Original Article 597

Free Flap Head and Neck Reconstruction with an

Emphasis on Postoperative Care
Daniel Richard van Gijn, MBBS, BDS, BSc, MFDS, MRCS1 Jacob D’Souza, FDS, RCS, MRCS, FRCS1
Wendy King, MBBS, BMedSci, FRCA1 Michael Bater, BDS, MBChB, LDS, RCS, FDS, MRCS, FRCS, DLO-HNS1

1 Department of Oral and Maxillofacial Surgery, Royal Surrey County
Hospital NHS Foundation Trust, Guildford, Surrey, United Kingdom
Facial Plast Surg 2018;34:597–604.
Address for correspondence Daniel Richard van Gijn, MBBS, BDS, BSc,
MFDS, MRCS, Department of Oral and Maxillofacial Surgery, Royal
Surrey County Hospital NHS Foundation Trust, Egerton Road,
Guildford GU2 7XX, Guildford, Surrey GU2 7XX, United Kingdom
(e-mail: danielvangijn@doctors.net.uk).

Abstract Microsurgical free tissue transfer represents the mainstay of care in both ablative
locoregional management and the simultaneous reconstruction of a defect. Advances

Downloaded by: The University of British Columbia Library. Copyrighted material.

Keywords
► microvascular
► free tissue transfer
► perioperative care
► surgical optimization
► head and neck
in microsurgical techniques have helped balance the restoration of both form and
function—decreasing the significant morbidity once associated with large ablative,
traumatic, or congenital defects—while providing immediate reconstruction enabling
early aesthetic and functional rehabilitation. There are a multitude of perioperative
measures and considerations that aim to maximize the success of free tissue transfer.
These include nutritional support, tight glycemic control, acknowledgment of psy-
chological and psychiatric factors, intraoperative surgical technique, and close post-
operative monitoring of the patients’ hemodynamic physiology. While the success
rates of free tissue transfer in experienced hands are comparable to alternative options,
the consequences of flap failure are catastrophic—with the potential for significant
patient morbidity, prolonged hospital stay (and associated increased financial implica-
tions), and increasingly limited options for further reconstruction. Success is entirely
dependent on a continuous arterial inflow and venous outflow until neovascularization
occurs. Flap failure is multifactorial and represents a dynamic process from the
potentially reversible failing flap to the necrotic irreversibly failed flap—necessitating
debridement, prolonged wound care, and ultimately decisions concerned with future
reconstruction. The overriding goal of free flap monitoring is therefore the detection of
microvascular complications prior to permanent injury occurring—identifying and
intervening within that critical period between the failing flap and the failed flap—
maximizing the potential for salvage. With continued technique refinement, micro-
vascular free flap reconstruction offers patients the chance for both reliable functional
and aesthetic restoration in the face of significant ablative defects. The caveat to this
optimism is the requirement for considered perioperative care and the optimization of
those factors that may offer the difference between success and failure.

Microsurgical free tissue transfer represents the mainstay of
care in both ablative locoregional management and the simul-
taneous reconstruction of a defect. Advances in microsurgical
techniques have helped balance the restoration of both form
and function—decreasing the significant morbidity once asso-
ciated with large ablative, traumatic, or congenital defects—
while providing immediate reconstruction enabling early
aesthetic and functional rehabilitation (►Figs. 1–4).
Following the initial description of the fibula free flap1
and its application in mandibular reconstruction,2 the use of
free tissue transfer has been popular in the head and neck
due to the ability to transfer both vascularized bone and soft

Issue Theme Postoperative Care in Copyright © 2018 by Thieme Medical DOI https://doi.org/
Facial Plastic Surgery; Guest Editor: Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0038-1676076.
Alwyn D’Souza, MBBS, FRCS Eng, FRCS New York, NY 10001, USA. ISSN 0736-6825.
(ORL-HNS), PGCertMedEd, EBFPRS Tel: +1(212) 584-4662.
598 Free Flap Head and Neck Reconstruction van Gijn et al.
Fig. 1 Cutaneous squamous cell carcinoma (SCC) involving total
forehead.
tissue at the time of resection with predictable success rates.
It offers the surgeon a wide range of reconstructive possibi-
lities—replacement of vital structures (maxilla, mandible,
tongue, facial skin), obliteration of cavities postablation
(along with volume and contour restoration), functional
muscle and nerve transfer (facial reanimation surgery),
Fig. 2 Forehead defect following excision of lesion.
Facial Plastic Surgery Vol. 34 No. 6/2018
and reconstruction of the upper aerodigestive tract (laryn-
gopharyngectomy defects).
A free flap consists of an autologous tissue in which the
vascular continuity is interrupted at the donor site and
subsequently reestablished at the recipient site. The tissue
may include muscle and musculocutaneous, fasciocuta-
neous, osseous, fascial, and osteocutaneous components.
Despite the plethora of flaps described and theoretically
available, there are a limited number of “workhorse” flaps
that are best suited to reconstruct the majority of head and
neck defects.3 These include the radial forearm and ante-
rolateral thigh for soft tissue reconstruction and the fibular,
vascularized iliac crest and scapular/parascapular free flaps
for composite reconstructions. The choice of flap depends on
the requirements of the defect in question and the quality
and characteristics of the donor sites.
The care of these patients requires input from a multi-
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disciplinary team. Standardized care following enhanced
recovery principles has been shown to reduce hospital length
of stay.4 This coordinated approach to the patient journey
ensures that patients receive targeted care on each post-
operative day by all team members. The ultimate focus is to
return the patient back to “normality” as soon as possible,
and this aim should be communicated with the patient prior
to surgery. This enables their expectations to be managed,
aiding their understanding of the importance of early nutri-
tion and mobilization, and encourages them to engage with
and take some ownership of their own recovery.
Preoperative Considerations that Influence
Postoperative Management
Comprehensive assessment of the patients’ physiological,
psychological, and social well-being is important. Lifestyle
factors resulting in head and neck cancer, and consequence
of such disease, have implications on patients’ periopera-
tive risk. A full medical history must be undertaken to rule
out the presence of cardiorespiratory, hepatic, and renal
diseases, along with coagulopathies that may adversely

Fig. 3 Harvest of radial forearm free flap; prior to division of vascular pedicle.
impact perioperative outcome, including flap success.
There is a high risk of poor nutrition and electrolyte
imbalance, limited cardiorespiratory reserve and exercise
tolerance, and concurrent malignancies resulting in pro-
longed intensive care dependency and associated economic
ramifications. “High-risk” patients are responsible for 80%
of postoperative deaths.5 Hypertension has been found to
correlate with anastomotic failure.6 Coronary artery dis-
ease has been reported as an independent predictor of
overall complications following free tissue transfer in the
elderly.7 It is worth noting that advanced age alone is not a
medical or surgical risk factor for complications following
free tissue transfer.8
Prehabilitation
The literature suggests that there is a place for preoperative
exercise training9—which should not be considered an option,
but rather a fundamental part of preoperative work-up. How-
ever, the recommended commencement of 4 weeks before
surgery might prove difficult where the duration between
Fig. 4 Final result.
Free Flap Head and Neck Reconstruction van Gijn et al. 599
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diagnosis and surgery is frequently short and in a patient group
where compliance can be difficult. It is suggested that this
work-up be extended to address other behavioral risk factors
discussed below, as a bundle of care including clinical issues
such as treating anemia prior to surgery.
Smoking and Alcohol
Tobacco smoking and alcohol are key (synergistic) risk factors
in patients with head and neck cancer. Advice and support
with alcohol and tobacco consumption and cessation help to
optimize patients’ functional capacity in the preoperative
period and should be of acknowledged importance. At-risk
patients should be identified early and managed according to
local detoxification guidelines. Alcohol abuse has wide reach-
ing effects that adversely affect surgical success and is an
independent risk factor for free tissue transfer.7 While beyond
the scope of this review, these include alcoholic liver disease,
cirrhosis, portal hypertension, ascites, variceal disease, acute
alcohol withdrawal, and electrolyte imbalance. Cirrhotic
patients in particular have a significant increase in morbidity
and mortality.10 Furthermore, alcohol increases both wound
healing complications and the risk of surgical site infection.11
The cardiorespiratory adverse effects of smoking are well
known. While smoking is strongly associated with (flap)
wound healing complications,12 it is not thought to be a
significant risk factor in free flap failure.13
Nutritional Support
Nutritional deficiency is both a cause and consequence of
disease and multifactorial—arising due to social neglect or as
a result of morbidity from the primary tumor itself. Malnutri-
tion is associated with both infectious and noninfectious com-
plications following surgery and is associated with increased
mortality and hospital stay.14 Nutritional support should be
considered in those who are malnourished (body mass index
< 18.5 kg/m2 or unintentional weight loss of > 10% in last 3–6
months) and those who are at risk of malnutrition with poor
absorptive capacity and catabolic state.15 Enteral feeding is
Facial Plastic Surgery Vol. 34 No. 6/2018
600 Free Flap Head and Neck Reconstruction van Gijn et al.
preferable to parenteral feeding and may be achieved by early
preoperative placement of a percutaneous or radiologically
inserted gastrostomy/nasogastric tube.
Blood Glucose
Tight blood glucose control can result in the reversal of the
short-term negative effects of hyperglycemia within 24 hours.
It is known that diabetes mellitus causes abnormalities in
blood flow and vascular endothelium. While microangiopathy
can potentially reduce the availability of flap donor sites and
flap success rates, a previous review has shown no significant
difference in flap survival or complications between those
with or without disease.16 However, poor blood glucose con-
trol in the perioperative period is an independent predictor of
infection and mortality17 and excellent glycemic control in the
perioperative period should be the goal.
Psychological
In addition to optimizing the patient’s physical well-being by
way of cardiorespiratory function, the psychological implica-
tions of such extensive surgery should not be overlooked.
Current research across multiple surgical disciplines is directed
at investigating the benefit of patient education often led by a
clinical nurse specialist through “surgery school,” ward/inten-
sive care visits and the sharing of experiences with other
patients.
Psychiatric Considerations
The impact of a cancer diagnosis and preoperative anxiety can
have significant ramifications on psychosocial functioning and
result in varying degrees of depression. This is further con-
founded by postoperative facial disfigurement and functional
difficulties including impairment of speech, swallowing, taste,
and chewing. There is a wide range of reported depression in
patients with head and neck cancer (6–48%) mainly due to
inconsistencies in measurements, timings of assessments, and
methods of investigation.18 The effects of untreated depres-
sion include poor compliance with treatment, adverse wound
healing, poor appetite, and prolonged hospital stays.19
Preoperative Investigations
Virtual surgical planning, utilizing computerized planning
programs, osteotomy guides, and prefabricated reconstruction
plates has been shown to improve the definition of tumor
resection margins, reduce operative time, and increase the
accuracy of reconstruction and predictability of outcomes.20
Previous neck dissection and irradiation of the neck have a
significant bearing on the availability of recipient vessels for
free tissue transfer.21 A careful review of previous operative
notes is important to help determine the vascular status of the
neck. Radiotherapy is associated with endothelial degenera-
tion and necrosis, vessel lumen narrowing, and a prothrom-
botic environment22 and there is a higher rate of complications
and flap failure in those who were previously operated on or
Facial Plastic Surgery Vol. 34 No. 6/2018
with irradiated necks.23 Assessment of donor site vessel suit-
ability (caliber, length, presence of atherosclerosis/anatomical
anomaly) ranges from clinical assessment (Allen’s test in radial
forearm free flaps), to color flow Doppler and magnetic
resonance imaging/invasive angiography.
Intraoperative Considerations that
Influence Postoperative Management
Intraoperative management during microvascular free flap
surgery is aimed at reducing risk and maximizing the chance
of success. While meticulous intraoperative technique is an
essential component in free tissue transfer success, more
general measures include the use of prophylactic antibiotics
and careful patient positioning to allow both anesthetic and
surgical access and reduce the risk of peripheral nerve injury.
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Anesthetic Considerations
The principle goal of the anesthetist during free tissue
transfer surgery is to consider the respective physiological
requirements of the free flap against those of the patient. The
patient should be warmed to prevent hypothermia and their
hemodynamic stability maintained to optimize flap perfu-
sion. Bispectral index monitoring enables optimal depth of
anesthesia, alongside goal-directed fluid therapy and the
judicious use of vasopressor or inotropic support. The opti-
mal inotropic drug should act to support blood pressure
without adversely causing flap vasoconstriction. The perio-
perative use of vasopressors and inotropes is a contentious
issue and largely beyond the scope of this article. There is,
however, evidence to suggest that the intraoperative use of
vasopressors such as noradrenaline is safe in head and neck
free tissue transfer,24,25 and that inotropes such as dobuta-
mine have beneficial effects on flap skin blood flow.26,27
Intra- and postoperative vasospasm of the pedicle can
occur following surgical handling and may respond favorably
to the topical administration of vasodilators such as papa-
verine, lignocaine,28 and verapamil.29
Neck Surgery
The recipient vessels are atraumatically exposed and assessed
for viability, length, and location. In those who were previously
operated on or with irradiated necks, if possible suitable
vessels should be identified outside the zone of previous insult.
Commonly used recipient vessels in the virgin neck are the
facial artery, faciolingual trunk, and superior thyroid arteries.
Up to one in five previously operated and/or irradiated necks
will require recipient vessels other than the external carotid
system30 such as the transverse facial artery, internal mam-
mary artery, contralateral vessels, and superficial temporal
artery. Use of the internal mammary artery is a high-risk
morbid procedure that requires the involvement of a cardi-
othoracic surgeon. Venous anatomy is significantly more
variable than arterial anatomy and the choice of vessel there-
fore less amenable to reproducible algorithm. The internal
jugular vein, however, is generally more reliable than the

external jugular vein and can accommodate multiple anasto-
moses and is less susceptible to kinking and compression.
Other options include the cephalic and thoracodorsal veins.
Tracheostomy
The use of tracheostomies to secure the postoperative airway
varies significantly between units. Management of the com-
promised airway postoperatively is challenging due to
edema, bleeding, altered anatomy, and surgical fragility. In
a less extensive head and neck resection, the option of
keeping patients intubated for 6 to 12 hours postoperatively
should be considered. Cameron et al31 developed a scoring
system to help objectify the decision-making process—using
parameters such as tumor site, whether a bilateral neck
dissection or mandibulectomy was performed, and whether
or not the defect required reconstruction. Patients with
oropharyngeal tumors accessed by mandibulectomy and
subjected to bilateral neck dissection with free tissue trans-
fer score highest and necessitate elective tracheostomy. The
decision to perform an elective tracheostomy is multifactor-
ial, case-dependent, and must be made according to the
surgeon and unit’s experience and expertise.
Postoperative Considerations
During the first 24 hours following free tissue transfer, a
majority of head and neck units choose to monitor their
patients in an intensive or high-dependency care environ-
ment with staff experienced in the management of micro-
vascular free tissue transfer cases.32 Patients may be kept
intubated and sedated overnight, this being especially
important if there is a risk of delirium tremens. Without
sedation, an anxious patient may be restless and potentially
dislodge any tubes/drains. This can directly disrupt the new
anastomoses, or indirectly through bleeding in the neck or
hematoma formation. The degree of sedation should be
balanced with maintenance of blood pressure and minimiz-
ing the need for inotropic support.
Other more simple measures involve maintaining the
patient’s head in a neutral position and the avoidance of
increased venous pressure in the neck that may jeopardize
the vascular pedicle—including the use of excessive positive
end-expiratory pressure and tracheostomy ties. General
considerations include the careful control of temperature,
hemodynamic stability and ventilation, early enteral feeding,
thromboprophylaxis, and the optimization of tissue oxyge-
nation by monitoring hemoglobin levels.
The flow behavior of blood in the microcirculation is
determined by several factors including red cell density,
blood viscosity, and red cell deformability—which may be
adversely affected by prolonged surgery and general
anesthesia. Keeping the patient warm perioperatively
reduces hypothermic-induced vasoconstriction and
increased viscosity and hematocrit—factors that may impair
microcirculatory flow in the flap. Blood viscosity rises dra-
matically at a hematocrit level of > 40% although the appeal-
ing flow of hemodilute blood is at the expense of poor oxygen
Free Flap Head and Neck Reconstruction van Gijn et al. 601
carrying capacity. An optimal hematocrit of approximately
30% is therefore thought to offer the best balance between
viscosity and oxygen delivery.
Fluids
The goal of fluid balance is normovolemia and normotension
while maintaining a urine output of 0.5 to 1.0 mL/kg/h.
Hypervolemia is generally avoided to prevent flap edema.
The general consensus is to use crystalloid replacement in
the preoperative setting, colloid for intraoperative blood
losses, and blood to maintain the hematocrit.33 The thresh-
old for blood transfusion is approximately 8 g/dL and is
patient, symptom, and hematocrit dependent. Blood trans-
fusion carries the risk of infection, reaction, intraoperative
arterial thrombosis, and host immunosuppression—along
with associations with cancer recurrence in the context of
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head and neck cancer reconstruction.34
Anticoagulation
The systemic intraoperative use of heparin has no proven
effect on the incidence of microvascular thrombosis,35 and
antithrombotic prophylaxis is generally achieved by the
administration of low molecular weight heparin, along
with standard mechanical prophylaxis.36
Free Flap Monitoring
While the success rates in experienced hands are comparable
to alternative options (95% or greater),37 the consequences of
flap failure are catastrophic—with the potential for signifi-
cant patient morbidity, prolonged hospital stay (and asso-
ciated increased financial implications), and increasingly
limited options for further reconstruction. Free tissue trans-
fer success is entirely dependent on a continuous arterial
inflow and venous outflow until neovascularization occurs.
Flap failure is multifactorial and represents a dynamic
process from the potentially reversible failing flap to the
necrotic irreversibly failed flap—necessitating debridement,
prolonged wound care, and ultimately decisions concerned
with future reconstruction. The overriding goal of free flap
monitoring is therefore the detection of microvascular com-
plications prior to permanent injury occurring—identifying
and intervening within that critical period between the
failing flap and the failed flap—maximizing the potential
for salvage. Flap salvage rate is variable, ranging from 70 to
80% depending on the monitoring techniques utilized,38 but
it is clear that this rate is higher with early detection.39
There are a multitude of techniques described for flap
monitoring, although there is a paucity of evidence for any
one technique over another. This appears largely due to
inherent difficulties in consistently identifying primary
endpoints. Optimal objective measures for monitoring the
efficacy of monitoring are flap salvage rate and false-posi-
tive rates—that is, the frequency in which free flaps are
explored unnecessarily following concerns of impending
failure.
Facial Plastic Surgery Vol. 34 No. 6/2018
602 Free Flap Head and Neck Reconstruction van Gijn et al.
Clinical Techniques for Flap Monitoring
Clinical monitoring includes the bedside assessment of flap
color, surface temperature, capillary refill, skin turgor,
(appropriate) bleeding on pinprick/scratching, and handheld
Doppler findings. Although subjective and experience-
dependent, meticulous and frequent clinical monitoring is
the current gold standard, the standard in which adjunctive/
alternative techniques are compared and has been demon-
strated to produce flap salvage rates of up to 80% and success
rates of up to 99%.37 Disa et al highlighted the importance of
clinical monitoring by demonstrating a zero percent salvage
rate of all unmonitored buried free flaps with a compromised
microcirculation.40 This also illustrates one of the significant
limitations of standard clinical monitoring—namely, the
inability to examine buried flaps or those in difficult-to-
access areas. Distal skin paddles, exteriorized flaps, and
chimeric flaps have all been used in an attempt to circumvent
this problem.
Handheld ultrasound Doppler is often used as an adjunct
to clinical examination to assess pedicle flow. It is difficult to
differentiate between pedicle and adjacent, native vessels and
artery and vein—which is further compounded by couplers
and buried flaps. The accuracy of ultrasound can be improved
with the use of a contrast media. Contrast-enhanced ultra-
sound (e.g., SonoVue; Bracco International), when combined
with a postprocessing perfusion software, can provide both
quantitative and qualitative information and is associated with
high sensitivity and specificity in predicting flap failure—with
a flap salvage rate of up to 85%.41
Invasive Techniques for Flap Monitoring
The Cook–Swartz implantable Doppler probe uses a 20-MHz
piezoelectric crystal embedded within a 5-mm silicone cuff
which directly measures blood flow at the pedicle when
applied around either the artery or vein. When around the
former, it will instantaneously detect arterial compromise
but cause a delay in the detection of venous occlusion by 3 to
4 hours.42 Implanted Doppler probes have been demon-
strated to be accurate and effective, and have shown an
increase in flap salvage rate when compared with clinical
monitoring.43 They are perhaps of greatest benefit in the
monitoring of buried flaps or those in poorly assessable
areas.44
Microdialysis is a technique first described by Udesen
et al,45 that analyzes the byproducts of metabolism within a
free flap as means of detecting early ischemia. Perfusate is
pumped into the flap and the dialysate (containing metabo-
lites such as lactate, glucose, glycerol, and pyruvate), follow-
ing equilibrium, passes through a semipermeable membrane
where it can be subsequently analyzed. The respective levels
and ratios of metabolites provide an objective and accurate
measure of flap metabolism in ischemia—and therefore a
sensitive indication of flap failure. It has potential in the
assessment of buried flaps but is expensive, has demon-
strated an increased false-positive rate, and no benefit when
compared with clinical monitoring.46
Facial Plastic Surgery Vol. 34 No. 6/2018
Fluorimetry (direct visual angiography) measures the
ultraviolet-induced fluorescence of fluorescein dye in the
tissue following intravenous injection and before renal
excretion—the arterial phase and venous phase, respectively.
Whitney et al in the early 1990s47 demonstrated a sensitivity
of 91% and flap salvage rate improvement from 55 to 85%
when compared with clinical monitoring. It is an extremely
sensitive technique that allows for a more targeted approach
to resolve a vascular compromise. The need for significant
expertise for interpretation and potential for anaphylaxis
should be borne in mind.
Other monitoring modalities include oximetry, spectro-
scopy (near-infrared, visible light), carbon dioxide monitor-
ing, and laser Doppler flowmetry. While promising, they are
largely beyond the scope of this review and generally require
further studies with larger numbers.
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Management of Complications
The key to flap salvage is in the early detection of the
reversibly failing free flap. Following detection, accurate
identification and correction of the causative factors must
be achieved intraoperatively. In the majority of cases, this is
due to venous thrombosis, potentially attributable to their
low flow, low intraluminal pressures, and thin, fragile walls.
Nonthrombotic causes include vasospasm, problems with
flap inset and pedicle compression, kinking, or injury.48
Corrective interventions are cause-dependent but include
performing a second venous anastomosis (if available), the
use of an interpositional vein graft (especially if the throm-
bosed segment of the vein/artery needs to be excised
entirely), aggressive debridement of the necrotic tissue
and antibiotic administration, and a meticulous and water-
tight closure to prevent or treat salivary fistulae and the
resultant pooling.
The majority (90%) of arterial thrombi occur within the
first 24 hours and venous thrombi within the second
24 hours49—with approximately 95% of all flap failures
occurring within the first 72 hours. In cases of failed flap,
salvage options include a second free flap, a pedicled flap, or
conservative regular wound care combined with secondary
intention, skin graft, or local flap reconstruction. The option
chosen and timing of surgery depends predominantly on the
functional requirements of the patient, any planned adjuvant
therapy, and assessment of the risks associated with
delayed secondary reconstruction including the need for
major vessel or dural coverage.
Conclusion
With continued technique refinement, microvascular free
flap reconstruction offers patients the chance for both reli-
able functional and aesthetic restoration in the face of
significant ablative defects. The caveat to this optimism is
the requirement for considered perioperative care and the
optimization of those factors that may offer the difference
between success and failure.

Note
The authors of this article practice in a U.K. regional center
for the management of head and neck cancer. They have
extensive experience in the treatment of patients with
free tissue transfer, and an interest in reducing complica-
tions and improving outcomes for this patient group.
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