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Microvascular free tissue transfer in head and neck and esophageal surgery
Microvascular Free Tissue Transfer in Head and Neck and Esophageal Surgery
Roger J. Tabah, MD, CM, Louisville,
Kentucky
Michael B. Flynn, MB, BCh, FACS, Louisville,
Kentucky
Robert D. Acland, FRCS, Louisville, Kentucky Joseph C. Banis, Jr., MD, Louisville, Kentucky
Aesthetic and functional deficits resulting from surgical treatment of head and neck tumors have long served as stimuli for improved methods of reconstruction. The concept of moving tissue freely from one territory of the body to another for reconstruction of severe deficits has been considered from the earliest era of modem surgery. One of the first clinical attempts at partial free tissue transfer in the head and neck region was reported by Dr. William P. Longmire in 1946 [I]. The patient described underwent esophageal reconstruction by means of a pedicled jejunal flap with the proximal end being revascularized to the internal mammary artery. This feat was carried out with 6-O silk suture and no magnification. In 1959, Seidenberg and associates [2] reported the first vascularized free tissue transfer of a free jejunal autograft, for the reconstruction of the cervical esophagus. This was followed by sporadic reports in the early 1960s that suggested the potential usefulness of the technique [3-51. A decade later, with the evolution of equipment, technique, and anatomic knowledge of cutaneous vascular supply, transfer of free cutaneous flaps became a reality [6-8]. In 1976, free flaps were first used in the reconstruction of oral cavity defects 191.Since then, a number of reports have clearly demonstrated the applications of free flap reconstruction of head and neck defects [IO-131. As a result, free microvascular transfer of bowel autografts and free flaps is no longer a curiosity applicable in isolated instances, but instead has become a recognized option in the recon-
struction neck.
of extirpative
defects
of the head and
From the Department of Surgery, University of Louisville, Louisville, Kentucky. Requests for reprints should be addressed to Michael 6. Flynn, MD. 601 South Floyd Street, Louisville, Kentucky 40202. Presented at the 30th Annual Meeting of the Society of Head and Neck Surgeons, New York, New York, May 13-17, 1994.
498
In 1978, we published our early experience with free dorsalis pedis and groin flaps in the reconstruction of oral cavity and oropharyngeal defects [14]. In 1979, we reported our initial experience with free intestinal autografts for reconstruction of pharyngolaryngoesophagectomy defects [15]. The purpose of this report is to update our experience in microvascular free tissue transfer reconstruction of head and neck and esophageal defects. Material and Methods The records of 70 patients who had undergone free tissue transfer either in conjunction with or after major ablative surgery in the head and neck region or esophagus were retrospectively reviewed. The procedures were performed at one of three University of Louisville affiliated hospitals (Norton Hospital, Jewish Hospital, and the Veterans Administration Hospital). All but one patien ::had an original diagnosis of malignant disease. In 59 of the 70 patients, extirpative surgery was planned and performed under the direction of one oncologic surgeon (MBF). The microvascular reconstructions were performed by one or both senior members of the microvascular team (RDA and JCB). All but three patients underwent ablative and reconstructive surgery simultaneously. The three remaining patients were referred for reconstructive surgery after earlier resection. Whenever possible, operative approaches were designed to allow for simultaneous performance of both the ablative and reconstructive procedures. The management and execution of the microsurgical free flap and bowel autograft procedures have been described in earlier reports [14,15]. The primary site and American Joint Committee on Cancer stage of disease were recorded and refer to the time of original diagnosis [IS]. In most instances, they approximate the site and stage at the time of free tissue transfer. Patients who had been irradiated preoperatively received 4,500 to 5,000 rads of external radiotherapy over a 4l/s to 5 week period. Postoperative radiotherapy involved me American
Journal of Surgery
Microvascular Free Tissue Transfer
dosages of 6,500 to 7,000 rads, with the highest dosage usually delivered to reduced fields. The magnitude of the ablative part of the combined procedures was classified as limited, intermediate, major, or extended. Limited resection involved procedures of lesser extent, such as excision of the primary tumor only with diiect closure. Intermediate resection involved greater amounts of soft tissue, with or without bone, for example, modified neck dissection, marginal resection of the mandible, or partial glossectomy. Major resection was more extensive resection of the primary tumor, usually with neck dissection, for example, “commando” procedures or laryngectomy with radical neck dissection. Extended resection was one that involved an aggressive excisional procedure, such as laryngopharyngoesophagectomy, bilateral neck dissection, or total glossectomy with laryngopharyngectomy. Free tissue transfers were classified either as free flaps or free bowel transfers. Free flaps were further categorized as cutaneous, myocutaneous, or osteocutaneous. Cutaneous free flaps were harvested from a number of donor sites, including the groin, dorsalis pedis, saphenous, lateral arm, and scapular areas [I 7-211. Myocutaneous free flaps consisted of either latissimus dorsi or tensor fascia lata. The osteocutaneous free flaps were taken from the lateral border of the scapula or the iliac crest, and the free bowel autografts were from the colon or jejunum [24-261. Survival of free tissue transfer was recorded as either a success, partial success, or failure. Success was defined as complete survival of the transplanted tissue, failure was necrosis of the free tissue transfer, and partial success referred to those situations in which tissue necrosis was observed to involve less than 50 percent of the volume of the tissue transfer. Vascular insufficiency is used herein to indicate impaired inflow to or outflow from the transferred tissue. Such impairment leads to tissue anoxia and if uncorrected, ultimately to necrosis of the tissue. Postoperative detection of vascular insufficiency was calculated from the time the patient was transported from the operating room. Local complications were those wound complications restricted to the site of the extirpative procedure. Local wound complications were classified as minor or major. Minor local wound complications usually resolved spontaneously, occasionally required surgical intervention, and never endangered the patient’s life. These included marginal flap necrosis, minor salivary fist&s, delay in wound healing, and local cellulitis. Major, potentially lifethreatening local wound complications did not resolve spontaneously, often required surgical intervention, and included complete wound breakdown, hemorrhage, abscess formation, or exposure of the great vessels of the neck. Results Between March 1,1977 and May 1,1983,70 patients underwent 75 free tissue transfers for esophageal and head and neck defects. Five patients re-
ceived two free tissue transfers. Three of these patients had the second procedure performed as part of the treatment of recurrent disease, and one patient had two free tissue transfers performed simultaneously. The fifth patient underwent the second procedure after failure of an earlier flap. Fifty of the 70 patients were male and 20 were fevolum4 149, octob4r 1994
male. The mean age of the patients at the time of diagnosis was 60 f 11 years, with a range of 14 to 90 years. Sixty-nine patients had a diagnosis of malignancy. The remaining patient suffered from a lymphangioma of the oral cavity. Sixty-five patients had a histologic diagnosis of squamous cell carcinoma. In the four remaining patients, there was one diagnosis of mucoepidermoid carcinoma, one of adenocarcinoma, one of poorly differentiated carcinoma, and one of malignant carcinoid. Of the 70 patients, the original site of tumor was the oral cavity in 41 (59 percent), the oropharynx in 15 (21 percent), the hypopharynx in 6 (9 percent), the larynx in 3 (4 percent), the skin in 3 (4 percent), and the thoracic esophagus in 2 (3 percent). In the patients with malignant disease, staging at the time of diagnosis was as follows: 1 patient was in stage I, 29 patients (42 percent) were in stage II, 26 patients (38 percent) were in stage III, and 13 patients (19 percent) were in stage IV. Of 75 microsurgical reconstructive procedures, previous treatment consisted of surgery alone in 6 patients (8 percent), radiotherapy alone in 17 patients (23 percent), combined surgery and radiotherapy in 19 patients (25 percent), chemotherapy alone in 4 patients (5 percent), combined chemotherapy and radiotherapy in 3 patients (4 percent), and surgery, radiotherapy, and chemotherapy in 2 patients (3 percent). Only 24 patients (32 percent) underwent combined ablative and reconstructive surgery as initial treatment. None of the 75 procedures involved a resection classified as limited. Four procedures (5 percent) were classified as intermediate resections, 34 (45 percent) were major resections, and 37 (49 perce&) were extended resections. The duration of surgery was less than 6 hours for 7 procedures (9 percent), between 6 and 10 hours for 49 procedures (65 percent), between 10 and 14 hours for 16 procedures (21 percent), and longer than 14 hours for 3 procedures (4 percent). There were 44 cutaneous flaps, 14 myocutaneous flaps, 3 osteocutaneous flaps, and 14 free bowel autografts. Our greatest experience was with the dorsalis pedis (20 procedures), groin (13 procedures), and latissimus dorsi (13 procedures) free flaps and with free jejunal autografts (12 procedures) (Table I). Successful free tissue transfer was recorded in 68 of the 75 procedures (91 percent). In three patients, vascular insufficiency occurred early, and the cause was corrected at reoperation. Partial success was observed in two patients reconstructed with dorsalis pedis free flaps. Failure occurred ‘.Afive patients (7 percent). Two of these patients underwent reoperations for salvage which were unsuccessful. In the remaining three patients, reoperation was not attempted because of the patients’ systemic condition or because of frank necrosis of the transplanted tissue. Failure was encountered in two groin, one dorsalis pedis, one latissimus dorsi, and in one lateral arm free flap (Table II). 499
Tabah et
al
TABLE I
Type ot Free Tissue Transfer In Relation to SHa ot Primary TUmOr
Cutaneousflaps Groin Dorsalispedis Sapnenous Lateral arm Scapular h4yocutaneous flaps LatlssimusUorsi Tensorfascia lata Osteocutaneousflaps Scapular6 bone Iliac crest Free bowel autografts Jejunum Colon Total
TABLE II
Oropharynx
11 19 1 4
... ...
2
Cutaneousflaps Groin Oorsalispedis Sapnenous Lateral arm Scapular Myocutaneousflaps Latlssimusdorsi Tensor fascia lata Osteocutaneousflaps Scapular8 bone iliac crest Free bowel autografts Jejunum Colon
11113 17120 l/l 617 313 12113 l/l
66175
(90%)
:i
13 1
... . *.
... ...
... ...
... ...
2 1
3 1
1 1
6
... ...
2
...
...
12 2
16
3
7
3
2
75
...
... ... 44
1
1
TABLE Ill
Failure 2113 l/20
ii;
...
*. .
...
1113
... ...
... ... 5175 (7%)
Of 75 free tissue transfers, only 5 were used for external defects. The remaining 70 were used for mucosal defects of the head and neck. Of the latter transfers, 63 (90 percent) were entirely successful, 2 (3 percent) were partially successful, and 5 (7 percent) were failures. Vascular insufficiency became evident postoperatively in 8 of 75 cases. Vascular insufficiency was detected within the first 12 hours after operation in three cases, between 12 to 24 hours postoperatively in one case, between 24 and 72 hours postoperatively in two cases, and after 72 hours in two cases. Five of the patients underwent immediate reoperation with successful reestablishment of blood flow in three patients. In three cases, vascular insufficiency was due to arterial thrombosis and in two, to venous thrombosis. Infection and torsion on the vascular
500
1 2
... ... ... ... ... ... ...
1 1
2175 (3%)
... . *. ...
Total
... ...
7
212 l/l 12112 212
1
Esophagus
... ...
...
... ...
...
Skin
... ...
6 1
ilib
... ... ...
t-Mpharynx
...
...
1 1
Partial success
Larynx
... ... ...
Outcome of 75 Free Tissue Transfers In Relation to Donor Site Success
Total
Oral Cavity
Previous radiation No previous radlation
1 7 3
Success of Free Tissue Transfer in Relation to Prevlous Radiology success
Partial Success
Failure
36/41(66%)
l/41 (2%)
4/41(10%)
32134 (94%)
l/34 (3%)
l/34 (3%)
pedicle were responsible in one case each. In one instance, the cause was multifactorial. Age was found to have no bearing on the outcome of free tissue transfer as 92 percent of the patients younger than the median age of 61 years and 88 percent of those older than the median age had successful procedures. Similarly, sex of the patient had no effect as 91 percent of the male patients and 90 percent of the female patients had successful procedures. Of 41 previously irradiated patients, regardless of dose or other associated therapeutic modalities, success of free tissue transfer was observed in 36 (88 percent), partial success in l(2 percent), and failure in 4 (10 percent). Of 34 nonirradiated patients, success was recorded in 32 (94 percent), partial success in 1 (3 percent), and failure in 1 (3 percent) (Table III). Of the 75 free tissue transfers, 17 (23 percent) were performed without donor, systemic, or local complications. Three perioperative deaths accounted for an operative mortality of 4 percent. The causes of death included myocardial infarction, cerebrovascular accident, and carotid artery hemorrhage. Forty-one procedures (55 percent) were followed by systemic complications. Respiratory tract complications were the most frequent systemic complication and occurred in 24 patients (32 percent). Cardiovascular complications were noted in 10 patients (13
RH)American
Journal of Sufgory
Microvascular Free Tissue Transfer
TABLE IV
Specific Donor Sfte Compllcatlons in Relation to Type of Free Tissue Transfer Groin Flap
Complications Minorskin graft loss Major skin graft loss Seroma Hemorrhage Hematoma Woundseparation,impairedhealing Infection IntussusceDtion
. iii3
Dorsalis Pedis Flap l/20 4120 2120
. ..
. ::: .
2/20
i;;
it13
l/20
...
...
.. ...
percent). Fourteen procedures (19 percent) were complicated by miscellaneous systemic events in the postoperative period. Local wound complications were noted in 27 patients (36 percent). Twenty-one wound complications (28 percent) were classified as minor, and the remaining 6 (8 percent) were classified as major. Local wound complications were more frequent in patients who had received previous radiotherapy. Of 41 procedures in which the patients had previous radiotherapy, local wound complications were noted in 18 (44 percent). Of 34 procedures in which the patients had no previous radiotherapy, local wound complications occurred in 9 (27 percent). Of the 75 free tissue transfers, donor site complications were noted in 17 (23 percent). Ten of these complications involved the dorsalis pedis donor site (Table IV). The mean hospital stay for all 75 procedures was 26 f 14 days, with a range of 7 to 90 days. In those patients without donor, local, or systemic complications, mean hospital stay was 16 f 4 days. In those patients with either donor, local, or systemic complications, and in those who experienced failure of free tissue transfer, the mean hospital stay was 29 f 15 days. Comments Free tissue transfer for the reconstruction of head and neck and esophageal defects was completely successful in 68 of the 75 cases (90 percent). Complete failure, which required removal of the necrotic tissue flap, was encountered in five cases (7 percent). Partial success, which required minor debridement and standard local wound care to achieve healing, was observed in two cases of free tissue transfers (3 percent). Reconstruction of the defect was successful in 70 cases (more than 93 percent). These observations compare favorably with those from our earlier report in which, of a total of 19 free tissue transfers, success was noted in 14 instances, partial success in 1, and failure in 4 [14]. The success of microvascular free tissue transfer in head and neck surgery is dependent on several elements, not the least of which is exacting surgical
volume149,ocmber1984
Lateral Arm Flap
Latissimus Dorsi Flap
. .. .. ...
l’/G
...
Iliac Crest FlaD
Jejunal Autowaft
.
Total 1
4 4 ;;i . .. .. .
.
1
...
.. . .
17’12
3 3 1
technique. Factors critical for success include close cooperation between the extirpative and reconstructive teams, a cooperative anesthesiologist and specially trained scrub nurses; proper maintenance of the operating microscope and microsurgical instruments; careful positioning of the patient; meticulous hemostasis; and correct design and positi&ing of a vascular pedicle to avoid kinking, stretching, or tension on the anastomosis [ZS]. Also of great importance is careful preoperative planning, with examination of the patient under anesthesia if necessary, so that the extent of the extirpative defect can be estimated and the optimal donor site of the free tissue transfer chosen. During the postoperative period, monitoring of the free tissue flap allows for earlier detection of vascular insufficiency and a better chance of successful reoperation. The basis of sound monitoring continues to be clinical judgment based on the traditional signs of color, blanching, and return of capillary refill in response to pressure and release, and brisk red bleeding in response to a pin prick. Although temperature monitoring can be of use where a free flap is used for skin cover, it is not useful for intraoral flaps since even a dead flap in this location maintains its temperature through body heat conduction. Recently, the photoplethysmograph has been used as an adjunct in monitoring. It has been particularly helpful in the monitoring of inaccessible flaps and in black patients. The photoplethysmograph consists of an infrared light source and a photoelectric cell. The emitted infrared light penetrates the surface of the tissue to a depth of several millimeters. The amount of light reflected back to the photoelectric cell varies with pulsatile changes at the capillary arteriolar level. This is recorded and displayed in a graphic fashion [27]. With free bowel transfers, because the transplanted jejunum is buried deep within the soft tissues of the neck, clinical examination of the tissue is rarely possible. To overcome this difficulty, a segment of 2 to 3 cm of the distal jejunal segment is separated, with care taken not to disturb its own vascular and mesenteric pedicle. This isolated monitor flap is brought out through the neck wound leaving it widely
501
Tabah et al
exposed where clinical and photoplethysmographic monitoring can easily be accomplished. Once the success of the free jejunal autograft is ensured, usually after 5 to 7 days, the pedicle of the monitor flap is ligated and divided at the skin edge. To date, no complications referrable to the use of this monitor flap have occurred. The selection of the donor flap depends largely on the location of the defect (Table II). Thinner dorsalis pedis and lateral arm flaps are more suitable for anterior defects in the oral cavity. This is especially true when the integrity of the mandibular arch is maintained, and it is necessary to cover a soft tissue defect that includes a rim of bone. Thin flaps will drape over the rim of bone and conform to the contour of the defect, which results in the best possible functional result. Posteriorly, in the oral cavity and in the oropharynx, a more bulky flap is preferred, particularly when excision of a portion of the mandible has given rise to a deep defect. It is important not to make the flap too large for the defect because excessive bulk can greatly hamper oral function. In outlining the flap, a template the same size as the defect is used to ensure an accurate fit. The standard free tissue transfers are devoid of intrinsic function, with the exception of the free bowel autografts. Their use in repairing defects of the oral cavity and oropharynx greatly improves function when compared with the practice of simply collapsing defects. The functional results when free flaps and pedicle flaps are compared are very similar. Exact tailoring of this flap to the defect and the absence of the mobility restrictions of the pedicle flaps produce a somewhat improved functional result with the free flap. The proper choice and positioning of a free flap in these situations can increase the volume of the upper aerodigestive tract and may act as a strut against which muscles pull or as a gutter, which facilitates oral continence and deglutition. In contrast to other methods of reconstructing head and neck defects, such as the forehead flap, the deltopectoral axial flaps, and the pectoralis major myocutaneous flap, free flaps offer several advantages. The wide choice in donor sites allows for more versatility. Free flaps can be chosen on the basis of bulk and can be trimmed to repair a defect optimally. There is a greater degree of freedom in the positioning of free flaps as their vascular pedicles are obviously more mobile. When free flaps are used for a mucosal defect, there is no need to create and subsequently close a controlled salivary fistula. Also, the vascularity of a free tissue transfer is more reliable-a factor which, under certain circumstances, such as previous radiotherapy, allows for improved wound healing. The survival of free tissue transfer in this study is comparable to that observed using the forehead and deltopectoral flaps under similar circumstances [28-321. The absence of a donor site in the head and neck region represents one of the major
502
advantages of this method of reconstruction. From a purely aesthetic standpoint, the improved appearance, when compared with various types of forehead, neck, and scalp flaps, is so obvious that the comparison becomes ludicrous. Even with less dramatic comparisons, such as the deltopectoral and pectoral myocutaneous flaps, the aesthetic benefits are clear. If postoperative radiotherapy is planned, it can be started within 2 to 3 weeks of surgery in patients demonstrating uncomplicated wound healing. When a free bowel transfer is contemplated, preoperative radiotherapy is recommended. Late stricture and fistula formation, as well as enteritis of the transplanted intestine, may occur when the patient is subjected to therapeutic doses of postoperative irradiation. Failure of free tissue transfer in previously irradiated patients was three times more frequent than in nonirradiated patients (Table III). This increased risk of failure is not a contraindication but rather an impetus for greater attention to detail, especially in selecting appropriate recipient vessels and in performing the microvascular anastomosis. Recipient vessels selected were commonly the facial artery and vein early in the series. The external carotid artery has been the preferred recipient artery since 1979 due to better ability to perform an adequate end-to-side anastomosis to this vessel. This obviates the frustrating problems we have occasionally had due to arterial vasoconstriction in an end-cut vessel. It is a particularly important consideration in transfer into an irradiated recipient bed where irradiation damage to the recipient vessels has occurred. Previous radiotherapy does not contraindicate the procedure, however, but simply means large vessels must be found and a meticulous endto-side anastomosis performed. For similar reasons, we often use the large, high flow internal jugular vein as the recipient vein. Alternatively, large external jugular or anterior facial veins can be utilized for venous drainage, and facial, lingual, and superior or inferior thyroid arteries can be used as a second choice for recipient arterial supply. Occasionally, the common carotid artery has been used for arterial supply when necessitated by an absence of other suitable vessels. In certain full-thickness defects, we have used folded free cutaneous flaps, with an intervening portion denuded of skin so that both the mucosal lining and skin cover may be provided from the same flap. This affords an economy of donor tissue. Great care is taken in the deepithelialization and folding of the free flap. No specific complication has been encountered in the use of this technique. An additional method of obtaining internal and external coverage is possible with the use of the scapular flap, on which pedicle a multiple flap pattern may be designed, with independent positioning of these flaps then being possible.
The American Journal of Surgery
Microvascular
Donor site complications occurred most commonly with the dorsalis pedis free flap (Table II). Indeed, the 10 recorded complications represent half of our experience with dorsalis pedis donor sites. The dorsalis pedis free flaps represent a special situation since the donor defect cannot be closed primarily, as is the case with most other donor sites. In our hands, proper closure requires split-thickness skin grafting, adequate bolus dressing, immobilization of the foot for a period of 7 to 10 days, and particular attention to the avoidance of undue dressing pressure on the skin graft. Attention to donor care with respect to these details has reduced the complications associated with this donor site to none in the most recent 10 consecutive cases. The rates of local wound complications that we observed in irradiated and nonirradiated patients (44 percent and 27 percent, respectively) are comparable to those recorded in earlier reports that dealt with patients who had undergone extirpative head and neck surgery [33-351. Respiratory tract complications were recorded in 32 percent of the procedures in this series, which is in agreement with an earlier report that identified respiratory tract complications as the most common systemic complications in a group of patients undergoing extensive head and neck surgery [33 1. In our experience, cardiovascular complications were the second most commonly encountered systemic complications. The mean hospital stay for patients with either donor, systemic, or local complications and for those who experienced failure of free tissue transfer (29 f 15 days) was nearly double that of those whose course was uncomplicated (15 f 4 days). Summary Successful reconstruction for excisional defects of the head and neck and esophagus was accomplished in 93 percent of our patients using microvascular free tissue transfer. Complete failure occurred in 7 percent of the patients. Major defects after head and neck cancer surgery constituted the main indication for use of microvascular free tissue transfer for reconstruction. Ninety-four percent of the patients had undergone an extensive excisional procedure. A wide range of cutaneous, myocutaneous, and osteocutaneous free flaps, as well as free bowel autotransfers were used. Complete failure was three times higher in the previously irradiated patients (4 of 41 patients) compared with nonirradiated patients (1 of 34 patients). Morbidity and mortality rates were consistent with expected ranges in patients who were undergoing major head and neck resection. Donor site complications occurred in 23 percent. Thin flaps are favored for reconstruction of anterior defects in the oral cavity, whereas bulkier flaps are more suitable for deeper defects in the oropharynx and hypopharynx. The advantages are both aesthetic and functional. The free jejunal autograft is considered
Volums148,Ociober1984
Free Tissue Transfer
the reconstructive method of choice for defects produced by laryngopharyngoesophagectomy. Highly developed and sophisticated microsurgical skills continue to be the mainstay of success. The implication of free tissue transfer failure, especially for defects of the upper aerodigestive tract, are impressive in terms of morbidity, mortality, and cost. These considerations limit the application of this method of reconstruction to centers that have sophisticated and productive reconstructive surgeons with microsurgical skills. References 1. Longmire WP, Jr., Baltimore MD. A modification of the Roux technique for antethoracic esophageal reconstruction. Surgery 1947;22:94. 2. Seklenberg B, Rosenak S, Hurwitt ES, Som ML. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 1959; 149: 162. 3. Roberts RE, Douglass FM. Replacement of the cervical esophagus and hypopharynx by a revascularized free jejunal autograft. N Engl J Med 196 1;264:342. 4. Nakayama K, Yamamoto K, Tamiya T, et al. Experience with free autografts of bowel with a new venous anastomosis apparatus. Surgery 1904;55:796. 5. Jurkiewicz MI. Vascularized intestinal graft for reconstruction of the cervical esophagus and pharynx. Plast Reconstr Surg 1965;36:509. 6. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomosis. Plast Reconstr Surg 1973;52: 111. 7. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243. 8. Acland RD. Instrumentation for microsugerY. Dtthop Clin North Am 1977;8:281. 9. Panje WR, Bardach J, Krause CJ. Reconstruction of the oral cavitv with a free flao. Plast Reconstr Sum 1976:58:415. 10. Leeb DC, Ben-liur N. M&arella L. Reconstru~ion of the floor of the mouth with a free dorsalis pedis flap. Plast Reconstr Surg 1977;59:379. 11. Zuker RM, Rosen IB, Palmer JA, et al. Microvascular free flaps in head and neck reconstruction. Can J Surg 1980;23: 157. 12. Zuker RM, Manktelow RT, Palmer JA. Rosen IB. Head and neck reconstruction following resection of carcinoma using microvascular free flaps. Surgery 1980;88:461. 13. Serafin D, Villarreal-Rios A, Georgiada NG. A rib containing free flap to reconstruct mandibular defects. Br J Plast Surg 1977;30:263. 14. Acland RD, Flynn MB. Immediate reconstruction of oral cavity defects using microvascular free flaps. Am J Surg 1978; 136:419. 15. Flynn MB, Acland RD. Free intestinal autografts for redonstruction following pharyngolaryngoesophagectomy. Surg Gynecol Obstet 1979;149:858. 16. Chandler JR. Guillamor&gui DM, Sisson GA, Strong EW, Baker HW. Clinical staging of cancer of the head and neck: a new “new” system. Am J Surg 1976;132:525. 17. Acland RD. The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg 1978:64:419. 18. Robinson DW. Dorsalis pedis flap in ‘microsurgical composite tissue transplantation’ St. Louis: CV Mosby, 1979;25784. 19. Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular free flap. Plast Reconstr Surg 1981;67: 763. 20. Katsaros J, Acland RD, Banis JC, Schusterman M, Beppu M. The lateral arm free flap. Ann Plast Surg 1984:6:489500.
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21. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982;69:601. 22. Maxwell GP, Stueber K, Hoopes JE. Free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1978;62:462. 23. Hill HL, Nahai F, Vasconez LO. The tensor fascia lata myocutaneous free flap. Plast Reconstr Surg 1978;61:517. 24. Teot L, Bosse JP, Moufarrege R, Papillon J, Beauregard G. The scapular crest pedicled bone graft. Int J Microsurg 1981; 31257. 25. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: clinical work. Plast Reconstr Surg 1979;64:745. 26. Acland RD. Factors that influence success in microvascular surgery. In: Serafin D, Buncke HJ eds. Microsurgical composite tissue transplantation. St. Louis: CV Mosby, 1979. 27. Creech BJ, Thorne FL. The pocket photoplethysmograph. Plast Reconstr Surg 1972;49:380. 28. Rosen IB, Palmer JA, Knutson GA. Comparison of recons-
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29. 30. 31.
32. 33. 34. 35.
tructive methods used following ablative head and neck operations. Can J Surg 1980;23:45. Bakamjian V. The deltopectoral flap. In: Grabb MC, Myers, MB, eds. Skin flaps. Boston: Little, Brown 1975. Lore JM, Zingapan EG. Deltopectoral flap. Arch Otolaryngol 1971;94:13. Krizek TJ, Robson MC. The deltopectoral flap for reconstruction of irradiated cancer of the head and neck.‘Surg Gynecol Obstet 1972;135:787. Rothaus KO, Acland RD. Free flap neovascularization: case report. Br J Plast Surg 1983;36:350. Flynn MB. Morbidity and mortality of mandibular resection for malignant disease. Am J Surg 1977;134:510. Donald PJ. Complications of combined therapy in head and neck carcinomas. Arch Otolaryngol 1976;104:329. Joseph DL, Shumrick DL. Risks of head and neck surgery in previously irradiated patients. Arch Otolaryngol 1973;97: 381.
The American Journal of Surgery
Roger J. Tabah, MD, CM, Louisville,
Kentucky
Michael B. Flynn, MB, BCh, FACS, Louisville,
Kentucky
Robert D. Acland, FRCS, Louisville, Kentucky Joseph C. Banis, Jr., MD, Louisville, Kentucky
Aesthetic and functional deficits resulting from surgical treatment of head and neck tumors have long served as stimuli for improved methods of reconstruction. The concept of moving tissue freely from one territory of the body to another for reconstruction of severe deficits has been considered from the earliest era of modem surgery. One of the first clinical attempts at partial free tissue transfer in the head and neck region was reported by Dr. William P. Longmire in 1946 [I]. The patient described underwent esophageal reconstruction by means of a pedicled jejunal flap with the proximal end being revascularized to the internal mammary artery. This feat was carried out with 6-O silk suture and no magnification. In 1959, Seidenberg and associates [2] reported the first vascularized free tissue transfer of a free jejunal autograft, for the reconstruction of the cervical esophagus. This was followed by sporadic reports in the early 1960s that suggested the potential usefulness of the technique [3-51. A decade later, with the evolution of equipment, technique, and anatomic knowledge of cutaneous vascular supply, transfer of free cutaneous flaps became a reality [6-8]. In 1976, free flaps were first used in the reconstruction of oral cavity defects 191.Since then, a number of reports have clearly demonstrated the applications of free flap reconstruction of head and neck defects [IO-131. As a result, free microvascular transfer of bowel autografts and free flaps is no longer a curiosity applicable in isolated instances, but instead has become a recognized option in the recon-
struction neck.
of extirpative
defects
of the head and
From the Department of Surgery, University of Louisville, Louisville, Kentucky. Requests for reprints should be addressed to Michael 6. Flynn, MD. 601 South Floyd Street, Louisville, Kentucky 40202. Presented at the 30th Annual Meeting of the Society of Head and Neck Surgeons, New York, New York, May 13-17, 1994.
498
In 1978, we published our early experience with free dorsalis pedis and groin flaps in the reconstruction of oral cavity and oropharyngeal defects [14]. In 1979, we reported our initial experience with free intestinal autografts for reconstruction of pharyngolaryngoesophagectomy defects [15]. The purpose of this report is to update our experience in microvascular free tissue transfer reconstruction of head and neck and esophageal defects. Material and Methods The records of 70 patients who had undergone free tissue transfer either in conjunction with or after major ablative surgery in the head and neck region or esophagus were retrospectively reviewed. The procedures were performed at one of three University of Louisville affiliated hospitals (Norton Hospital, Jewish Hospital, and the Veterans Administration Hospital). All but one patien ::had an original diagnosis of malignant disease. In 59 of the 70 patients, extirpative surgery was planned and performed under the direction of one oncologic surgeon (MBF). The microvascular reconstructions were performed by one or both senior members of the microvascular team (RDA and JCB). All but three patients underwent ablative and reconstructive surgery simultaneously. The three remaining patients were referred for reconstructive surgery after earlier resection. Whenever possible, operative approaches were designed to allow for simultaneous performance of both the ablative and reconstructive procedures. The management and execution of the microsurgical free flap and bowel autograft procedures have been described in earlier reports [14,15]. The primary site and American Joint Committee on Cancer stage of disease were recorded and refer to the time of original diagnosis [IS]. In most instances, they approximate the site and stage at the time of free tissue transfer. Patients who had been irradiated preoperatively received 4,500 to 5,000 rads of external radiotherapy over a 4l/s to 5 week period. Postoperative radiotherapy involved me American
Journal of Surgery
Microvascular Free Tissue Transfer
dosages of 6,500 to 7,000 rads, with the highest dosage usually delivered to reduced fields. The magnitude of the ablative part of the combined procedures was classified as limited, intermediate, major, or extended. Limited resection involved procedures of lesser extent, such as excision of the primary tumor only with diiect closure. Intermediate resection involved greater amounts of soft tissue, with or without bone, for example, modified neck dissection, marginal resection of the mandible, or partial glossectomy. Major resection was more extensive resection of the primary tumor, usually with neck dissection, for example, “commando” procedures or laryngectomy with radical neck dissection. Extended resection was one that involved an aggressive excisional procedure, such as laryngopharyngoesophagectomy, bilateral neck dissection, or total glossectomy with laryngopharyngectomy. Free tissue transfers were classified either as free flaps or free bowel transfers. Free flaps were further categorized as cutaneous, myocutaneous, or osteocutaneous. Cutaneous free flaps were harvested from a number of donor sites, including the groin, dorsalis pedis, saphenous, lateral arm, and scapular areas [I 7-211. Myocutaneous free flaps consisted of either latissimus dorsi or tensor fascia lata. The osteocutaneous free flaps were taken from the lateral border of the scapula or the iliac crest, and the free bowel autografts were from the colon or jejunum [24-261. Survival of free tissue transfer was recorded as either a success, partial success, or failure. Success was defined as complete survival of the transplanted tissue, failure was necrosis of the free tissue transfer, and partial success referred to those situations in which tissue necrosis was observed to involve less than 50 percent of the volume of the tissue transfer. Vascular insufficiency is used herein to indicate impaired inflow to or outflow from the transferred tissue. Such impairment leads to tissue anoxia and if uncorrected, ultimately to necrosis of the tissue. Postoperative detection of vascular insufficiency was calculated from the time the patient was transported from the operating room. Local complications were those wound complications restricted to the site of the extirpative procedure. Local wound complications were classified as minor or major. Minor local wound complications usually resolved spontaneously, occasionally required surgical intervention, and never endangered the patient’s life. These included marginal flap necrosis, minor salivary fist&s, delay in wound healing, and local cellulitis. Major, potentially lifethreatening local wound complications did not resolve spontaneously, often required surgical intervention, and included complete wound breakdown, hemorrhage, abscess formation, or exposure of the great vessels of the neck. Results Between March 1,1977 and May 1,1983,70 patients underwent 75 free tissue transfers for esophageal and head and neck defects. Five patients re-
ceived two free tissue transfers. Three of these patients had the second procedure performed as part of the treatment of recurrent disease, and one patient had two free tissue transfers performed simultaneously. The fifth patient underwent the second procedure after failure of an earlier flap. Fifty of the 70 patients were male and 20 were fevolum4 149, octob4r 1994
male. The mean age of the patients at the time of diagnosis was 60 f 11 years, with a range of 14 to 90 years. Sixty-nine patients had a diagnosis of malignancy. The remaining patient suffered from a lymphangioma of the oral cavity. Sixty-five patients had a histologic diagnosis of squamous cell carcinoma. In the four remaining patients, there was one diagnosis of mucoepidermoid carcinoma, one of adenocarcinoma, one of poorly differentiated carcinoma, and one of malignant carcinoid. Of the 70 patients, the original site of tumor was the oral cavity in 41 (59 percent), the oropharynx in 15 (21 percent), the hypopharynx in 6 (9 percent), the larynx in 3 (4 percent), the skin in 3 (4 percent), and the thoracic esophagus in 2 (3 percent). In the patients with malignant disease, staging at the time of diagnosis was as follows: 1 patient was in stage I, 29 patients (42 percent) were in stage II, 26 patients (38 percent) were in stage III, and 13 patients (19 percent) were in stage IV. Of 75 microsurgical reconstructive procedures, previous treatment consisted of surgery alone in 6 patients (8 percent), radiotherapy alone in 17 patients (23 percent), combined surgery and radiotherapy in 19 patients (25 percent), chemotherapy alone in 4 patients (5 percent), combined chemotherapy and radiotherapy in 3 patients (4 percent), and surgery, radiotherapy, and chemotherapy in 2 patients (3 percent). Only 24 patients (32 percent) underwent combined ablative and reconstructive surgery as initial treatment. None of the 75 procedures involved a resection classified as limited. Four procedures (5 percent) were classified as intermediate resections, 34 (45 percent) were major resections, and 37 (49 perce&) were extended resections. The duration of surgery was less than 6 hours for 7 procedures (9 percent), between 6 and 10 hours for 49 procedures (65 percent), between 10 and 14 hours for 16 procedures (21 percent), and longer than 14 hours for 3 procedures (4 percent). There were 44 cutaneous flaps, 14 myocutaneous flaps, 3 osteocutaneous flaps, and 14 free bowel autografts. Our greatest experience was with the dorsalis pedis (20 procedures), groin (13 procedures), and latissimus dorsi (13 procedures) free flaps and with free jejunal autografts (12 procedures) (Table I). Successful free tissue transfer was recorded in 68 of the 75 procedures (91 percent). In three patients, vascular insufficiency occurred early, and the cause was corrected at reoperation. Partial success was observed in two patients reconstructed with dorsalis pedis free flaps. Failure occurred ‘.Afive patients (7 percent). Two of these patients underwent reoperations for salvage which were unsuccessful. In the remaining three patients, reoperation was not attempted because of the patients’ systemic condition or because of frank necrosis of the transplanted tissue. Failure was encountered in two groin, one dorsalis pedis, one latissimus dorsi, and in one lateral arm free flap (Table II). 499
Tabah et
al
TABLE I
Type ot Free Tissue Transfer In Relation to SHa ot Primary TUmOr
Cutaneousflaps Groin Dorsalispedis Sapnenous Lateral arm Scapular h4yocutaneous flaps LatlssimusUorsi Tensorfascia lata Osteocutaneousflaps Scapular6 bone Iliac crest Free bowel autografts Jejunum Colon Total
TABLE II
Oropharynx
11 19 1 4
... ...
2
Cutaneousflaps Groin Oorsalispedis Sapnenous Lateral arm Scapular Myocutaneousflaps Latlssimusdorsi Tensor fascia lata Osteocutaneousflaps Scapular8 bone iliac crest Free bowel autografts Jejunum Colon
11113 17120 l/l 617 313 12113 l/l
66175
(90%)
:i
13 1
... . *.
... ...
... ...
... ...
2 1
3 1
1 1
6
... ...
2
...
...
12 2
16
3
7
3
2
75
...
... ... 44
1
1
TABLE Ill
Failure 2113 l/20
ii;
...
*. .
...
1113
... ...
... ... 5175 (7%)
Of 75 free tissue transfers, only 5 were used for external defects. The remaining 70 were used for mucosal defects of the head and neck. Of the latter transfers, 63 (90 percent) were entirely successful, 2 (3 percent) were partially successful, and 5 (7 percent) were failures. Vascular insufficiency became evident postoperatively in 8 of 75 cases. Vascular insufficiency was detected within the first 12 hours after operation in three cases, between 12 to 24 hours postoperatively in one case, between 24 and 72 hours postoperatively in two cases, and after 72 hours in two cases. Five of the patients underwent immediate reoperation with successful reestablishment of blood flow in three patients. In three cases, vascular insufficiency was due to arterial thrombosis and in two, to venous thrombosis. Infection and torsion on the vascular
500
1 2
... ... ... ... ... ... ...
1 1
2175 (3%)
... . *. ...
Total
... ...
7
212 l/l 12112 212
1
Esophagus
... ...
...
... ...
...
Skin
... ...
6 1
ilib
... ... ...
t-Mpharynx
...
...
1 1
Partial success
Larynx
... ... ...
Outcome of 75 Free Tissue Transfers In Relation to Donor Site Success
Total
Oral Cavity
Previous radiation No previous radlation
1 7 3
Success of Free Tissue Transfer in Relation to Prevlous Radiology success
Partial Success
Failure
36/41(66%)
l/41 (2%)
4/41(10%)
32134 (94%)
l/34 (3%)
l/34 (3%)
pedicle were responsible in one case each. In one instance, the cause was multifactorial. Age was found to have no bearing on the outcome of free tissue transfer as 92 percent of the patients younger than the median age of 61 years and 88 percent of those older than the median age had successful procedures. Similarly, sex of the patient had no effect as 91 percent of the male patients and 90 percent of the female patients had successful procedures. Of 41 previously irradiated patients, regardless of dose or other associated therapeutic modalities, success of free tissue transfer was observed in 36 (88 percent), partial success in l(2 percent), and failure in 4 (10 percent). Of 34 nonirradiated patients, success was recorded in 32 (94 percent), partial success in 1 (3 percent), and failure in 1 (3 percent) (Table III). Of the 75 free tissue transfers, 17 (23 percent) were performed without donor, systemic, or local complications. Three perioperative deaths accounted for an operative mortality of 4 percent. The causes of death included myocardial infarction, cerebrovascular accident, and carotid artery hemorrhage. Forty-one procedures (55 percent) were followed by systemic complications. Respiratory tract complications were the most frequent systemic complication and occurred in 24 patients (32 percent). Cardiovascular complications were noted in 10 patients (13
RH)American
Journal of Sufgory
Microvascular Free Tissue Transfer
TABLE IV
Specific Donor Sfte Compllcatlons in Relation to Type of Free Tissue Transfer Groin Flap
Complications Minorskin graft loss Major skin graft loss Seroma Hemorrhage Hematoma Woundseparation,impairedhealing Infection IntussusceDtion
. iii3
Dorsalis Pedis Flap l/20 4120 2120
. ..
. ::: .
2/20
i;;
it13
l/20
...
...
.. ...
percent). Fourteen procedures (19 percent) were complicated by miscellaneous systemic events in the postoperative period. Local wound complications were noted in 27 patients (36 percent). Twenty-one wound complications (28 percent) were classified as minor, and the remaining 6 (8 percent) were classified as major. Local wound complications were more frequent in patients who had received previous radiotherapy. Of 41 procedures in which the patients had previous radiotherapy, local wound complications were noted in 18 (44 percent). Of 34 procedures in which the patients had no previous radiotherapy, local wound complications occurred in 9 (27 percent). Of the 75 free tissue transfers, donor site complications were noted in 17 (23 percent). Ten of these complications involved the dorsalis pedis donor site (Table IV). The mean hospital stay for all 75 procedures was 26 f 14 days, with a range of 7 to 90 days. In those patients without donor, local, or systemic complications, mean hospital stay was 16 f 4 days. In those patients with either donor, local, or systemic complications, and in those who experienced failure of free tissue transfer, the mean hospital stay was 29 f 15 days. Comments Free tissue transfer for the reconstruction of head and neck and esophageal defects was completely successful in 68 of the 75 cases (90 percent). Complete failure, which required removal of the necrotic tissue flap, was encountered in five cases (7 percent). Partial success, which required minor debridement and standard local wound care to achieve healing, was observed in two cases of free tissue transfers (3 percent). Reconstruction of the defect was successful in 70 cases (more than 93 percent). These observations compare favorably with those from our earlier report in which, of a total of 19 free tissue transfers, success was noted in 14 instances, partial success in 1, and failure in 4 [14]. The success of microvascular free tissue transfer in head and neck surgery is dependent on several elements, not the least of which is exacting surgical
volume149,ocmber1984
Lateral Arm Flap
Latissimus Dorsi Flap
. .. .. ...
l’/G
...
Iliac Crest FlaD
Jejunal Autowaft
.
Total 1
4 4 ;;i . .. .. .
.
1
...
.. . .
17’12
3 3 1
technique. Factors critical for success include close cooperation between the extirpative and reconstructive teams, a cooperative anesthesiologist and specially trained scrub nurses; proper maintenance of the operating microscope and microsurgical instruments; careful positioning of the patient; meticulous hemostasis; and correct design and positi&ing of a vascular pedicle to avoid kinking, stretching, or tension on the anastomosis [ZS]. Also of great importance is careful preoperative planning, with examination of the patient under anesthesia if necessary, so that the extent of the extirpative defect can be estimated and the optimal donor site of the free tissue transfer chosen. During the postoperative period, monitoring of the free tissue flap allows for earlier detection of vascular insufficiency and a better chance of successful reoperation. The basis of sound monitoring continues to be clinical judgment based on the traditional signs of color, blanching, and return of capillary refill in response to pressure and release, and brisk red bleeding in response to a pin prick. Although temperature monitoring can be of use where a free flap is used for skin cover, it is not useful for intraoral flaps since even a dead flap in this location maintains its temperature through body heat conduction. Recently, the photoplethysmograph has been used as an adjunct in monitoring. It has been particularly helpful in the monitoring of inaccessible flaps and in black patients. The photoplethysmograph consists of an infrared light source and a photoelectric cell. The emitted infrared light penetrates the surface of the tissue to a depth of several millimeters. The amount of light reflected back to the photoelectric cell varies with pulsatile changes at the capillary arteriolar level. This is recorded and displayed in a graphic fashion [27]. With free bowel transfers, because the transplanted jejunum is buried deep within the soft tissues of the neck, clinical examination of the tissue is rarely possible. To overcome this difficulty, a segment of 2 to 3 cm of the distal jejunal segment is separated, with care taken not to disturb its own vascular and mesenteric pedicle. This isolated monitor flap is brought out through the neck wound leaving it widely
501
Tabah et al
exposed where clinical and photoplethysmographic monitoring can easily be accomplished. Once the success of the free jejunal autograft is ensured, usually after 5 to 7 days, the pedicle of the monitor flap is ligated and divided at the skin edge. To date, no complications referrable to the use of this monitor flap have occurred. The selection of the donor flap depends largely on the location of the defect (Table II). Thinner dorsalis pedis and lateral arm flaps are more suitable for anterior defects in the oral cavity. This is especially true when the integrity of the mandibular arch is maintained, and it is necessary to cover a soft tissue defect that includes a rim of bone. Thin flaps will drape over the rim of bone and conform to the contour of the defect, which results in the best possible functional result. Posteriorly, in the oral cavity and in the oropharynx, a more bulky flap is preferred, particularly when excision of a portion of the mandible has given rise to a deep defect. It is important not to make the flap too large for the defect because excessive bulk can greatly hamper oral function. In outlining the flap, a template the same size as the defect is used to ensure an accurate fit. The standard free tissue transfers are devoid of intrinsic function, with the exception of the free bowel autografts. Their use in repairing defects of the oral cavity and oropharynx greatly improves function when compared with the practice of simply collapsing defects. The functional results when free flaps and pedicle flaps are compared are very similar. Exact tailoring of this flap to the defect and the absence of the mobility restrictions of the pedicle flaps produce a somewhat improved functional result with the free flap. The proper choice and positioning of a free flap in these situations can increase the volume of the upper aerodigestive tract and may act as a strut against which muscles pull or as a gutter, which facilitates oral continence and deglutition. In contrast to other methods of reconstructing head and neck defects, such as the forehead flap, the deltopectoral axial flaps, and the pectoralis major myocutaneous flap, free flaps offer several advantages. The wide choice in donor sites allows for more versatility. Free flaps can be chosen on the basis of bulk and can be trimmed to repair a defect optimally. There is a greater degree of freedom in the positioning of free flaps as their vascular pedicles are obviously more mobile. When free flaps are used for a mucosal defect, there is no need to create and subsequently close a controlled salivary fistula. Also, the vascularity of a free tissue transfer is more reliable-a factor which, under certain circumstances, such as previous radiotherapy, allows for improved wound healing. The survival of free tissue transfer in this study is comparable to that observed using the forehead and deltopectoral flaps under similar circumstances [28-321. The absence of a donor site in the head and neck region represents one of the major
502
advantages of this method of reconstruction. From a purely aesthetic standpoint, the improved appearance, when compared with various types of forehead, neck, and scalp flaps, is so obvious that the comparison becomes ludicrous. Even with less dramatic comparisons, such as the deltopectoral and pectoral myocutaneous flaps, the aesthetic benefits are clear. If postoperative radiotherapy is planned, it can be started within 2 to 3 weeks of surgery in patients demonstrating uncomplicated wound healing. When a free bowel transfer is contemplated, preoperative radiotherapy is recommended. Late stricture and fistula formation, as well as enteritis of the transplanted intestine, may occur when the patient is subjected to therapeutic doses of postoperative irradiation. Failure of free tissue transfer in previously irradiated patients was three times more frequent than in nonirradiated patients (Table III). This increased risk of failure is not a contraindication but rather an impetus for greater attention to detail, especially in selecting appropriate recipient vessels and in performing the microvascular anastomosis. Recipient vessels selected were commonly the facial artery and vein early in the series. The external carotid artery has been the preferred recipient artery since 1979 due to better ability to perform an adequate end-to-side anastomosis to this vessel. This obviates the frustrating problems we have occasionally had due to arterial vasoconstriction in an end-cut vessel. It is a particularly important consideration in transfer into an irradiated recipient bed where irradiation damage to the recipient vessels has occurred. Previous radiotherapy does not contraindicate the procedure, however, but simply means large vessels must be found and a meticulous endto-side anastomosis performed. For similar reasons, we often use the large, high flow internal jugular vein as the recipient vein. Alternatively, large external jugular or anterior facial veins can be utilized for venous drainage, and facial, lingual, and superior or inferior thyroid arteries can be used as a second choice for recipient arterial supply. Occasionally, the common carotid artery has been used for arterial supply when necessitated by an absence of other suitable vessels. In certain full-thickness defects, we have used folded free cutaneous flaps, with an intervening portion denuded of skin so that both the mucosal lining and skin cover may be provided from the same flap. This affords an economy of donor tissue. Great care is taken in the deepithelialization and folding of the free flap. No specific complication has been encountered in the use of this technique. An additional method of obtaining internal and external coverage is possible with the use of the scapular flap, on which pedicle a multiple flap pattern may be designed, with independent positioning of these flaps then being possible.
The American Journal of Surgery
Microvascular
Donor site complications occurred most commonly with the dorsalis pedis free flap (Table II). Indeed, the 10 recorded complications represent half of our experience with dorsalis pedis donor sites. The dorsalis pedis free flaps represent a special situation since the donor defect cannot be closed primarily, as is the case with most other donor sites. In our hands, proper closure requires split-thickness skin grafting, adequate bolus dressing, immobilization of the foot for a period of 7 to 10 days, and particular attention to the avoidance of undue dressing pressure on the skin graft. Attention to donor care with respect to these details has reduced the complications associated with this donor site to none in the most recent 10 consecutive cases. The rates of local wound complications that we observed in irradiated and nonirradiated patients (44 percent and 27 percent, respectively) are comparable to those recorded in earlier reports that dealt with patients who had undergone extirpative head and neck surgery [33-351. Respiratory tract complications were recorded in 32 percent of the procedures in this series, which is in agreement with an earlier report that identified respiratory tract complications as the most common systemic complications in a group of patients undergoing extensive head and neck surgery [33 1. In our experience, cardiovascular complications were the second most commonly encountered systemic complications. The mean hospital stay for patients with either donor, systemic, or local complications and for those who experienced failure of free tissue transfer (29 f 15 days) was nearly double that of those whose course was uncomplicated (15 f 4 days). Summary Successful reconstruction for excisional defects of the head and neck and esophagus was accomplished in 93 percent of our patients using microvascular free tissue transfer. Complete failure occurred in 7 percent of the patients. Major defects after head and neck cancer surgery constituted the main indication for use of microvascular free tissue transfer for reconstruction. Ninety-four percent of the patients had undergone an extensive excisional procedure. A wide range of cutaneous, myocutaneous, and osteocutaneous free flaps, as well as free bowel autotransfers were used. Complete failure was three times higher in the previously irradiated patients (4 of 41 patients) compared with nonirradiated patients (1 of 34 patients). Morbidity and mortality rates were consistent with expected ranges in patients who were undergoing major head and neck resection. Donor site complications occurred in 23 percent. Thin flaps are favored for reconstruction of anterior defects in the oral cavity, whereas bulkier flaps are more suitable for deeper defects in the oropharynx and hypopharynx. The advantages are both aesthetic and functional. The free jejunal autograft is considered
Volums148,Ociober1984
Free Tissue Transfer
the reconstructive method of choice for defects produced by laryngopharyngoesophagectomy. Highly developed and sophisticated microsurgical skills continue to be the mainstay of success. The implication of free tissue transfer failure, especially for defects of the upper aerodigestive tract, are impressive in terms of morbidity, mortality, and cost. These considerations limit the application of this method of reconstruction to centers that have sophisticated and productive reconstructive surgeons with microsurgical skills. References 1. Longmire WP, Jr., Baltimore MD. A modification of the Roux technique for antethoracic esophageal reconstruction. Surgery 1947;22:94. 2. Seklenberg B, Rosenak S, Hurwitt ES, Som ML. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 1959; 149: 162. 3. Roberts RE, Douglass FM. Replacement of the cervical esophagus and hypopharynx by a revascularized free jejunal autograft. N Engl J Med 196 1;264:342. 4. Nakayama K, Yamamoto K, Tamiya T, et al. Experience with free autografts of bowel with a new venous anastomosis apparatus. Surgery 1904;55:796. 5. Jurkiewicz MI. Vascularized intestinal graft for reconstruction of the cervical esophagus and pharynx. Plast Reconstr Surg 1965;36:509. 6. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomosis. Plast Reconstr Surg 1973;52: 111. 7. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243. 8. Acland RD. Instrumentation for microsugerY. Dtthop Clin North Am 1977;8:281. 9. Panje WR, Bardach J, Krause CJ. Reconstruction of the oral cavitv with a free flao. Plast Reconstr Sum 1976:58:415. 10. Leeb DC, Ben-liur N. M&arella L. Reconstru~ion of the floor of the mouth with a free dorsalis pedis flap. Plast Reconstr Surg 1977;59:379. 11. Zuker RM, Rosen IB, Palmer JA, et al. Microvascular free flaps in head and neck reconstruction. Can J Surg 1980;23: 157. 12. Zuker RM, Manktelow RT, Palmer JA. Rosen IB. Head and neck reconstruction following resection of carcinoma using microvascular free flaps. Surgery 1980;88:461. 13. Serafin D, Villarreal-Rios A, Georgiada NG. A rib containing free flap to reconstruct mandibular defects. Br J Plast Surg 1977;30:263. 14. Acland RD, Flynn MB. Immediate reconstruction of oral cavity defects using microvascular free flaps. Am J Surg 1978; 136:419. 15. Flynn MB, Acland RD. Free intestinal autografts for redonstruction following pharyngolaryngoesophagectomy. Surg Gynecol Obstet 1979;149:858. 16. Chandler JR. Guillamor&gui DM, Sisson GA, Strong EW, Baker HW. Clinical staging of cancer of the head and neck: a new “new” system. Am J Surg 1976;132:525. 17. Acland RD. The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg 1978:64:419. 18. Robinson DW. Dorsalis pedis flap in ‘microsurgical composite tissue transplantation’ St. Louis: CV Mosby, 1979;25784. 19. Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular free flap. Plast Reconstr Surg 1981;67: 763. 20. Katsaros J, Acland RD, Banis JC, Schusterman M, Beppu M. The lateral arm free flap. Ann Plast Surg 1984:6:489500.
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21. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982;69:601. 22. Maxwell GP, Stueber K, Hoopes JE. Free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1978;62:462. 23. Hill HL, Nahai F, Vasconez LO. The tensor fascia lata myocutaneous free flap. Plast Reconstr Surg 1978;61:517. 24. Teot L, Bosse JP, Moufarrege R, Papillon J, Beauregard G. The scapular crest pedicled bone graft. Int J Microsurg 1981; 31257. 25. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: clinical work. Plast Reconstr Surg 1979;64:745. 26. Acland RD. Factors that influence success in microvascular surgery. In: Serafin D, Buncke HJ eds. Microsurgical composite tissue transplantation. St. Louis: CV Mosby, 1979. 27. Creech BJ, Thorne FL. The pocket photoplethysmograph. Plast Reconstr Surg 1972;49:380. 28. Rosen IB, Palmer JA, Knutson GA. Comparison of recons-
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29. 30. 31.
32. 33. 34. 35.
tructive methods used following ablative head and neck operations. Can J Surg 1980;23:45. Bakamjian V. The deltopectoral flap. In: Grabb MC, Myers, MB, eds. Skin flaps. Boston: Little, Brown 1975. Lore JM, Zingapan EG. Deltopectoral flap. Arch Otolaryngol 1971;94:13. Krizek TJ, Robson MC. The deltopectoral flap for reconstruction of irradiated cancer of the head and neck.‘Surg Gynecol Obstet 1972;135:787. Rothaus KO, Acland RD. Free flap neovascularization: case report. Br J Plast Surg 1983;36:350. Flynn MB. Morbidity and mortality of mandibular resection for malignant disease. Am J Surg 1977;134:510. Donald PJ. Complications of combined therapy in head and neck carcinomas. Arch Otolaryngol 1976;104:329. Joseph DL, Shumrick DL. Risks of head and neck surgery in previously irradiated patients. Arch Otolaryngol 1973;97: 381.
The American Journal of Surgery