The basic goal of head and neck reconstruction is to replace soft tissue and bony defects with similar tissue, restoring function, and optimizing cosmesis. Reconstructive surgical options are typically thought of in a hierarchy called the reconstructive ladder. (Table 78–1) Each step on the ladder increases the invasiveness and complexity of the reconstruction. Selection of the appropriate procedure depends on the defect and the goals of reconstruction.
Table 78–1. Reconstructive Ladder |Favorite Table|Download (.pdf)
Table 78–1. Reconstructive Ladder
- secondary intention
- primary closure
- split thickness skin graft
- full thickness skin graft
- tissue expansion
- local flap
- regional pedicled flap
- microvascular free-tissue transfer
Microvascular free-tissue transfer is a reconstructive technique in which tissue units are separated from their native blood supply and moved from one part of the body to a new location. The donor tissue has an identifiable artery and vein that are reanastomosed to recipient vessels, thus reestablishing blood flow. The potential for sensory reinnervation also exists through the reanastomosis of cutaneous nerves.
Refinements in free-tissue transfer over the last two decades have revolutionized the reconstruction of head and neck defects resulting from trauma, congenital anomalies, and ablative procedures for neoplastic processes. Free-tissue units are custom-designed for defects to provide characteristics similar to those of the original tissue. This versatility allows free flaps to serve multiple purposes, such as lining oropharyngeal defects and providing soft tissue support for maxillary defects. Free flaps offer other advantages because they do not have the anatomic constraints of regional pedicled flaps; they can be completed in a single stage, allow a simultaneous two-team approach, and have allowed ablative surgeons to expand their resection boundaries.
Important considerations in patient selection for free-flap reconstruction include age, comorbidities, and functional needs. Older patients are more likely to have comorbid factors that may increase their risk of exposure to prolonged anesthesia, affect wound healing, and decrease their tolerance for donor site morbidity. Some patients may not need the additional functional advantages gained from free-flap reconstruction. The risks and benefits of free-flap reconstruction must be considered for each individual patient.
Preoperative planning and communication with the anesthesia, nursing, and other involved surgical teams facilitate an efficient and well-executed surgical procedure. The tissue defect, functional needs of the patient, or both must be anticipated so that the optimal free flap is selected. Factors to be considered are donor tissue characteristics and composition, the length of pedicle, color match, soft tissue bulkiness, and the functional disability of the donor site. Communication about the patient's intraoperative position and the preservation of adequate recipient vessels in the head and neck for anastomosis should also be relayed with the appropriate teams.
Although careful preoperative planning, patient selection, and flap design are important factors in free-tissue transfers, a meticulous microvascular technique is essential for the successful insetting and revascularization ...