Free tissue transfer in head and neck reconstruction

Am

J Otolaryngol

10:110-123,1989

Free Tissue Transfer in Head and Neck Reconstruction SEBASTIANARENA, MD, MICHAEL FRITSCH, MD, AND ELIAS Y. HILL, MD With continuing advances in microsurgery, the importance of free flap transfers in reconstruction has increased in every branch of surgery. Several free flaps (both simple and compound) will be described. The transfer of a bulk of tissue by microvascular tissue transfer is a reliable and proven method of reconstruction. The objective for microvascular surgery is to develop techniques of tissue transfer that restore function and improve appearance. There is no greater challenge than reconstructive surgery of the head and neck. AM J OTOLARYNGOL~~:~~O-~~~.O 1989 by W.B.SaundersCompany. Key words: functional reconstruction, microvascular techniques, donor sites.

Stapling and adhesive techniques, so-called non-suture anastomoses, were first used in the field of microvascular surgery. In 1960,a 1.4-mm diameter artery was successfully anastomosed using 7-O suture material under the operating microsc0pe.l Since then, the advantages and expanded applications of microsurgical techniques have been widely recognized, and experimental and clinical work in this field has progressed rapidly. In 1973, Daniel and Taylor reported the successful distant transfer of an island flap.’ That report firmly established the concepts of free tissue transfer, and many flap types, both simple and compound, have been developed and used clinically. Microsurgical instrumentation for microvascular surgery can be simple or complex. However, the use of too many instruments makes the operation more complicated and prolonged, and frequent instrument changes promote fatigue (Fig 1). In our practice, we use Acland single clamps, which have lighter closing pressure to avoid injuring the intima. The vessel is cut with the sharp edge of a broken razor blade or with sharp microscissors with a single cut. Multiple cuts make the vessel edge irregular and contribute to

postoperative thrombosis. The lumen is then rinsed with heparinized saline solution with a tuberculin syringe or a 25-gauge needle, and the adventitia is removed from the vessels using microforceps and curved microscissors. Each suture penetrates the entire vessel wall, and it must be remembered that each puncture injures the intimal layer. The effect is cumulative: too many suture passes will result in platelet aggregation with eventual occlusion of the anastomoses. After completing the suturing, an anastomosis will bleed for a short time. Small leaks are treated by gentle pressure with the tips of the microforceps and do not require additional sutures. However, if bleeding is prolonged and light compression is not effective, additional sutures will be needed. The chance of thrombus formation at the site of anastomoses is greatest 15 to 20 minutes following anastomosis. Occlusion of an anastomosis after 20 minutes may be due to abnormal kinking or compression. A successful anastomosis depends on several other factors: (1) The vessels must be handled very gently, grasping only the adventitia to minimize injury to the vessel wall. When performing an anastomoses, the pedicles have to be long enough to avoid traction on the suture line. Abnormal kinking must also be avoided. (2) The exposed vessels must be constantly moistened with saline to prevent desiccation. (3) When blood clots or pieces of sponge fiber stick to the suture, they must be removed before the suture passes through the vessel wall. (4) Ischemic time of free flaps is a factor. In prolonged ischemia, sodium enters the cell and cellular swelling occurs. In the capillary system, this may occlude capillaries and terminal arteri-

Received June 1, 1988, from the Division of Otolaryngology and Maxillofacial Surgery, Mercy Hospital, Pittsburgh; and The Otology Group, Nashville, TN. Accepted for publication August 27, 1988. Address correspondence and reprint requests to Sebastian Arena, MD, Division of Otolaryngology and Head and Neck Surgery, Mercy Hospital, Pittsburgh, PA 15219. 0 1989 by W.B. Saunders Company. 0198-0709/89/1002-0009$5.00/O 110

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Figure

1. Microvascular tray with heparinized saline solution, neural paddies, clamp applicators, micro instruments, and a bipolar micro forcep.

oles and venules, preventing the “reflow” of blood.3 (5) During wound closure, kinking and compression must be avoided. The reconstruction of defects in the head and neck, whether congenital or acquired [traumatic or postsurgical) has always been challenging to the head and neck surgeon because of the complex functions of respiration, deglutition, and speech, as well as cosmetic considerations. Microsurgical techniques give us more options to correct physiologic defects caused by disease and acquired defects. These techniques do not replace other reconstructive procedures, such as the pedicle, island, or myocutaneous flap, when these flaps give equal or better results (cosmetically or functionally]; however, in certain situations, free flaps are the method of choice. There are numerous situations in which free tissue transfer can accomplish what other techniques cannot, or with superior results, such as in compound defects, transfer of functional units (microneurovascular), adjustment of depressed areas, treatment of heavily irradiated areas, and esophageal reconstruction. Clearly, the head and neck surgeon must have microvascular skills to be a complete reconstructive surgeon. There are some contraindications to free flap transfer. The absence of adequate recipient vessels and severe artherosclerosis are absolute contraindications. Age and operative time in poorrisk patients are relative contraindications and these factors must be weighed. The operative procedure requires preoperative coordination between surgeons, nurses, and an-

esthesiologists, adequate preparation of the recipient site, harvesting of the donor flap, and microvascular transfer and closure of the donor and recipient sites. The latter demands meticulous hemostasis and wide undermining of skin. During the preparation of the recipient site, the vessels should be healthy and of appropriate size, with adequate blood flow. The choice of the donor flap should meet the requirements of the recipient vessels in both size and length of the vessels. In addition, the appropriate cosmetic and functional requirements should be met. The latter factor will determine which flap is to be harvested and whether it should be a free skin flap transfer or a compound flap transfer. THE GROIN FLAP The anatomic basis for the groin flap has been described by Smith et al4 but credit for transferring and using it as a free flap belongs to Daniel and Taylor.7V8 This flap remains a favored flap, widely used and tested, with a hidden donor site. Its main disadvantages are its color, a relatively short pedicle, and a complex anatomy. The superficial circumflex iliac artery @CIA) is constant and usually the larger of the two main arteries.5 Figure 2 illustrates the variability of the arterial anatomy. The SCIA begins at the anterolateral aspect of the femoral artery, 2 cm below the inguinal ligament and bilaterally above the fascia of the iliacus. While the sartorius lies beneath the sartorius fascia, the superficial iliac artery (SEA) is on the medial side of the femoral artery and runs

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Figure 2. The anatomy of the SCIA and SEA. The SCIA is 2 cm below the inguinal ligament on the lateral side of the femoral artery and the SEA on the medial side. Also illustrated are variations commonly encountered in the system, ie, a common trunk, and origin from the posterior portion of the femoral artery.

cephalad toward the abdomen (Fig 2). Venous drainage is by the superficial circumflex iliac vein (SCIV) and the superficial epigastric vein (SEV), which form a common trunk to the saphenous bulb. Technique of the Groin Flap

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The landmarks for the elevation of the groin flap are the anterior superior iliac spine, the inguinal ligament, and the femoral artery. The axis of the flap is a line drawn between the points of the anterior iliac spine (AIS), 2 cm below the inguinal Iigament at the femoral artery. The outline of the flap is then designed. The flap is raised from either the medial or lateral approach. We use the lateral approach” and incise the skin first at this point until the anterior superior iliac spine (ASIS) is reached (Fig 3). The flap is raised quickly when the sartorius muscle is reached. The fascia is included in the flap for 4 to 5 cm, and further dissection will reveal the entire course of the SCIA. The lateral cutaneous nerve is sacrificed. The dissection continues over the iliacus muscle to its point of origin. The location

Figure 3. The flap has been raised from its lateral aspect. The fascia has been included as far as the vessels pierce this fascia at the medial aspect of the sartorious.

of the SEA origin is then determined (Fig 4). Venous drainage is then identified coursing over the femoral artery, and traced to the saphenous bulb. Usually, the SCIV is larger than the SEV and is the vein of choice. On occasion, they combine to form a common trunk. The donor site can usually be closed primarily. ILIAC CREST FREE FLAP In 1974, Ostrup and Fredrickson published an experimental series on transferring live bone.g This set the stage for the clinical use of free bone transfer in head and neck reconstruction. The tissues supplied by the deep circumflex iliac artery (DCIA), developed and described by Taylor et a1,7,8 have the distinct advantage of providing large, well-vascularized iliac bone grafts. The DCIA supplies the greater portion of the anterior lateral iliac crest, with multiple direct perforations into the bone. Additionally, perfusion of the overlying skin allows harvest of a skin paddle, if necessary. Thus, large bony defects, such as a hemi mandible, may be reconstructed from one iliac crest. The cost is a rela-

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Anatomy

Figure 4. Further SCIA and SEA.

dissection

to the point of origin of the

tively long scar and proximity to the femoral motor nerve, iliac vessels, peritoneum, and bowel, with the possibility of corresponding complications.

The vascular anatomy of the DCIA has been well-studied and outlined. It is a consistently large diameter artery, averaging 2 mm. It originates on the external iliac artery (EIA), approximately 1 cm proximal to the inguinal ligament. Usually, the origin of the inferior epigastric artery (IEA) is immediately opposite the EIA. The DCIA then passes directly toward the ASIS in a fascial tunnel. On reaching the ASIS, the artery has completed its straight inguinal course and begins its iliac course along the curvature of the iliac bone crest (Fig 5). This is begun by piercing the fascial tunnel of the transversalis fascia. Thus, the artery lies external and parallel to the attachment of the transversalis fascia along the inner lip of the iliac crest. During the middle and latter part of its iliac course, the artery gives off direct and indirect bone and musculocutaneous perforators at l- to 2-cm intervals. The musculocutaneous perforators may lie 2 cm above the iliac crest. Approximately 5 to 10 cm from the ASIS, the artery divides into terminal anostomotic branches, primarily with the iliolumbar artery. Along its inguinal course, the DCIA may give off several branches, of which three are important. First, in an anatomic variation, the SCIA which usually arises from the femoral artery 2 cm below the inguinal ligament, may arise from the DCIA. Also, when approximately 1 cm medial to the ASIS, the DCIA gives rise to a large ascending branch that may be mistaken for the DCIA as it penetrates the transver-

Figure 5. Vascular anatomy of the DCIA taking off from the lateral aspect of the external iliac artery. Also depicted is the curved course along the iliac crest after it completes its straight course. The opposite side depicts the crest of free bone and the skin it supplies. Note that the skin supply is more lateral than the groin flap. This has been clearly described by Taylor.7~8

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Figure 6. External and internal oblique muscles have been cut. Note that the DCIA pierces the fascial tunnel at the ASIS and that the DCIA gives off an ascending branch.

salis muscle to lie between it and the internal oblique (Fig 6). This ascending branch is a muscular feeder and eventually arches superiorly to anastomose with the IEA branches. Occasionally, this ascending branch may arise 2 to 3 cm from the origin of the DCIA. Technique The patient is prepped and draped in the supine position with the table rotated toward the surgeon for better viewing over the crest of the iliac bone [Fig 6). The skin paddle, or a linear

incision parallel to the iliac crest, is outlined. An incision parallel to the inguinal ligament is outlined. External and internal oblique muscles are incised individually at a distance ~3 cm above the iliac crest to spare the musculocutaneous perforators. Skin is sewn to underlying muscle and periosteum to prevent shearing stresses to the vessels. At the ASIS, the incision continues above the inguinal ligament to enter the inguinal canal. The inguinal canal is located medially beneath the internal oblique muscle. The transversalis fascia lying on the EIA is incised and the

Figure 7. From the ASIS, the DCIA proceeds medial to the DSIA, sparing vessels to bone.

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Figure 8. The COI mpound skin, mluscle, and bolne flap is depicts ?d pedicled on the DCIA \ ressels after ment.

DCIA and vein origins are identified. Dissection continues with direct visualization of the vessels at all times. From the ASIS laterally, dissection proceeds approximately 1 cm medial to the DCIA through iliacus muscle to bone. The vessels are visualized through the fascia. In this way, perforators to the bone are spared (Fig 7). The external iliac attachments of tensor fascia lata and gluteus medius are transsected and elevated to expose the lateral aspect of the iliac bone. The inguinal ligament and sartorius muscle and lateral femoral cutaneous nerve are divided. Osteotomy cuts are made to suit the size

and shape of the bony defect (Fig 8). The vessels are irrigated with 1% lidocaine and patency confirmed. Microvascular technique is used to harvest the flap. For closure, the iliacus fascia is sewn to the transversalis and its fascia. The external oblique is sewn to the gluteus and tensor fascia lata. The inguinal ligament is reattached laterally to bone and sartorius muscle. Subcutaneous and skin closure follow. THE SUBSCAPULAR ARTERIAL SYSTEM Important axial pattern flaps are available from the subscapular artery [Fig 9):

Figure 9. Three axial pattern flaps emanating from the subscapular artery are depicted: the two scapular flaps from the circumflex scapular artery, the latissimus dorsi myocutaneous flap from the thoracodorsal artery, and the compound serratus anterior flap from branches to the serratus anterior from the thoracodorsal artery.

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scapular artery (the first (2) The circumflex branch of the subscapular artery may arise from the axillary artery. This supplies the scapular flap. LATISSIMUS DOW

FLAP

Anatomy The thoracodorsal artery is a good diameter, from 2 to 3 mm. It enters the latissimus dorsi muscle at its deep surface, where it divides into two branches: an anterior longitudinal branch and a posterior transverse branch which is not vital to the flap (Fig 10). At its point of entry it also gives off two branches to the serratus anterior. The thoracodorsal vein is approximately 2 to 4 mm and drains into the axillary vein. The vascular pedicle is long (approximately 6 to 8 cm).

Figure 10. Flap elevation completed, gitudinally along the muscle.

depicting vessels lon-

artery is a continuation (1) The thoracodorsal of the subscapular artery after it gives off the circumflex scapular artery. This supplies the latissimus dorsi muscle flap and also sends branches to the serratus anterior muscle.

The patient is placed in a 60” to 70” rotated position and the arm is elevated and flexed at the elbow and placed on an arm rest positioned over the patient.l’ The flap is then designed, keeping in mind the approximate points of vessel entry. The incision is then made over the anterior border of the latissimus dorsi muscle and continued up to the axilla. The vessels are easily identified in a retrograde fashion and dissected to their point of origin. The accompanying thoracodorsal nerve is approximately 2mm in diameter and is readily identified in the neurovascular bundle.

Figure 11. The circumflex scapular vessels passing through the triangular space. Also depicted is horizontal “scapular” flap and the oblique “parascapular” flap.

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Figure 14. Dissection beginning laterally under the fascia. The triangular area of skin was described by Harii13 to facilitate closure.

Figure 12. flap.

Completed

dissection

illustrating

the scapular

THE SCAPULAR FREE FLAP The subscapular artery gives rise to several branches, each of which produce tissue within distinct boundaries. One of these, the circumflex

scapular artery, supplies the skin of the scapular and parascapular territories. The tissue available for reconstruction using these flaps is skin and subcutaneous fat with a fascial undersurface. These flaps are relatively thin and pliable. Flap size is intermediate with dimensions of approximately 6 to 10 cm in width and 10 to 18 cm in

volul me 10 Nun lber 2

Figure 13. Scheme of the DP flap to the axillary fold with the perforating branches of the internal mammary artery.

Figure 15. Third and fourth perforating one will be selected.

branches; the larger

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F‘igulre 16. Loop of 1he jejuniurn bleing harves :ted.

length. Random extensions of skin are less reliable; if more tissue is needed, another flap should be chosen. The flaps are not innervated. The arterial pedicle length ranges from 6 to 8 cm with a diameter of 2 to 3 mm. The vessels in men are larger than those in women. Venous drainage is by venea comitantes. Anatomy The vascular anatomy begins as the subscapular artery exits from the axillary artery and crosses the brachial plexus. After approximately

3 cm, it divides into the circumflex scapular and thoracodorsal arteries. The circumflex scapular artery courses through the triangular space.*l This space is formed by the teres major muscle inferiorly, the teres minor muscle superiorly, and the long head of the triceps laterally (Fig 11). Deep branches to the surrounding musculature usually arise before the artery emerges from the triangular space, where it courses medially and branches to the skin. Blood supply to the skin is twofold. A horizontal midscapular branch travels 4 to 7 cm below the spine of the scapula. The other branch

Figure 1/. Barium swallow of a jeju .nal transfer This illustratio nd oes not diepict the “double SW ,allow.” ”

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Figs m 18. T2 lesion of 13alate (:hard and soft).

travels vertically along the lateral border of the scapula. Therefore, two distinct vascular territories exist: the horizontal “scapular” and the vertical “parascapular,” which are traced out on the left side of Fig 11. Technique The patient is prepared and draped in the lateral or supine position, as the recipient site warrants. The arm is prepared so that it is mobile. The landmarks of the scapular spine, the inferior

angle, and the lateral border of the scapula are marked. The axis of the flap will lie approximately half way between the spine of the scapula and the inferior angle. It will extend from the midline to just lateral to the scapula at a point approximately 2 cm above the axillary fold, and just inferior to the deltoid muscle. Thus, the vessels will enter the flap at its lateral margin and travel lengthwise to the medial border. The triangular space is marked so that the surgeon can retain a perspective on vessel origins throughout the dis-

Figure 19. Postoperative photo of the palate.

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Figure 20. mandible.

A radiograph

of the free iliac bone repair of the

section. A Doppler probe can be helpful in tracing the two branches. The fusiform shape of the flap is marked. Incisions starting 2 cm lateral to the vertebral spine are created. The incisions continue through the subcutaneous fascia to expose the trapezius muscle. Dissection will continue in this plane over muscles and under the fascia. The flap is elevated toward the lateral base, constantly keeping the vessels in view through the fascia.

As the vessel origin area is approached, the scapular skin vessels will pierce the fascia to connect with the circumflex scapular vessels deep in the triangular space (Fig 12). Cautious dissection at this point allows direct visualization of the vessels, which are surrounded by fatty tissue. Deep muscular branches are ligated when encountered. Continuing the retrograde dissection, the origin of the circumflex scapular vessel is traced. If the scapular flap is combined with other flaps on a single pedicle, such as the latissimus dorsi or serratus anterior, an axillary incision is made. Primary closure is fascilitated by underwiring the surrounding skin. The parascapular flap harvest is similar, except that the axis of this flap ranges from the triangular space to the inferior scapular angle (Fig 11). A vascularized bone flap may be harvested from the lateral margin of the scapula. The arterial supply, although distinct from that of the skin, is also a branch of the circumflex scapular artery. THE DELTO PECTORAL FREE FLAP The delto pectoral flap was first reported by Bankamjian in 1965,l’ and Harii et al used it as a free flap in 1974.13 The flap is designed along the axillary line in its usual configuration, with the second, third, and fourth perforating vessels of the internal mammary artery as its basis (Fig 13). The dissec-

Figure 21. Illustration of the intraoral reconstruction.

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but in rare cases, can mean the fourth (Fig 15). The donor area can be closed primarily. The advantages of this flap are that its color and texture match the skin of the head and neck, its position, and its easy availability for the head and neck surgeon. Its disadvantages are a very short pedicle and a small vessel diameter of 1 mm. JEJUNUM TRANSFER FOR ESOPHAGEAL REPAIR

Figure 22. A 6%year-old man with epidermoid of the maxilla, invading the right eye and skin.

carcinoma

tion begins laterally and proceeds medially under the fascia (Fig 14). When the vessels are seen through the fascia, the largest vessels are selected. This usually means the third perforator,

In 1959, Seidenberg reported his first successful use of the jejunal transfer. Many investigations have since used this technique. This method requires careful planning. We use a visor flap when no neck dissection is planned, and a half-H incision when a neck dissection is performed. The recipient vessels can be the transverse cervical, superior thyroid, lingual, and external maxillary. The veins used are the corresponding veins, but when feasible the internal or external jugular veins are used. When using the internal jugular vein, an end-to-side anastomosis is done and the vein is directed downward to take advantage of the venturi effect. A general surgeon with peripheral vascular training harvests the jejunum, and transfer occurs only when the recipient and donor vessels are properly prepared. This significantly decreases jejunal ischemic time (Fig 16). The main advantage of this technique is that it

Fig ure 23. Resected specimen including the maxilla orbit and the skin of the facte.

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can be used when the excision upper mediastinum, and when irradiation. Its disadvantages are inal cavity entry and spasm positioned jejunal segment on lowing (Fig 17).

extends to the there has been risks of abdomof the centerinitiating swal-

Case Reports A 62-year-old woman presented with a squamous cell cancer involving the hard palate and soft palate, and extending to one tonsil (Fig 18). She underwent a left neck dissection, mandibulotomy, and resection of pterygoids, tonsil, soft palate, and hard palate. Resection resulted in exposure of the maxillary sinus and nasal cavity. A groin flap was harvested for repair of the defect. Figure 19 illustrates the successful cover of the maxillary sinus inferiorly. The patient died of other causes 3 years later. A 32year-old man with T3 lesion of the retromolar area underwent a left neck and partial mandibular resection, An iliac bone graft was harvested along with a skin paddle based on the DCIA. Figure 20 is a radiograph showing the mandibular repair, while Fig 21 illustrates the

intraoral reconstruction. The patient has been free of this tumor for 2 years. A 69-year-old man with squamous cell cancer of maxilla invading the skin, right eye, and pterygoids [Fig 22) underwent a total maxillectomy, orbital exenteration, and excision of skin (Fig 23). He was repaired using a latissimus dorsi flap. (Fig 24). He developed recurrent disease within six months after postoperative irradiation and died. A 40-year-old man presented for facial reanimation following successful ablative surgery 15 years earlier (Fig 25). The latissimus dorsi muscle with the nerve was harvested and transferred to the face. The harvested nerve was anastomosed to the facial nerve within the temporal bone. Reanimation was successful (Fig 26). Other Flaps There are many other flaps described in the literature. The dorsalis pedis flap has favorable vessels and pedicles with thin skin. However, the morbidity of the skin graft at the donor site is significant and we have discontinued using this flap.

Figure 25. before.

Appearance following ablative surgery

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astating to the patient and surgeon. Vascular injury during the preparation of the flap or in the course of the anastomosis are the most common causes of thrombosis. The technical errors, mentioned earlier, and hematoma must be avoided. An alternative reconstructive procedure should always be a part of preoperative planning. References 1. Jacobsen JJ, Suarez EL: Microsurgery in anastomosis of small vessels. Surg Forum 1960; 11243 2. Daniel RK, Taylor CL Distant transfer of an island flap by microvascular anastomosis. Plast Reconstr Surg 1973; 52:111-116 3. May JW, Chait LA, O’Brien BM, et al: The no-reflow

phenomenon in experimental free flaps. Plast Reconstr Surg 1978; 61:256-267 4. Smith PJ, Foley B, McGregor IA, et al: The anatomical basis of the groin flap. Plast Reconstr Surg 1972; 49:4147 5. Taylor GI, Daniel RK: The anatomy of several free donor sites. Plast Reconstr Surg 1975; 56:243 6. Harii K, Ohmori K, Ohmori S: The successful clinical

7.

8. Figure 26. Appearance dorsi muscle.

1 year after transfer

of latissimus 9.

The forearm flap has many of the characteristics of the dorsalis pedis flap with regard to vessel and pedicle size and hairless, thin skin. We have avoided using this flap because most of our patients are smokers and the risk of vasoconstriction and possible loss of a hand is unacceptable. Complications are related to the recipient and donor sites. Total necrosis of a flap can be dev-

10. 11.

12.

13.

transfer of 10 free flaps by microvascular anastomosis. Plast Reconstr Surg 1976; 53:259 Taylor IG, Townsend P, Corlett R: Superiority of the deep circumflex iliac vessels as the supply for free groin flaps, experimental work. Plast Reconstr Surg 1979; 64:595-604 Taylor IG, Townsend P, Corbett R: Superiority of the deep circumflex vessels as the supply for the groin flap, clinical work. Plast Reconstr Surg 1979; 64:745759 Ostrup LT, Fredrickson JM: Distant transfer of a free, living bone by microvascular anastomosis. An experimental study. Plast Reconstr Surg 1974; 54:274 Bailey BN, Godfrey A: Latissimus dorsi muscle free flaps. Br J Plast Surg 1982; 35:47 Mayou BJ, Whitby D, Jones BM: The scapular flap-An anatomical and clinical study. Br J Plast Surg 1982; 35:8-13 Bankamjian VY: A two stage method of pharyngo esophageal reconstruction with primary pectoral skin flap. Plast Reconstr Surg 1965; 36:173-184 Harii K, Ohmori, Ohmori: Free deltopectoral skin flaps. Br J Plast Surg 1974; 27:231-237

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