OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

FREE TISSUE TRANSFER FLAPS IN HEAD & NECK RECONSTRUCTION:

MICROVASCULAR ANASTOMOSIS TECHNIQUE Ottie van Zyl, Johan Fagan

This chapter describes the surgical techni- bosis, limb trauma and varicose veins;
que of microvascular anastomosis, and the previous trauma or fractures may warrant
management of patients undergoing vascu- taking x-rays. An Allen test should be done
larrised free tissue transfer reconstruction prior to harvesting a RFFF to assess
of the head and neck. whether collateral ulnar arterial supply to
the hand is sufficient if radial artery supply
Readers are referred to the open access is lost (Table 1).
atlas chapters on vascularised free fibula
(FFF), radial free forearm (RFFF), an- • Elevate hand
terolateral thigh (ALTF), rectus abdomi- • Clench hand into fist for 30 seconds
• Occlude both ulnar and radial arteries
nis and jejenum flaps for technical details • Open hand while still elevated
about how to raise these flaps, and to • Hand appears blanched
chapters about their applications to recon- • Release pressure on ulnar artery
• Colour returns in <7 seconds
struct oropharyngeal, cervical oesopha- • Positive Allen test
geal, floor of mouth, partial glossectomy, o Colour does not return/ returns after >7-10 seconds
o Ulnar arterial supply to hand insufficient
total glossectomy, total maxillectomy, o RFFF has risk of causing vascular insufficiency
inferior maxillectomy, and total laryngec-
tomy defects. Table 1: Allen test

Preoperative evaluation Only if concerns exist about arterial and/or

venous insufficiency are further investi-
Preoperative evaluation is important in gations indicated. Duplex colour-flow
order to select the most suitable flap, and Doppler will usually suffice. Only very
to select patients and to optimise their rarely is MRI angiography or invasive an-
medical status. Factors to consider include: giography indicated. Should there be a
• Flap major concern about vascular supply then
o Vascular status an alternative donor site should be
o Tissue quantity and quality considered.
• Donor site: Functional and cosmetic
morbidity Tissue quantity and quality of flap
• Patient: Medical and oncologic status
Adequate skin should be harvested to
Vascular status reconstruct the defect. With through-and-
through defects one may add a 2nd skin
Most head and neck cancer patients are island based on the same pedicle; or a 2nd
smokers and are middle aged or older. free flap; or leave muscle of the flap
Therefore, one must carefully assess the exposed intraorally to epithelialise; or
peripheral circulation and the quality of the cover the external surface of the flap with
skin. Severe atherosclerosis is not necessa- split skin graft. Thick inelastic skin may be
rily a contraindication to free flap surgery; inappropriate to reconstruct defects where
in the authors’ experience, with careful mobility is important e.g. RFFF is the
suturing, rigid, hard arterial walls of flap preferred option for larger floor of mouth
vessels actually splint and keep an anasto- or anterior tongue defects. Thickness of
mosis patent. Enquire about a history of subcutaneous fat is important in terms of
intermittent claudication, deep vein throm- tissue bulk and pliability; it should be
minimal with anterior oral cavity recon- gional flaps e.g. pectoralis major myo-
struction and may preclude using ALTFs cutaneous flaps may appear to be a more
in some patients. In other situations addi- sensible choice in high risk patients, it may
tional bulk may be advantageous e.g. be detrimental, firstly because operating
following total glossectomy. The quality, time may be increased when a 2-team
volume and length of bone required with approach is not possible and, secondly
osseous flaps depend on the defect. Fibula because pain at the donor site may increase
(FFF) is the most versatile bone to risks of atelectasis and chest infection.
reconstruct bony defects in the head and
neck. Bone stock should be adequate if Operating room setup
dental implants are to be inserted.
Resect the primary tumour and elevate the
Donor site: Functional and cosmetic flap simultaneously as a 2-team approach
morbidity to reduce surgical time (Figure 1); mini-
mising length of surgery has benefits both
Functional morbidity may influence the for the patient and for flap survival.
choice of flap e.g. a painter or sportsman
may prefer to have the non-dominant
forearm used. Avoid using disfiguring
pedicled flaps from the head/neck/
shoulder/chest regions, and flaps that cause
tethering or downward traction on facial
tissue (e.g. pectoralis major and deltopec-
toral flaps). Skin that is transposed from
the trunk and limbs is of a much lighter,
pale/yellow colour (especially Caucasians)
compared to the face, whereas regional
flaps taken from the neck such as
submental artery flaps gives a better colour
match (has limited utility if neck dissection
done). The ALTF has gained popularity Figure 1: Two-team approach with anaes-
because unlike the RFFF its scar is less thetic equipment stationed at foot of bed
obtrusive and can be hidden under
clothing. Create working space around the head and
neck region by placing the anaesthetic
Patient: Medical and oncologic status machinery at the foot of the bed with
extensions for intravenous lines and anaes-
Assess the patient’s fitness to undergo thetic tubing. Two electrocautery systems
major surgery and optimise his/her medical are used. Cautery and other equipment are
status. Advanced age and lack of fitness positioned at the foot of the bed, contra-
does not rule out using free flaps per se. It lateral to the operated limb. A warming
is critical not to waste time by working as blanket covers the torso and the opposite
two surgical teams and being technically limb when elevating a FFF or ALTF. The
competent and quick in frail patients; with heights of the table and/or chair are
high risk patients one might even opt for a adjusted so that the surgeon and assistant
much quicker and less invasive option such are seated while raising the flap (Figure 1).
as simple primary closure following e.g.
hemimandibulectomy. Although using re-

2
Loupes vs. Microscope 1 (Figure 2) Surgical instrumentation (Figures 3-5)

While many surgeons use microscopes, it • Microsurgical forceps x 3 (minimum)

is the 1st author’s preference to use loupes • Micro needle holder
with 4-5x magnification whenever possi- • Microscissors (straight and curved)
ble; the assistant may use 2.5x (Figure 2). • Microvascular clamp (selection of
Recipient vessels in the neck are quite single and double clamps)
large as are vessels in free flaps used in • Baby Satinsky vascular clamp (for end-
head and neck reconstruction (unlike to-side anastomoses)
replant and experimental laboratory surge- • Bipolar coagulation forceps
ry). Loupes are more appropriate for • Haemostatic Ligaclip appliers (small
surgeons with steady hands and stable and medium)
heads. As long as a surgeon is capable and
confident about his/her visual acuity and
never has doubts about placing sutures,
surgery with loupes is very efficient.

Advantages of loupes include:

• No visual adjustment required between

elevating the flap and suturing the
anastomosis
• Wider field of vision
• Greater mobility and ability to access
difficult areas
• Can move around patient’s head for Figure 3: Microinstruments and single
better position and improved visual microvascular clamps
access
• Quicker surgery, shorter operating time
• More space in the operating room
• Ability to work in different hospitals
and operating rooms without needing
to adjust to unfamiliar microscopes
• Assistants do not need to be trained to
work with an operating microscope
• Cheaper Figure 4: Baby Satinsky vascular clamp
and double microvascular clamp

Figure 2: Surgeon uses 4.5x loupes; Figure 5: Haemostatic Ligaclip applier

assistant can use 2.5x loupes and clips

3
It is preferable to use longer forceps and anterolateral thigh and radial forearm
needle holders as it reduces crowding in flaps for detail).
restricted spaces by the 2 pairs of hands.
Shorter forceps are also less stable if not Flap design
securely placed on the dorsal aspect of the
first web of the hand. The flap should ideally have been elevated
at the same time as completion of resection
The most appropriate suture to use for the of the primary and the neck dissection.
microvascular anastomosis when using With a two-team approach the oncologic
loupes, is 8/0 nylon. surgeon therefore resects the primary
tumour early so that the reconstructive
Irrigation fluids surgeon can inspect the defect and plan the
flap. The resection is done first, or imme-
Heparin-saline solution diately following dissection of Levels I &
II of the neck. The reconstructive surgeon
• 5000 units in 50 ml saline starts elevating the flap once he/ she has
• Mixed in a small bowl some idea about the dimensions of the
• Draw up two 5ml syringes with intra- defect, or if the proportions of the flap can
venous cannula attached be adjusted subsequently.
• To flush and irrigate vessels (without
separating or damaging endothelial It is best to inspect the tumour at the time
layer of artery) of initial exposure prior to resection and to
• To hydro-dissect adventitia off vessels “picture” the normal anatomy and that of
the defect; then to draw the flap on paper;
Lignocaine solution 1% to cut out the paper template and then to
transpose it to the donor site to plan the
• 5ml/500mg ampoule in 50 ml saline dimensions of the flap (The author rarely
measures the resected specimen to deter-
• Apply topically via 20ml syringe with
mine the dimensions of the flap, as shrin-
venous cannula attached
kage of soft tissue and postsurgical chan-
• To relieve spasm with small calibre
ges can modify the shape and size of the
vessels while dissecting a perforator
defect). With experience, inspecting the
flap
tumour prior to dissection is often adequate
to design an appropriate flap.
Lignocaine 10 % (undiluted)
Unexpected problems may necessitate one
• Soaked into a gauze swab
to raise a different size or shape of flap, or
• Applied topically to anastomosis to even a totally different flap e.g. the resec-
relieve spasm (if necessary) tion may be greater or lesser than planned;
• Papaverine may be used as an one may encounter unexpected anatomical
alternative, but is less readily available variations; or there may be severe athero-
sclerosis or unreliable perforators (Figures
Choice of limb 6, 7)
Selecting the appropriate donor leg or arm
is based on the type and location of the
surgical defect and which the side of the
neck is to be used for the vascular anasto-
moses (Refer to chapters on free fibula,
4
 Ligaclips (Figure 5)

Ligaclips are preferable to bipolar coagu-

lation. Only use bipolar coagulation away
from vessels supplying/draining the flap,
as coagulation can cause thermal injury of
critical vessels; this is certainly true when
elevating perforator flaps. Ligaclips avoid
narrowing or occlusion of veins sometimes
seen when venous tributaries are ligated
Figure 6: Skin island, perforator, fibula, with braided (silk/vicryl) ties.
and vascular pedicle ready to be detached
Preparing the vascular pedicle

• Continuously apply topical lignocaine

to the perforator pedicle
• Keep vessels (especially veins) intact
until a decision has been made about
what vessels are to be used for the
anastomosis
• Fashion the length of the pedicle so
that it reaches the mid-internal jugular
vein, the superior thyroid artery, facial
artery or transverse cervical artery
• Problems with pedicle length may
Figure 7: Perforators tracking across the
occur especially when the contralateral
posterior crural intermuscular septum of
neck is used for vascular anastomoses
the leg (free fibula flap)
e.g. with revision flaps, following pre-
vious neck dissection or irradiation, or
Principles of elevating a flap
when reconstructing midface or maxil-
la. In such cases the oncologic surgeon
Size
should maintain continuity of the facial
artery and keep the common facial vein
Design a large enough flap but avoid large
and/or external jugular vein intact;
and bulky flaps especially in the anterior
even the anterior jugular veins may be
oral cavity (See chapters on specific flaps).
used
• Select the most suitable vein and ligate
Bloodless field
the others; only one vein is generally
needed
Perforator flaps are meticulously elevated
• It is better to interpose a vein graft to a
in a bloodless field without using a tourni-
larger vessel than to anastomose to a
quet. RFFF and FFFs are done with tourni-
small vein or for the anastomosis to be
quet compression; in adults the average
under tension
tourniquet pressure for the arm is
250mmHg, and 300mmHg for the leg. • Carefully separate the vein and artery
Note: vessels appear smaller when opera- from each other to permit the arterial
ting with a tourniquet in a bloodless field. and venous anastomoses to be placed
some distance from each other if
necessary

5
• Deflate the tourniquet hyoid muscle may improve access to the
• Obtain meticulous haemostasis of the stump of the facial artery. When the artery
flap and the surgical bed with bipolar of the flap is hard and rigid due to
cautery, ligaclips and ligatures atherosclerosis and cannot be twisted or
curved towards the donor artery, warn the
Preparing the flap oncologic surgeon that a longer donor
artery pedicle is required that can reach
In order to minimise ischaemic time, leave across to the flap’s artery.
the flap attached by its vascular pedicle
until tumour resection is complete, and the An end-to-side venous anastomosis is
donor vessels have been prepared. If possi- generally done to the internal jugular vein,
ble, complete the osteotomies and secure or to one of its major tributaries.
bony segments to the reconstruction plate
before detaching the vascular pedicle Preparing the donor artery in the neck
(Figure 8) so that the bony reconstruction
is virtually completed with the vascular • Determine the required length of the
pedicle still attached. Only if this is not artery
possible should the bony segments be fixed • Place a micro clamp proximally on the
to the plate after transposing the flap to the donor artery (Figures 3, 4, 9)
mandibular or maxillary defect. • Divide the artery with micro scissors
• Remove excess adventitia from the tip
of the artery

Figure 8: Bony segments fixed to plate

with vascular pedicle still attached to leg

Selecting the donor vessels Figure 9: Microvascular clamp placed

across origin of superior thyroid art-
An end-to-end arterial anastomosis is ery; peroneal artery of free fibula flap
generally done to the facial, superior thy- vascular pedicle lies adjacent
roid, external carotid or transverse cervical
arteries. The surgeon selects the most • Irrigate the lumen with heparin/saline
suitable donor artery based on the ana- • Inspect the arterial lumen and remove
tomical relationship of the donor artery to fibrin from the lumen with micro-
the defect, access to do the anastomosis, forceps (occurs if artery was ligated
the relative diameters of the flap and neck during neck dissection)
arteries, atherosclerosis, scarring from pre- • Carefully dilate the arterial lumen with
vious surgery and/or irradiation, and the the rounded tip of a micro needle
length of the vascular pedicle. Dividing the holder taking extreme care not to
posterior belly of digastric and the stylo- traumatise the endothelium
6
• Observe whether the endothelium has • Flush the vein and the artery with the
separated from the mesothelium; this heparin/saline solution
necessitates additional trimming of the
end of the artery, or taking special care Securing the flap prior to doing the
to catch the loose endothelial layer microvascular anastomosis
with the sutures when doing the micro-
anastomosis, thus preventing dissect- • Secure bone flaps to mandible/maxilla
tion of the endothelial layer, formation and suture skin flaps to mucosa or skin
of an endothelial flap and thrombosis (Figure 11) to avoid inadvertently ap-
• Again, irrigate the arterial lumen with plying traction to the microvascular
heparin/saline to remove blood clots anastomoses
• Trim loose advential strands around the • Do not entirely suture a skin flap at this
tip of the vessel with microscissors to stage to have access to the deep aspect
prevent them from prolapsing into the of the flap to secure haemostasis
arterial lumen and causing thrombosis should bleeding occur from the flap
once it is revascularised
Preparing the Internal Jugular Vein

• Select the segment of the jugular vein

that is to be used for the anastomosis
• Use hydro dissection to elevate and
separate any remaining adventitia
(carotid sheath) over the vein by
irrigating the surface of the vein with
the heparin/saline solution (Figure 10)
• Remove this adventitial layer with
microscissors

Figure 11: Flap partially sutured and bone

secured prior to commencing microvascu-
lar anastomosis

Orientating the vascular pedicle

It is crucial to avoid kinking or rotating the

vascular pedicle. Mark the anterior edge of
the pedicle with blue ink as it lies in situ,
to avoid twisting the pedicle when it is
Figure 10: Separating adventitia of carotid transferred. Consider that the pedicle
sheath off internal jugular vein with gentle elongates after it has been revascularised
hydrodissection due to the vessels distending with blood.

Dividing the vascular pedicle of the flap It may be difficult to atraumatically pass
the vascular pedicle through a soft tissue
• Divide and ligate the vascular pedicle tunnel. A long artery forceps can be passed
of the flap only after the recipient ves- through the tunnel, taking hold of
sels in the neck have been prepared adventitia near the end of the pedicle and

7
gently drawing the pedicle through the geon needs to adapt to the pulsa-
tunnel. Alternatively, it can be done by tions of the carotid
first passing a pencil drain through the • Avoid moving one’s hands outside the
tunnel, advancing the pedicle into the visual field
pencil drain by flushing saline through the • Suturing tips
drain alongside the pedicle, and then o It is easier to run a suture towards
jointly retracting drain and pedicle into the yourself
neck. o Avoid transferring a needle directly
from forceps to needle holder as the
Handling the microinstruments "spring" in a curved needle can
propel the needle and thread a
Microinstruments are extremely delicate considerable distance from the
and are expensive and must be handled operating field
with extreme care (Figure 3, 4) o Pass the needle through the vessel
• Do not drop the forceps as the tips will wall about a vessel wall’s thickness
bend out of alignment or break (or slightly more) from the free
• Place microinstruments separately and edge of the vessel
away from other surgical instruments o Pull the thread through the wall to
• The scrub nurse should clean the 1-2cms from the end of the suture
microinstruments with a warm, wet o Pass the needle through the other
gauze swab every time they are handed vessel’s wall
off to remove dried blood and tissue o The assistant uses microforceps to
• Microsuture needles, sutures and mi- approximate the ends of the pedicle
croclips are easily lost during surgery; and donor vessels
once lost they are extremely difficult to o Tie a knot by holding the longer
find length of suture with the needle
holder about 2-3cms from the exit
Suturing technique and tips point from the vessel and then tying
it to the shorter suture
It is the authors’ preference to employ a
continuous suture technique for both the Arterial microvascular anastomosis
arterial and venous anastomoses, except
when suturing extremely small vessels. The arterial microanastomosis is usually
Although many surgeons use interrupted done first. This allows one to untwist and
sutures, using continuous sutures is much correctly position the remainder of the
quicker and causes less anastomotic leaks. pedicle and the vein; kinking and twisting
• Suturing technique should be practiced the vein can block venous outflow. If the
in an animal laboratory artery and vein of the pedicle cross over
• The author uses an 8/0 nylon suture on each other, then the vein should be
a taper pointed needle orientated to cross superficially over the
• Stabilizing the wrists is important artery.
o Rest them on the operative field
o A patient's chest movement may The author employs two anastomotic
affect the stability of a surgeon's techniques depending on the relative
hand diameters of the donor and recipient
o The arterial anastomosis is usually vessels i.e. end-to-end and occasionally, a
done close to the carotid; the sur- sleeve anastomosis

8
End-to-end arterial anastomosis • Complete the 2nd side of the anastomo-
sis with a running suture (Figure 13)
• Flush the donor and recipient arteries • Tie the end of the suture to the 1st stay
with the heparin/saline solution again suture
• Join the two vessels with a single stay
suture, knot it, and cut it to a length of
about 2cms (Figure 12)
• Insert a 2nd stay suture at the opposite
side of the vessel’s circumference, knot
it, but do not cut it (Figure 12)
• The assistant stabilises the vessels by
holding the two stay sutures with non-
toothed forceps (Figure 12)

Figure 13: Completed arterial anastomosis

Sleeve arterial anastomosis (Figure 14)

The 1st author uses the sleeve anastomosis

technique only when a substantial mis-
match exists in the diameters of a larger
flap vessel and smaller recipient vessel
which makes an end-to-end anastomosis
Figure 12: Stay sutures held with curved difficult to achieve. It is quick and fairly
non-toothed forceps while surgeon inserts simple and there are no intraluminal
row of running sutures sutures; however, the mismatch in vessel
diameters must not be too great, and vessel
• Anastomose the anterior walls of the spasm is more pronounced and lasts longer
vessels with a continuous running su- following release of the clamps.
ture taking care to:
o Avoid constricting the lumen
o Avoid catching the back walls of
the vessels with the sutures
o Include the endothelial layer with
the suture, especially if separated
from the mesothelium
o Space the sutures to compen-sate
for vessels of unequal diameter
• Tie it to the 2nd stay suture
• Flip / rotate the vessels to access the
side opposite to the anastomosis
• Check the suturing on the inside of the
vessel

9
 • Cut the flap vein obliquely to angle the
end-to-side anastomosis at 450
• Choose the exact point of the internal
jugular for the anastomosis
o Vein must reach it comfortably
o Avoid suturing under tension or
under suboptimal conditions -
rather interpose a vein graft
o Anastomosis usually on the side of
the vein so that vein of the pedicle
lies comfortably without a likeli-
hood of kinking
• Atraumatically isolate the segment of
internal jugular vein with a baby
Satinsky vascular clamp (Figure 15)

Figure 14: Sleeve arterial anastomosis

(arrow indicates direction of blood flow):
Cut proximal vessel at 450 angle; pass
suture into lumen of larger vessel some
distance from end, and through adventitia
close to end of smaller vessel; pass suture
back along lumen of larger vessel and
through its wall; telescope smaller vessel
Figure 15: Applying baby Satinsky
into larger vessel; tack adventitiae
vascular clamp to internal jugular vein
together
• Incise the internal jugular vein with
Venous microvascular anastomosis
sharp microscissors. The defect in the
vein should exceed the diameter of the
The venous anastomosis is done end-to-
recipient vein to stretch the vein open
side to the internal jugular vein, or to a
major tributary e.g. the common facial • Flush the lumen of the internal jugular
vein. Rarely, it is done as an end-to-end vein with heparin/saline solution
anastomosis to a very small internal jugu- • Join the two vessels together at one end
lar vein or one of its tributaries. Never of the incision in the internal jugular
allow the internal jugular vein to dry out vein with a single stay suture, knot it,
as it is then more likely to thrombose with and cut it to a length of about 2cms
loss of the flap. • Insert a 2nd stay suture at the opposing
• Identify the vein in the vascular pedicle end of the jugular vein incision, knot it,
which is to be anastomosed but do not cut it
• Ensure that the vein is not kinked or • The assistant may hold the stay sutures
rotated with non-toothed forceps to improve
• Flush the vein with heparin/saline solu- exposure
tion
10
• Anastomose one side of the suture line • Check for arterial filling/distension and
with a continuous suture arterial pulsation in the pedicle
• Space the sutures to compensate for • If arteries are in spasm, apply a swab
unequal lengths of the vessel walls soaked in 10% lignocaine to the vessel
• Tie the suture to the stay suture on for a few minutes
completion of the 1st suture line • Check for bleeding from the arterial
• Flip / rotate the vessels to access the anastomosis
2nd anastomotic suture line o Minor bleeding settles within a few
• Irrigate the lumen of the internal jugu- minutes
lar vein and inspect the completed su- o Significant leaks need to be sutured
ture line
• Complete the 2nd suture line taking care
not to catch the back walls of the
vessels (Figure 16) Facial artery

• Tie the suture to the stay suture on Anastomosis

completion of the 2nd suture line Flap artery

Flap pedicle

Venous
anastomosis

IJV

Figure 17: Pedicle anastomosed to facial

artery (FA) and internal jugular vein (IJV)

Anastomotic bleeding

• The assistant irrigates the suture line

Figure 16: Complete 1st anastomotic
with heparin/saline solution to better
suture line; commencing 2nd suture line
identify the site of the leak
• Insert a single 8/0 suture at bleeding
Revascularising the flap (Figure 17)
point and ligate to seal the bleeding
point
• Ask the anaesthetist to raise the mean
arterial blood pressure to within a
Checking perfusion of the flap
normal range
• Release the vascular clamp on the Be happy with the anastomosis before
internal jugular vein closing the wound. Check flow across the
• Check venous filling/distension in the anastomoses and perfusion of the flap
vascular pedicle using the following measures:
• Check for bleeding from the venous • Ensure an adequate blood pressure
anastomosis • Observe and feel pulsation of the
• Minor bleeding settles within a few arterial pedicle
minutes; significant leaks need to be • Check for bleeding from the flap
sutured
• Release the microclamp on the artery

11
• Prick the skin flap with a needle if internal jugular vein and cause throm-
spontaneous bleeding is not observed bosis and flap failure)
o No bleeding suggests arterial in- • Suture the tracheostomy to the skin;
flow obstruction avoid ties around the neck as they may
o Dark blood suggests venous out- occlude the internal jugular vein and
flow obstruction cause venous outflow obstruction and
• Intra- and postoperative Doppler of the flap failure
vascular pedicle (not routinely) • Repair the donor site
• Continuous invasive monitoring of
oxygenation of the flap e.g. Licox P02 Postoperative management
microprobe (not routinely)
Patients are ideally initially managed in a
Complete inset of skin flap high care / step down unit where the fol-
lowing parameters that may contribute to
Always leave some of the suturing of the flap failure are closely monitored and
flap to be done after the anastomoses have corrected:
been completed to be able to control • Reduced cardiac output
bleeding from the deep aspect of the flap. • Hypotension
This also creates time for blood pressure to • Hypovolaemia
normalise, spasm to settle, and for a "2nd • Hypercoagulability
look", prior to closing the neck. If neces- • Anaemia or polycythaemia
sary, cover the arterial anastomosis and • Hypothermia
pedicle with a swab soaked in 10% lingo- • Shifting of suction drain to cross and
caine to relieve arterial spasm while compress internal jugular vein
completing the soft tissue repair. If any • Wound haematoma
doubt exists about the anastomosis it
• Tracheostomy tapes too tight (once
should be taken down and redone.
tube is changed)
• Excessive movement of flap
Haemostasis
• Neck position which may kink the
It is critical to achieve meticulous haemo- pedicle
stasis before closing the neck as a haema- • Wound sepsis
toma increases the failure rate of flaps. • Alcohol withdrawal syndrome
Inspect the deep aspect of the skin flap and
obtain haemostasis with bipolar cautery Monitoring flap perfusion
and/or ligaclips. Take care not to injure the
vascular pedicle or perforators. A Valsalva Flaps are most likely to fail in the 1st 48hrs.
manoeuvre is done, and the neck wound If detected and acted on timeously it may
checked for bleeding. be possible to salvage a poorly perfused
flap. Therefore, regular and close monitor-
Wound closure ing of perfusion is imperative. The follow-
ing methods may be employed to monitor
• Insert a suction drain into the neck perfusion:
taking care for it not to pass close to • Colour
the anastomoses, and not to cross over • Temperature
the microvascular repair or over the • Needle pricks to check bleeding (pres-
internal jugular vein (may obstruct ence/absence and colour)

12
• Invasive monitoring of oxygen satura- • Rectus abdominis flap
tion (Licox) • Anterolateral free thigh flap
• Doppler monitoring of arterial inflow • Thoracodorsal artery scapular tip
(TDAST) flap
Final comments
Author
Successful free tissue transfer depends on
the many factors outlined in this chapter. JE (Ottie) Van Zyl MBChB, FCS
By attending to all these measures one can Plastic & Reconstructive Surgeon
achieve outstanding results even in a Groote Schuur Hospital
developing world setting (flap success Cape Town, South Africa
rates approx. 95% in our own public ottie@mweb.co.za
hospital in Cape Town 1. However, failure
to pay attention to detail and to all these Author and Editor
factors may lead to flap failure and a very
difficult and often catastrophic course for a Johan Fagan MBChB, FCS(ORL), MMed
head and neck patient. Professor and Chairman
Division of Otolaryngology
Reference University of Cape Town
Cape Town, South Africa
1. Dos Passos G, Rogers A, Price C, et al. johannes.fagan@uct.ac.za
Loupe Magnification for Head and
Neck Free Flap Reconstruction in a THE OPEN ACCESS ATLAS OF
Developing Country. European J
OTOLARYNGOLOGY, HEAD &
Plastic Surg 2015:1-8
(http://link.springer.com/article/10.100 NECK OPERATIVE SURGERY
7/s00238-015-1108-z) www.entdev.uct.ac.za

Other flaps described in The Open

Access Atlas of Otolaryngology Head &
Neck Operative Surgery The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
johannes.fagan@uct.ac.za is licensed under a Creative
• Pectoralis major flap Commons Attribution - Non-Commercial 3.0 Unported
• Buccinator myomucosal flap License

• Buccal fat pad flap

• Nasolabial flap
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• Deltopectoral flap
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• Upper and lower trapezius flaps
• Cervicofacial flaps
• Submental artery island flap
• Supraclavicular flap
• Latissimus dorsi flap
• Local flaps for facial reconstruction
• Radial free forearm flap
• Free fibula flap

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