Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care

Abstract

Microsurgical free tissue transfer represents the mainstay of care in both ablative locoregional management and the simultaneous reconstruction of a defect. Advances 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 psychological and psychiatric factors, intraoperative surgical technique, and close postoperative 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 implications), 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, microvascular 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.

Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia

“…Expert group members completed 2 surveys where draft consensus statements were reviewed and each indicated their agreement according to a 9-point Likert Scale. The scale included the following anchors: (1) strongly disagree, (3) disagree, (5) neutral, (7) agree, (9) strongly agree in response to the request, "Please indicate your agreement with the statement. "…”

“…Head and neck cancer patients are often malnourished or unable to feed properly due to the presence of a mass obstructing or compressing the upper aerodigestive tract. [6][7][8][9][10][11] Indexes that describe poor…”

“…60 Ongoing clinical observation by trained and experienced staff is the most common method of monitoring not only sufficient flap perfusion but also overall patient wellbeing, including psychologic and nutritional support. 7,9 Additional monitoring methods such as implantable Doppler flowmetry are increasingly used, especially when transposed tissue is placed deep to other anatomic structures making clinical observation difficult, and may require additional expertise to optimize its utility. 61 ECS 14.…”

Rehabilitation Treatment and Orthopedic Prosthetics of Cancer Patients With Postoperative Defects of the Maxillofacial Region

“…The best results, in terms of survival, are obtained through a combination of chemotherapy, radiation and surgical treatment. However, surgery on the MFA is often accompanied by complex and serious defects, which can result in disturbance of the functions of chewing, swallowing, respiration, and speech [9][10][11][12][13][14]. Furthermore, cosmetic changes to the face may have a negative infl uence on the patients' mental state, and their return to society is another major problem of MFA and neck tumors.…”

Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting

“…5,7 Still, they are extremely complex procedures requiring a large swath of resources, and they have the potential to be highly morbid, with either donor or recipient site complications, prolonged intensive care unit (ICU) and hospital stays, and occasionally, mortality. [7][8][9][10][11] As such, it is imperative that these procedures should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. Previous studies have found mostly equivalent outcomes for free flaps performed in university and community hospital settings.…”