Microvascular Free Flap Reconstruction After Head and Neck Cancer

Microsurgery developed in the 1960s by Jacobson + Suarez — first clinical vessel microanastomosis. Applied to head and neck surgery in the late 1970s; first successful free flap series by Soutar and colleagues using radial forearm (1983). Standard practice since the 1990s.

Pre-microsurgical reconstruction options: local-rotation flaps (forehead, deltopectoral), pedicled distant flaps (pectoralis major myocutaneous — 1970s gold standard), primary closure (limited), grafts (skin graft — non-functional). These poorly cover large defects and provide limited functional restoration.

Microsurgical advantages: (1) Donor site flexibility — tissue from anywhere; (2) Defect-similar tissue match — bone for bone, thin mucosa for thin skin; (3) Vascular guarantee after anastomosis; (4) Single-stage reconstruction; (5) Oncologic radicality preserved (less fear of leaving large defect); (6) Postop radiotherapy tolerated (vascularised flap).

Vessel microanastomosis: recipient + donor vessel (artery 1-3 mm, vein 2-4 mm) sutured under microscope magnification (10-25×) with 9-0 or 10-0 monofilament nylon. Types: end-to-end (most common — equal calibre), end-to-side (recipient larger — facial branch to external carotid main wall), interposition vein graft (long distance — saphenous from leg).

Patency check: hourglass-timed flow inspection, doppler probe, "milking test" (compress vessel; rapid refill if anastomosis open). Thrombosis risk: vein > artery (lower pressure, fewer collaterals), highest first 24-48 hours.

Flap monitoring — critical postop: first 24 hours hourly, first 72 hours 4-hourly, then daily. Clinical: skin colour (pink good, pale arterial ischaemia, blue/dark red venous congestion), capillary refill (normal 3-4 s), temperature, turgor. Implantable doppler (Cook-Swartz) modern gold standard — continuous arterial flow monitoring.

Salvage surgery: flap ischaemia/congestion → emergency re-exploration — thrombectomy + anastomosis revision. First 4-6 hours window critical — re-exploration in this window salvages 70-80%; >12 hours success drops. Hence close monitoring essential.

Microsurgery learning curve: laboratory rat vessel (1 mm) training, then human case observation + assistance with experienced surgeon. Independent practice typically after 3-5 years. Microsurgery practice well developed in Turkish major academic + private centres.

Oncologic principles inviolable: reconstruction concerns must NOT limit resection extent. R0 (tumour-free margin) is the goal; reconstruction is planned afterwards "however large the defect". Hence multidisciplinary head and neck oncologic surgery — surgical oncologist resects, reconstruction surgeon prepares in parallel. Related overview: our head and neck cancer surgery programme.

Flap selection by defect characteristics — tissue type (skin, muscle, bone, combined), defect size, functional need (swallow, speech), cosmetic expectation, donor site morbidity.

Radial forearm free flap (RFFF — Yang flap): thin pliable skin + fascia from distal forearm. Pedicle: radial artery + cephalic or basilic vein. Size: 4×6 cm to 12×20 cm. Advantages: thin + pliable (excellent oral mucosa match), long pedicle (~15 cm — easy recipient access), two-team simultaneous use (lower extremity used). Indications: hemiglossectomy/base of tongue, soft palate, floor of mouth, lower lip, partial larynx, pharyngeal wall. Donor morbidity: forearm full-thickness skin graft (cosmetic concern); radial artery sacrificed (Allen test mandatory — ulnar adequacy); wound healing problems <5%; hand function preserved.

Fibula osteocutaneous free flap (FOCFF — Hidalgo flap, Wei modification): leg fibula bone (up to 25 cm) ± peroneal artery skin paddle (up to 10×20 cm) ± peroneus longus muscle. Pedicle: peroneal artery + vein. Gold standard for mandibular reconstruction — high bone quality, osteotomies shape mandibular arch, dental implants feasible. Indications: segmental mandibular defect, maxillary bone defect (Le Fort I-II-III). Donor morbidity: fibula is not a stability bone (tibia carries load) — walking preserved; 6-8 cm distal fibula left (lateral malleolus stability); low ankle morbidity with peroneal nerve preservation.

Anterolateral thigh free flap (ALT — Song flap, Wei popularisation): large skin + fat ± vastus lateralis from anterolateral thigh. Pedicle: lateral circumflex femoral artery (LCFA) descending branch. Size: 6×8 cm to 20×35 cm (one of body's largest skin flap options). Advantages: ideal for huge defects; long pedicle (15+ cm); minimal donor morbidity (primary closure or skin graft); vastus inclusion adds volume + nerve to bulk option. Indications: total glossectomy, extensive oropharyngeal resection, large skin defect (scalp, neck, face), pharyngo-oesophageal reconstruction (tubularised ALT).

Latissimus dorsi pedicled + free flap: large back muscle + skin. Pedicle: thoracodorsal artery (subscapular branch). Size: 8×15 cm to 25×35 cm. Indications: very large defects (radical resection, radiation osteonecrosis, skull base + neck large defects), salvage (previous flap failure). Pedicled use possible (neck reach — shorter pedicle). Donor morbidity: shoulder dysfunction mild (especially adduction-internal rotation), long scar.

Rectus abdominis flap: midline abdominal muscle + skin. TRAM (transverse rectus abdominis myocutaneous) or VRAM. Advantage: thick safe pedicle, medium-large tissue. Disadvantage: abdominal scar, hernia risk (mesh reduces). Less common in head and neck — popular in breast reconstruction.

Scapular flap: back skin + bone (lateral scapular edge). Mandibular composite skin-bone defects (usually fibula preferred; scapular combination older type).

Gracilis muscle flap: small-medium thigh medial muscle; modern priority for functional reconstruction (facial reanimation after palsy — muscle + nerve transfer).

Selection factors: defect size, bone need (fibula), thin/pliable need (oral mucosa — radial), large volume need (extensive oropharyngeal — ALT or latissimus), donor morbidity (elderly + already poor walker — fibula unsuitable), prior surgery/radiation (recipient vessel quality — irradiated neck difficult; may need vein graft), patient preference (skin scar, functional loss).

Patient selection: free flap reconstruction is major surgery — 8-12 hours, hospitalisation 7-14 days, ICU postop. Comorbidities reviewed: cardiovascular (long anaesthesia tolerance), diabetes (microvascular thrombosis + healing), peripheral vascular disease (lower extremity donor), prior radiotherapy (neck recipient vessels scarred), nutrition (BMI, albumin), smoking (must stop — minimum 2 weeks perioperatively).

Multidisciplinary tumour board: pathologist, radiologist, ENT oncologic surgeon, plastic/microsurgeon, radiation oncologist, medical oncologist, speech-language therapist, nutritionist — plan the case together. Surgical margins + reconstruction strategy + adjuvant pathway agreed jointly.

Imaging: contrast neck CT (tumour + nodes), contrast neck + maxillofacial MRI (soft tissue, perineural invasion), PET-CT (distant metastasis + nodal staging), chest CT (lung mets), donor-site imaging (fibula leg CTA — peripheral vessel patency, peroneal dominance; ALT thigh perforator mapping — preoperative doppler ultrasound). 3D modelling + virtual surgical planning (especially mandibular reconstruction — CT-based custom cutting guide manufacture).

Preoperative assessment: cardiac (ECG, echo; cardiology consult as needed), pulmonary (PFT if COPD), nutrition (preoperative PEG tube — optimisation), dental (oral cavity surgery — infection reduction), psychological evaluation + patient-family education (long pathway).

Surgical day — two-team approach: Team 1 (ENT oncologic): oral cavity tumour resection + neck dissection (selective or modified radical). Team 2 (reconstructive plastic/microsurgery): parallel donor-site flap dissection (e.g. fibula — bone + skin + vessel mobilisation). Teams synchronise — when resection complete, flap ready, recipient vessels prepared in neck (external carotid branches + jugular vein). Defect assessment + flap insetting (positioning + osteotomy shaping + skin closure). Microsurgery phase: vessel anastomosis (1 artery + 1 vein, or 1 artery + 2 veins for venous drainage safety). Total 8-12 hours depending on complexity.

Anaesthesia management: TIVA usually preferred (less perfusion variability vs inhalers), normothermia (hypothermia thrombosis), normotension (hypotensive technique increases thrombosis — controlled), normocarbia (hypercarbia vasodilation was previously thought useful; modern preference normocarbia), appropriate fluid management (hypovolaemia thrombosis; hypervolaemia oedema — middle target).

ICU postop: first 24-48 hours. Goals: flap perfusion monitoring (hourly), systemic stability (cardiovascular, respiratory, renal), pain control (epidural or PCA), antibiotic prophylaxis (cefazolin + metronidazole — 24 hours), DVT prophylaxis (LMWH — flap thrombosis vs DVT prevention balance, standard in modern protocols), nutrition (parenteral or tube feeding), early tracheostomy practice (post long surgery + large reconstruction — airway protection).

Flap monitoring: first 24 hours hourly (colour, refill, temperature, doppler), 24-72 hours 4-hourly, then routine. Implantable doppler (Cook-Swartz) modern: continuous arterial flow with alarm on loss. Soft-tissue flaps visually accessible; buried flaps (osteocutaneous, internal — fibula osteocutaneous intraoral skin paddle typically leaves a sentinel skin window externally).

Early complications (first 72 hours): vascular thrombosis (3-5% — most salvaged with re-exploration), bleeding (anastomosis or neck — re-exploration), haematoma (compression flap ischaemia), infection (rare — prophylaxis reduces), neck skin necrosis (more frequent after radiotherapy history), fistula (oral cavity or pharynx — healing problem, prolonged feeding tube).

Late complications: persistent swallowing dysfunction (rehab mitigates), speech disorder (rehab, voice prosthesis as needed), cosmetic (skin colour/texture mismatch, local swelling — improves with time), donor-site issues (radial — mild hand function; fibula — ankle weakness; ALT — moderate strength loss), trismus (post-mandibular reconstruction), bone non-union (at fibula osteotomy — modern plate technology has reduced), psychological (depression, anxiety — major life change).

Discharge criteria: stable flap, stable oral or tube feeding, controlled pain, normal labs, mobilising. Usually 7-14 days. Home care + first outpatient review 1 week, suture removal 2 weeks, detailed wound + rehabilitation plan at 1 month. More detail: multidisciplinary tumour board.

Microvascular reconstruction technical success (no flap loss) is one goal; real success is patient swallowing + speaking + returning to social life. Hence multidisciplinary rehabilitation plan is critical.

Swallowing rehabilitation: speech-language therapist (SLT) led. Postop month 1: oral motor evaluation + videofluoroscopic swallow study (VFSS) or fibreoptic endoscopic evaluation of swallowing (FEES). If aspiration risk, continue tube feeding. Treatment: lip, tongue, jaw exercises, swallowing manoeuvres (effortful swallow, Mendelsohn, supraglottic), texture modification (thickened liquid → puree → soft → normal). 4-8 week pathway — most reach oral diet.

Speech rehabilitation: post-total/partial glossectomy speech changes — articulation difficulties (especially dental + alveolar — t, d, n, l, s, z), intonation. SLT works on tongue-lip-soft palate exercises, alternative phonation strategies. Post-laryngectomy voice rehab — special: tracheo-oesophageal prosthesis (TEP — Provox, Blom-Singer) placed postop 2-4 weeks; oesophageal speech (older, harder to learn); electrolarynx (alternative). Most regain functional speech within 2-6 months.

Dental rehabilitation: dental implants + prosthesis after mandibular/maxillary reconstruction. 6-12 months postop (after bony union + radiotherapy completion). Fibula bone implant-suitable (typically 4-6 implants supporting mandibular fixed prosthesis). Prior radiotherapy raises osteoradionecrosis risk — hyperbaric oxygen (HBO) prophylaxis considered. Modern zirconia implants + hygienic superstructure standard.

Nutrition rehabilitation: dietitian led. PEG tube placed preoperatively or postop — long-term feeding security. Target: adequate calories (35 kcal/kg) + protein (1.5-2 g/kg/day — wound healing), vitamin D + B12 + folate, hydration. Gradual oral diet — by swallowing function. Quitting smoking + alcohol critical (healing + second tumour risk).

Psychological rehabilitation: head and neck cancer patients have high depression (30-40%), anxiety (25-35%), body image disturbance, social isolation. Clinical psychologist/psychiatrist consult standard. Individual therapy + family counselling + support groups helpful. SSRI antidepressants (sertraline, escitalopram) — improve QoL.

Cosmetic rehabilitation: skin scar + flap colour/texture mismatch improves with time. Postop 6-12 months fine-tuning (revision — fat grafting, lipodebulking, dermabrasion, laser resurfacing). Permanent make-up (brows, lip line) useful in some. Accessories (wig if scalp involved, intraoral obturator prosthesis) as needed.

Vocational rehabilitation: most patients return to work in 6-12 months — role may change by voice + swallowing function (e.g. speech-heavy job → administrative/written role). Return to work important for social-economic recovery.

Adjuvant therapy: 4-6 weeks after surgery for wound healing, then radiotherapy (T3-T4 tumour or regional nodes positive — usually recommended) ± chemotherapy (high-risk pathology — extracapsular spread, R+/close margin, perineural or lymphovascular invasion). Radiotherapy field includes the flap — flap tolerates well (vascularised tissue); xerostomia, mucositis, dental sensitivity are expected side effects.

Long-term follow-up: surveillance after surgery + adjuvant. First 2 years every 1-3 months, 2-5 years every 6 months, after 5 years annually. Clinical exam + fibreoptic endoscopy + contrast MRI (every 6 months) + PET-CT (annual). Second tumour risk (especially in smokers + alcohol use history — annual chest CT or similar screening). Dental follow-up + implant control. Nutrition + speech + QoL surveys (UW-QOL, EORTC QLQ-H&N35) — follow-up parameters.

Turkish head and neck reconstruction centres: Istanbul (Memorial, Acıbadem, Anadolu, university hospitals), Ankara (Bayındır, Hacettepe, Gazi), Izmir (Ege University, KEAH). Centres with >50 cases/year preferred — outcomes volume-related. Related reading: our multidisciplinary tumour board.