PREVENTING COMPLICATIONS: PRINCIPLES

OF FLAP RECONSTRUCTION
MARK S. PERSKY, MD

The head and neck surgeon must be prepared to reconstruct surgical defects to provide adequate postoperative form
and function. The extent of tumor resection should not be compromised by lack of familiarity with the various
methods of reconstruction. The simplest means of wound closure (ie, primary closure, secondary intention healing,
grafts) should be considered before using more complex flaps, with a thorough knowledge of their advantages and
disadvantages. Successful flap reconstruction relies on attention to flap anatomy, avoiding wound tension, and
meticulous detail to hemostasis and flap manipulation. The patients' postoperative rehabilitation is influenced by
thoughtful reconstructive efforts of the surgeon.

The experienced head and neck surgeon must be as
familiar and comfortable with options for head and neck
reconstruction as he or she is with a multitude of proce-
dures for tumor ablation. It is a disservice to the patient
and a failure of sound oncologic principles if the surgeon
compromises tumor resection because of limited experi-
ence or knowledge about methods of reconstruction. The
concept of defining the surgical ablation and reconstruc-
tion according to the surgeon's abilities is unacceptable.
Patients may suffer from the results of compromising
tumor resection with an increased risk of tumor recur-
rence. Additionally, postoperative form and function may
not be optimal and patient rehabilitation will be hindered.
Reconstructive efforts of the head and neck translate into
very real results concerning patients' self-image and func-
tion. The concept of familiarity with flaps is important, but
the experienced surgeon also realizes that a specific defect
may have an excellent result by using one of several
options for reconstruction.
A dogmatic approach in reconstruction only tends to
limit the available options and prohibits the surgeon from
using his imagination and his experience to obtain optimal
results. The patient's age, sex, occupation, skin redun-
dancy, medical condition, smoking history, and functional
capacity should all be influential in choosing forms of
reconstruction.
NONFLAP RECONSTRUCTION
Keep it simple (Fig 1). Define the simplest approach to
accomplish the reconstructive goal of providing optimal
From the Department of Otolaryngology--Headand Neck Surgery, Beth
Israel Medical Center, and Albert Einstein College of Medicine, New York,
NY.
Address reprint requests to Mark S. Persky, MD, Beth Israel Medical
Center, Phillips Ambulatory Care Center, 10 Union Square East--Suite 4J,
New York, NY 10003.
Copyright © 2000 by W.B. Saunders Company
1043-1810/00/1102-0010510.00/0
doi:10.1053/otot.2000.8061
form and function. The more complex forms of reconstruc-
tion (eg, free flaps) involve more extensive harvesting of
tissue from donor sites, resulting in additional cosmetic
and functional considerations. In addition, prolonged oper-
ating time is more stressful on the patient, and the need for
an additional reconstructive team impacts on hospital
costs. Use the simpler, less complex forms of reconstruc-
tion to accomplish the same results.
Primary closure of the defect is the simplest form of
reconstruction, but it is too often overlooked as a possibil-
ity. Undermining of adjacent skin or mucosa and primary
closure without tension and avoiding restricted motion of
adjacent areas (eg, tongue, lips, and eyelids) may be the
ideal form of closure. Lax facial and neck skin, especially in
older patients, may provide surprising amounts of adja-
cent tissue for simple closure of defects. If possible, the
lines of excision should be oriented within the lines of skin
tension for the best scar results.
Healing by secondary intention may also represent the
best method of "reconstruction." This would obviously not
be appropriate for large defects, and more extended post-
operative care of the wound during its healing phase
would be required. Allowance must be made for wound
contraction as part of the long-term postoperative result. 1
For example, secondary intention healing of the w o u n d
adjacent to the lower eyelid may result in an ectropion, and
would therefore be contraindicated. The same size wound
on the mid-scalp may heal with perfectly acceptable
results.
Skin grafts are an excellent method for providing an
epithelial surface. Split-thickness skin grafts have a higher
rate of "take," undergo more long-term postoperative
contraction, and result in a more atrophic appearance as
compared with full-thickness skin grafts. Grafts on more
cosmetically apparent areas of the face (eg, eyelids, nose)
would require a full-thickness skin graft. Full-thickness
grafts result in better cosmetic results, especially if adjacent
head and neck skin is used. The contralateral eyelid as well
as postauricular and cervical skin provide excellent donor
sites that are easily closed primarily. There has also been

126 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 11, NO 2 (JUN), 2000: PP 126-129
 PRIMARY CLOSURE
SECONDARY INTENTION
GRAFTS - SPLIT, FULL, DERMAL, MUCOSAL
RANDOM FLAPS
(e.g. rotation, transposition)
AXIAL MYOCUTANEOUS FLAPS AXIAL CUTANEOUS FLAPS
(e.g. pectoralis major) (e.g. delto-pectoral, forehead)
FREE FLAPS
FIGURE 1. Methodsof reconstruction--increasingorderof
complexity.
remarkable success with composite free grafts such as
nasal alar reconstruction with free-skin/cartilage grafts
from the auricle. Grafting of mucosal defects within the
head and neck may require donor tissue less prone to
forming a keratinizing layer with its resultant crusting.
Possible donor sites include buccal mucosa, nasoseptal
mucosa, and dermis. Free grafts should be used with
caution on previously irradiated recipient sites, because
vascularity may be compromised and these grafts rely on
revascularization from the underlying tissue.
Not all surgical defects require immediate definitive
reconstruction. Occasionally, even large facial defects are
best handled by long-term postoperative observation with-
out flap reconstruction. There are instances when delayed
reconstruction should be considered.
Large, infiltrating skin neoplasms, recurrent after prior
surgery or radiation therapy, result in difficult-to-ascertain
margins of resection. Even computed tomography and
magnetic resonance imaging studies cannot accurately
define the extent of the tumor in the setting of scarring
from previous surgery or changes from radiation therapy.
Meticulous microscopic examination of the surgical speci-
men requires time to confirm the adequacy of the surgery.
The potential for tumor "skip" areas, perineural invasion,
subcutaneous extension of tumor, and local dermal metas-
tases predispose to local recurrence. Immediate major
reconstructive efforts may only serve to obscure persistent
neoplasm and render the patient more difficult to evaluate
for tumor recurrence. Simple skin-graft reconstruction of
even large facial defects will provide a quickly epitheliazed
surface that can be easily examined for tumor recurrence.
Additional resection of microscopically confirmed positive
margins of resection can then be easily addressed without
having to deal with mobilizing previously inset flaps for
reexposure of the surgical site. Certainly, massive defects,
functional problems, and dural a n d / o r carotid artery
exposure require immediate flap coverage. Ultimately, the
surgeon's judgment most often is relied u p o n to determine
the necessity or prudence of delayed reconstruction. Large,
cosmetically evident, and deforming resections may re-
quire immediate reconstruction if the patient's resultant
quality of life is unacceptable. Additionally, brachytherapy
will often require coverage with previously unradiated
tissue.
MARK S. PERSKY
FLAP RECONSTRUCTION/GENERAL
PRINCIPLES
Skin flaps provide many advantages over grafting. If
preoperative planning anticipates a postoperative defect
requiring flap reconstruction, attention to basic precepts is
necessary. Local tissue is often of similar color, thickness,
and hair-bearing quality as the adjacent resected skin.
Most often, flap donor sites may be closed primarily,
thereby avoiding additional cosmetic deformity. Aging
skin with wrinkle formation provides easier mobilization
of skin to accomplish primary closure. Again, undermin-
ing of the adjacent skin provides release of tension on
closure. Free grafts may become atrophic (sometimes
hypertrophic), h y p o p i g m e n t e d (sometimes hyperpig-
mented), and undergo contraction, whereas local flaps
provide a more normal appearance. Examination of other
facial or neck scars would indicate any predisposition to
keloid formation that may require postoperative local
steroid injections for optimal cosmetic results. Prior radia-
tion therapy to the regional site of reconstruction compro-
mises local flap viability, and distant flaps beyond the
radiated areas would ensure better results.
Systemic factors have a significant influence on success-
ful flap reconstruction. Diabetes mellitus, atherosclerosis,
smoking, alcoholism, autoimmune diseases, chronic ste-
roid use, immune deficiency disorders, and ongoing chemo-
therapy with weight loss and hypoproteinemia may effect
the vascularity, resistance to infection, collagen formation,
and general healing properties that are necessary for
ultimate flap success. Aggressive treatment of these prob-
lems will improve flap survival. Medical control of diabe-
tes, cessation of smoking and alcohol abuse, and, if pos-
sible, tapering of steroid usage will enhance healing.
Percutaneous endoscopic gastrostomy (PEG) is an impor-
tant tool in management of patients with upper aerodiges-
tive tract malignancies with resultant weight loss from
their obstructing and painful tumors, especially those
undergoing radiation treatments. The PEG ensures ad-
equate nutritional intake and is capable of reversing the
catabolic state so detrimental to w o u n d healing.
Flap failure, partial or total, is an occasional complica-
tion that will occur even in the most experienced surgeon's
practice. However, adherence to certain principles will
serve to potentiate flap survival.
METICULOUS ATTENTION TO HEMOSTASIS
Postoperative hematomas compromise flaps. Intraopera-
tive hemostasis is of prime importance. Electrocautery
should be set on the lowest effective intensity, thereby
minimizing the effect on surrounding vascularity and
avoiding increased tissue necrosis. Bipolar cauterization
causes less tissue damage with more precise action. Special
care is taken to avoid undo trauma to vascularity within
the flap pedicle. Suction drainage should be used wherever
possible (with caution to avoid suction on the flap's
pedicle). Postoperative hematomas should be identified
early and evacuated with control of bleeding. Avoid large,
occlusive dressings that interfere with observation of the
wound. Coagulopathies must be identified and treated.
ATTENTION TO FLAP ANATOMY AND
INTRAOPERATIVE MANIPULATION
Proper flap design will preserve arterial and venous
blood supply for axial flaps. The configuration of the flap
127
should adhere to the well-described construction of the
flap, and modification, based on more random circulation,
should be considered with caution. Retraction should be
minimized, and torsion of the pedicle is to be avoided.
Prevent desiccation by frequent irrigation and protecting
the flap with moistened towels during prolonged proce-
dures.
AVOID TENSION
Wound closure under tension is doomed to dehisce. Flap
design should allow for adequate coverage of the defect
without undo tension. Hesitancy to provide a flap of
adequate size will result in wound breakdown. Addition-
ally, inadequate tumor resection to avoid more extensive
reconstructive efforts will result in an increased incidence
of tumor recurrence. The flap to be used should be
determined after tumor ablation and evaluation of the
reconstructive needs of the defect. The flap pedicle should
be treated with care and provide enough length for
insetting without stretching. If the flap appears compro-
mised postoperatively, then several sutures can be re-
moved to release tension. If problems persist, the flap may
have to be removed and an alternative plan of reconstruc-
tion used. Occasionally, packing the wound and using the
flap in a delayed fashion can be considered. Torsion or
kinking of the flap pedicle will compromise distal flap
circulation. Make sure that the flap is transferred without
undue twisting and that there is no pressure constricting
circulation at the flap base.
SPECIAL CONSIDERATIONS
Random flaps are dependent on their subdermal, random-
ized blood supply (Fig 2). They do not contain specific
"named" blood vessels within their pedicle. They are often
designated by the method of mobilization, ie, advance-
ment, transposition, rotation. The length: width ratio does
not necessarily effect the survival capabilities of the distal
flap. 2 Prior radiation treatment of tissue within the region
of local random-flap selection limits the use of these flaps.
Tissue expanders provide more surface area for random
flaps and increase the length/width viability factors, but
still are more compromised in previously irradiated areas. 3
Axial skin flaps have a specific "named" vessel within
the pedicle that supplies a specific flap area (Fig 3).
Extension of the flap beyond this designated area relies on
,------ Dern~s
:i
Subdermal plexus O
.~-.a.~--~
° Subcutaneous
• ,.~,~ tissue
FIGURE 2. Random skin flap with random-pattern subdermal
vessels within mobilized flap.
128
t:
. ~ Dermis
Main axial pedicle
I ,.;f~ Subcutaneous
.... tissue
FIGURE 3. Axial skin flap with major vessels within flap pedicle.
the random subdermal circulation, and this portion of the
flap is less reliable. The length:width ratio of the flap is
proportionately greater than that of random flaps, because
there is a more reliable vascular supply. These flaps include
both skin and subcutaneous tissue, and therefore may be
thicker than random flaps. The more versatile axial flaps
include the deltopectoral and median forehead flap.
Myocutaneous flaps are supplied by named vessels
providing circulation to muscles that also supply the
overlying skin via perforators (Fig 4).4 The skin paddle is
mobilized with the underlying muscle, and the pedicle
with the nutrient vessels can be trimmed considerably to
allow for more freedom of rotation for distant reconstruc-
tion. The most frequently used myocutaneous flap for head
and neck reconstruction is the pectoralis major myocutane-
ous flap based on the pectoral branch of the thoraco-
acromial artery. 5 Other myocutaneous flaps include the
trapezius and latissimus dorsi.
The ability to successfully perform microvascular anasta-
mosis has expanded reconstructive possibilities within the
head and neck. Vascularized donor tissue no longer need
be restricted to local sites or within a pedicle's length of
rotation. The choice of multiple, distant tissue-donor sites
increases the possibility of supplying tissue that fulfills the
specific requirements of reconstruction, depending on the
Ve~
FIGURE 4. Myocutaneous flap with skin supplied by vessels
perforating through underlying muscle.
PRINCIPLES OF FLAP RECONSTRUCTION
resected area. The donor site to be used is dictated by the
area to be reconstructed and the need for an epithelial
surface, tissue bulk, and repair of bony defects. Donor-site
morbidity should also be considered in the choice of flaps.
The most commonly used flaps include the fibular osteocu-
taneous flap, radial forearm flap, rectus abdominus myocu-
taneous flap, and jejunal flap. Each of these flaps have
distinct advantages that warrant their use for particular
reconstructive requirements. The fibular osteocutaneous
flap provides large amounts of bone, up to 25 cm, that can
be contoured to reconstruct large mandibu-lar defects with
replacement of adjacent mucosa or skin. 6 Radial forearm
flaps are ideal for oral mucosal defects that require a
relatively thin epithelial skin paddle, with the ability to
recreate a sulcus so necessary for proper oral function. 7
Neural anastamoses to the lingual nerve may render the
radial forearm flap with proprioceptive capabilities. 8 Rec-
tus abdominus flaps, with or without a skin paddle, are
reliable flaps for skull-base reconstruction, repairing soft
tissue mass, and possible epithelial coverage for large
defects requiring prevention of cerebrospinal fluid leaks.
Jejunal flaps serve well for reconstruction of the pharynx
and esophagus, and represent one of the first uses of free
flaps. 9
Adhering to the basic principles of flap reconstruction
will result in successful rehabilitation of patients having
undergone tumor resection. Re-establishing form and func-
tion allows the patients to continue with their lives while
maintaining their self-image, and they have confidence in
knowing that, hopefully, not only have they undergone
MARK S. PERSKY
oncologically successful tumor ablative surgery, but they
have received the optimal reconstructive effort of the
surgeon.
REFERENCES
1. Zitelli JA: Wound healing by secondary intention. A cosmetic ap-
praisal. J Am Acad Dermatol 9:4407-4415, 1983
2. Milton SH: Pedicled skin flaps: The fallacy of the length-width ratio. Br
J Surg 57:502-508,1970
3. Kane WJ, McCaffrey TV, Wang TD, et al: The effect of tissue expansion
on the random flap viability and wound tensile strength of previously
irradiated rabbit skin. Arch Otolaryngol Head Neck Surg 119:417-422,
1993
4. McCraw JB, Vasconez LO: Musculocutaneous flaps: Colon principles.
Clin Plast Surg 7(1):9-13, 1980
5. Ariyan S: The pectoralis major myocutaneous flap. A versatile flap for
reconstruction of the head and neck. Plastic Reconstr Surg 63(1):73-81,
1979
6. Hidalgo DA: Fibular free flap: A n e w method of mandibular reconstruc-
tion. Plast Reconstr Surg 84(1):71-79, 1989
7. Evans GR, Schusterman MA, Kroll SS, et al: The radial forearm free flap
for head and neck reconstruction: A review. Am J Surg 168:446-450,
1994
8. Urken ML, Weinberg H, Vickery C, et al: The combined sensate radial
forearm and iliac crest free flaps for reconstruction of significant
glossectomy-mandibulectomy defects. Laryngoscope 102:5543-5558,
1992
9. Seidenberg B, Rosenack SS, Hurwitt ES, et al: Immediate reconstruc-
tion of the cervical esophagus by a revascularized isolated jejunal
segment. Am Surg 149:162-171,1959
129