Strategies for Avoiding Complications with Vascularized Bone Flaps in Head and Neck Microvascular Reconstruction

ABSTRACT

Effective osseous reconstruction of the head and neck after congenital, traumatic, and particularly ablative oncologic procedures is a relatively recent innovation. Whereas pioneers led with individual donor sites, it is only in the past 20 years that most centers have developed teams comfortable with use of the four common donor sites for free flaps: iliac crest, fibula, radius, and scapula. Calvarium, though much less frequently used, is a useful donor site for specific reconstructive challenges. Less commonly used sites such as femur, humerus, and rib have not proved universally reliable. This article aims to illustrate some refinements and pitfalls in vascularized osseous reconstruction of the head and neck using the well-recognized flaps, including calvarium, in a variety of pathologic conditions, recipient-site defects, and comorbidities. Strategies for error avoidance will be emphasized. The authors hope that this will support the concept of a reconstructive “toolbox” for this complex area.

KEYWORDS

Error avoidance - microsurgery - head and neck - osseous free flaps

REFERENCES

• 1 Wei F C, Mardini S. General principles and analysis of defects in head and neck reconstruction.  Semin Plast Surg. 2003;  7 259-266
• 2 Cordeiro P G, Dissa J J, Hidalgo D A, Hu Q Y. Reconstruction of the mandible with osseous free flaps: a 10 year experience with 150 consecutive patients.  Plast Reconstr Surg. 1999;  104 1314-1320
• 3 Mehrara B J, Cordeiro P G. Avoiding and dealing with complications after head and neck microvascular reconstruction.  Semin Plast Surg. 2003;  17 267-274
• 4 Towler J. Cigarette smoking and its effects on wound healing.  J Wound Care. 2000;  9 100-104
• 5 Yaffe B, Cushin B J, Struub B. Effect of cigarette smoking on experimental microvascular anastomosis.  Microsurgery. 1984;  5 70-72
• 6 Jones J K, Triplett R G. The relationship of cigarette smoking to impaired intraoral wound healing: a review of evidence and implications for patient care.  J Oral Maxillofac Surg. 1992;  50 237-239
• 7 Reus III W F, Cohen L B, Straker D J. Tobacco smoking and complications in elective microsurgery.  Plast Reconstr Microsurg. 1992;  89 490-494
• 8 Esclamado R M, Carroll W R. The pathogenesis of vascular thrombosis and its impact on microvascular surgery.  Head Neck. 1999;  21 355-359
• 9 Mitchell D A, Gorton H. The effect of central venous manipulation on coagulability: an observational study.  Br J Oral Maxillofac Surg. 2005;  43 215-218
• 10 Disa J J, Polvora V P, Pusic A L, Singh B, Cordeiro P G. Dextran-related complications in head and neck microsurgery: do benefits outweigh the risks? A prospective randomized analysis. 2003.  Plast Reconstr Surg. 2003;  112 1534-1539
• 11 Agnelli G. Prevention of venous thrombosis in surgical patients.  Circulation. 2004;  110 IV-4-IV-12
• 12 Friedman H I, Fitzmaurice M, Lefaivre J F, Vecchiolla T, Clarke D. An evidence-based appraisal of the use of hyperbaric oxygen on flaps and grafts.  Plast Reconstr Surg. 2006;  117 175S-190S
• 13 Antonyshyn O, Coldeugh R G, Hurst L N, Anderson C. The temporalis myo-osseous flap: an experimental study.  Plast Reconstr Surg. 1986;  77 406-501
• 14 Ewers R. Reconstruction of the maxilla with a double musculoperoiosteal flap in connection with a composite calvarial bone graft.  Plast Reconstr Surg. 1988;  79 431-436
• 15 Matsuba H M, Hakki A R, Little J W, Spear S L. The temporal fossa in head and neck reconstruction: twenty-two flaps of scalp, fascia and full thickness cranial bone.  Laryngoscope. 1988;  98 444-447
• 16 Moor J, Moor J, Fabbroni G, Mitchell D A. Mucinous intestinal adenocarcinoma of the sinonasal tract induced by passive hardwood inhalation; case report.  J Craniomaxillofac Surg. 2005;  32 228-232
• 17 Forrest C, Boyd R, Manktelow R, Zuker R, Bowen V. The free vascularised iliac crest tissue transfer: donor site implications associated with eighty-two cases.  Br J Plast Surg. 1992;  45 89-93
• 18 Urken M L, Vickery C, Weinberg H, Buchbinder D, Cawson W, Biller H F. The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction.  J Reconstr Microsurg. 1989;  5 203-207
• 19 Rogers S N, Lakshmiah S R, Narayan B et al.. A comparison of the long term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer.  Plast Reconstr Surg. 2003;  112 1517-1525
• 20 Taylor G I, Townsend P, Cortlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flap. Experimental work.  Plast Reconstr Surg. 1979;  64 361-367
• 21 Brown J S. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect.  Head Neck. 1996;  18 414-421
• 22 Mao C, Cai Z, Peng X, Liou D, Yu G. The value of preoperative routine donor leg angiography in free fibula flaps.  Zhonghua Kuo Qiang Yi Xue Za Zhi. 2002;  37 15-21
• 23 Goodacre T EE, Walker C J, Jawad A S, Jackson A M, Brough M D. Donor site morbidity following osteocutaneous free fibular transfer.  Br J Plast Surg. 1990;  43 410-416
• 24 Takushima A, Harii K, Asato H, Nakatsuka T, Kimata Y. Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases.  Plast Reconstr Surg. 2001;  108 1555-1563
• 25 Soutar D S, Widdowson W P. Immediate reconstruction of the mandible using a vascularised segment of the radius.  Head Neck Surg. 1986;  8 232-246
• 26 Timmons M J, Missotten F EM, Poole M D, Davies D M. Complications of radial forearm flap donor sites.  Br J Plast Surg. 1986;  39 176-182
• 27 Villaret D B, Futran N A. The indications and outcomes in the use of osteocutaneous radial forearm free flap.  Head Neck. 2003;  25 475-481
• 28 Chambers P A, Harris L, Mitchell D A, Corrigan A M. Comparative study of the ipsilateral full thickness forearm skin graft in closure of radial forearm flap donor site defects.  J Craniomaxillofac Surg. 1997;  25 245-248
• 29 Swartz W M, Banis J C, Newton E D, Ramasastry S S, Jones N F, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction.  Plast Reconstr Surg. 1986;  77 530-537
• 30 Upton J, Albin R E, Mulliken J B, Murray J E. The use of scapular and parascapular flaps for cheek reconstruction.  Plast Reconstr Surg. 1992;  90 959-1003
• 31 Coleman J J, Sultran M K. The bipedicle osteocutaneous scapula flap: a new subscapula system free flap.  Plast Reconstr Surg. 1991;  87 682-692