The Role of Free Flaps in Head and Neck Reconstruction

"Irrespective of the donor site, the main objective of cranial base reconstruction is to separate the CNS from the sinonasal cavity. When compared with local and pedicled flaps, free flap reconstruction has been demonstrated to be the safest and most economical method for skull base reconstruction offering the best outcomes after extensive surgical resections."

Mark L. Urken

"In our current cost-conscious medical environment, many have questioned whether complex surgical procedures such as free flaps would be supported in an era where the cost of care plays a major role in determining patient treatment."

Eugene N. Myers

"Depending on the selection of free flap, it is possible to transfer skin and subcutaneous tissue as a single entity, muscle, fascia, bone, and even nerve-muscle combinations to achieve goals of re-animation. This flexibility to transfer a combination of different types of tissue facilitates surgical creativity to precisely tailor the reconstruction to the defect by replacing the type of tissue that has been destroyed by cancer or trauma."

David E. Schuller

The Role of Free Flaps in Head and Neck Reconstruction

Eric M. Genden and Mark L. Urken

CHAPTER 13

The role of free flap surgery in contemporary head and neck reconstruction is the culmination of several decades of trying to solve a select group of reconstructive challenges, using conventional local and regional flaps, as well as an evolution in technique and technology that have enhanced the safety and reliability of this method of reconstruction. Although the first successful free flap in humans was performed in 1959, it took several decades before free tissue transfer surgery became a widely accepted method of head and neck reconstruction.1 Initially, it was the problem of the pharyngoesophageal defect and the segmental mandibulectomy defect that provided the impetus for applying microvascular surgery to the head and neck region. Over the past decade, advances in skull base surgery have led to new reconstructive demands for reliable soft tissue flaps, in order to permit the safe application of new surgical techniques to remove benign and malignant neoplasms located at the cranial base. The role of free flaps in contemporary head and neck reconstruction has become much broader than for these three defects. Reinnervated flaps have been used to restore dynamic activity for patients with facial paralysis and to restore sensation to the lining of the upper aerodigestive tract. However, a discussion of the history and of the requirements for successful restoration of circumferential pharyngoesophageal defects, segmental mandibular defects, and extensive skull base defects serves as the focus of this chapter on the role of free tissue transfer in head and neck reconstruction.

Before 1963, postablative surgical defects were either closed primarily or with random pattern or axial pattern skin flaps. As a result, functional and cosmetic outcomes were often quite poor. Limited mobility and reliability restricted the use of such donor sites as the nape of neck, acromial thoracic, and forehead flaps. These donor sites supplied a small area of cutaneous tissue with a limited arc of rotation and little or no bulk. The reconstructive techniques available at the time often limited the extent of an ablative surgical resection, compromising curative surgical therapy. Free tissue transfer in the head and neck was first reported in 1959 by Seidenberg et al.,1 who, without the benefit of an operating microscope, transferred a free jejunal segment for reconstruction of a circumferential mucosal defect after a laryngopharyngectomy. Although free tissue transfer was a novel reconstructive approach, limited donor sites, as well as extensive, often exhaustive, intraoperative time requirements, and technical limitations, prevented its widespread acceptance.

The introduction of the pedicled latissimus dorsi myocuta-neous flap by Olivari,2 in 1976, led the way for the next reconstructive technologic breakthrough, the myocutaneous flap. Along with the latissimus flap, the pectoralis flap, introduced by Ariyan in 1979,3 and the trapezius flap4 described shortly thereafter, composed the vast majority of the head and neck reconstructive armamentarium. These flaps were reliable and easy to harvest and served to reconstruct a wide range of soft tissue defects of the head and neck. The rich vascular supply of the muscle component of these myocutaneous flaps served to protect the carotid artery, while providing the reconstructive surgeon with a one-stage reconstruction that was relatively simple to harvest. However, it soon became apparent that complex hard and soft tissue defects of the pharyngoesophagus, mandible, and skull base were poorly managed by pedicled flap reconstruction. Attempts at tubing myocutaneous flaps were often fraught with complications. Similarly, mandibular reconstruction by transferring rib with pectoralis muscle led to limited success.5 Although regional myocutaneous flaps were thought to be the panacea, it became evident that predictable reconstruction of the mandibular, pharyngoesophageal, and skull base defects required a more sophisticated form of reconstruction. Furthermore, the impetus for an improved functional outcome in these areas encouraged the development of reliable free tissue transfer. During the mid- and late 1970s, when most head and neck surgeons relied on pedicled myocutaneous flaps, Taylor et al.6 and others7 identified a series of free tissue donor sites with longer and larger-diameter vascular pedicles, which resulted in a dramatic improvement in reliability and applicability. In addition to soft tissue donor sites, several composite bone flaps were described. All head and neck reconstruction has benefited from these developments in free tissue transfer, but reconstruction of the pharyngoesophagus, mandible, and the skull base have shown the most profound improvements.

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