the perforator of the
flap is damaged, particularly if it is per-
formed at an early stage. Liposuction sys-
tems are more effective with subcutaneous
fat than fibrotic tissues. Previously1, the
possibility was briefly mentioned of
debulking free perforator flaps for head
and neck reconstruction using an arthro-
scopic shaver. The aim of this paper was to
describe in detail the technique and success
of using an arthroscopic shaver for flap
debulking in 11 patients with previous head
and neck reconstruction.
Patients and methods
A total of 11 patients from the period of
May 2004 to July 2005 were included
(Table 1). Myocutaneous anterior lateral
thigh free flaps had been used in all
cases for head and neck reconstruction.
After a minimum of 6 months follow up,

0901-5027/050450 + 03 $30.00/0 # 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Debulking of free flaps with arthroscopic shaver 451

as there is the possibility of causing vas-

cular compromise to the flap. Many
patients may not in fact need any debulk-
ing as postoperative radiotherapy and
muscle atrophy cause the flap to shrink
to an acceptable size. The delayed
approach permits sufficient neovasculari-
zation of the flap to allow it to become
pedicle independent3 and at the same time
avoids premature overcorrection.
Many techniques have been developed
for the debulking or defatting of flaps.
Suction-assisted lipectomy was first advo-
cated by GRAZER3 and HALLOCK4, and more
recently YAMANAKA et al.9 reported flap
defatting using an ultrasonic surgical
aspirator. WU & CHAN8 reported three
Fig. 1. Arthroscopic shaver. cases of skin flap defatting after micro-
surgical reconstruction of the hand using
an arthroscopic shaver.
debulking is offered to patients who have
unacceptable facial contouring and are
disease free.
An arthroscopic shaver (Hummer TPS,
Leibinger, Stryker, Germany), which is a
motorised system consisting of an outer and
an inner sheath (Fig. 1) is used. The window
of the inner sheath functions as a cylindrical
blade that rotate into the outer sheath and
cuts the soft tissues sucked in by a standard
operating theatre suction system.

Technique
The procedure is easy and performed
under local anaesthesia. A small 1–
1.5 cm skin incision on the edge of the
flap is all that is needed to allow the shaver
to enter the selected layer to be debulked.
The device is then activated. The sur-
geon’s non-dominant hand is used to guide
the tip of the shaver and assess the thick-
ness of the tissues between the instrument
and skin. The superficial 3–5 mm of sub-
dermal tissue is preserved to prevent
bleeding, skin necrosis and depression.
Care is taken to avoid the region of the
flap pedicle. The whole procedure takes
about 20 min and the skin incision is
closed at the end. There were no compli-
cations such as flap necrosis, infection,
contour irregularities, seroma or haema-
toma in all 11 cases. One representative
clinical case is shown (Fig. 2).

Discussion
Myocutaneous free flaps, although bulky,
are preferentially used in head and neck
reconstruction. Debulking thus may be
needed to improve contouring. Although
some papers have reported primary
debulking of free flaps7, immediate or
primary debulking may not be advisable, Fig. 2. (A) Preoperative frontal view. (B) Postoperative 2-week frontal view.
452 Tan et al.

Table 1. Patient data 3. Grazer FM. Suction-assisted lipectomy,

Patient no. Age (years) Sex Diagnosis Site Radiotherapy suction lipectomy, lipolysis, and lipexer-
esis. Plast Reconstr Surg 1983: 72: 620–
1 39 Male SCC Oral Yes 623.
2 42 Male SCC Oral Yes 4. Hallock GG. Defatting of flaps by means
3 63 Male SCC Oral Yes of suction-assisted lipectomy. Plast
4 38 Male SCC Oral No Reconstr Surg 1985: 76: 948–952.
5 40 Female SCC Oral Yes 5. Hallock GG. Liposuction for debulking
6 50 Male SCC Oral Yes free flaps. J Reconstr Microsurg 1986: 2:
7 68 Male SCC Oral No 235–239.
8 45 Male SCC Oral Yes 6. Hallock GG. Conventional liposuction-
9 52 Female SCC Oral Yes assisted debulking of muscle perforator
10 42 Male SCC Oral Yes flaps. Ann Plast Surg 2004: 53: 39–43.
11 46 Male SCC Oral Yes 7. Mowlavi A, Brown RE. Suction lipect-
omy during flap reconstruction provides
immediate and safe debulking of the skin
Here is reported in detail 11 cases of to allow a better assessment of the amount island. Ann Plast Surg 2003: 51: 189–
head and neck free flap debulking using an of skin to be excised. 193.
arthroscopic shaver. In comparison to Debulking using an arthroscopic shaver 8. Wu WC, Chan WF. Defatting of skin flaps
liposuction, arthroscopic shaving allows appears to be safer and produces a better using arthroscopic instruments—an effec-
easy removal of fibrotic tissues on the aesthetic outcome than liposuction. This tive alternative. J Hand Surg [Br] 2000: 25:
submucosal plane of the oral cavity, remains to be further elucidated in clinical 300–303.
which is particularly difficult with lipo- trials. 9. Yamanaka K, Ichikawa T, Horiuchi Y.
suction especially after radiotherapy. The Flap defatting with an ultrasonic surgical
area near the flap pedicle is avoided to aspirator. Plast Reconstr Surg 1997: 99:
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