Manual of Head and Neck Reconstruction Using Regional and Free Flaps

Boban M. Erovic • Piero Lercher

Manual of Head and Neck Reconstruction Using Regional and Free Flaps

ISBN 978-3-7091-1171-0 ISBN 978-3-7091-1172-7 (eBook)DOI 10.1007/978-3-7091-1172-7Springer Wien Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014941287

All photos by Boban M. Erovic. The copyright for all illustrations remains with Piero Lercher. © Springer-Verlag Wien 2015This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law.The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-tion does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.While the advice and information in this book are believed to be true and accurate at the date of publica-tion, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

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Springer is part of Springer Science+Business Media (www.springer.com)

Boban M. ErovicDepartment of OtorhinolaryngologyHead and Neck SurgeryMedical University of ViennaViennaAustria

Piero LercherPublic HealthMedical University of ViennaVienna Austria

I am deeply grateful to all of my patients for their trust and faith in me, and for allowing me to use their photographs in this book.I dedicate this book to my beloved wife Inamaria, the sun of my life, and my lovely children Katharina, Konstantin, and Viktoria, of whom I am very proud and who constantly showing me what is really important in life.Special thanks to my first mentor Dietmar Thurnher for his tremendous support, teach-ing, and patience.To Csilla Neuchrist and Matthaeus Ch. Grasl for their faith, friendship, and encouragement.To my mentors and friends in Toronto, Dale Brown, Patrick Gullane, and Jonathan C. Irish, from whom I learned so much and continue to learn.Special thanks to David Goldstein, who intro-duced me to the wonderful world of microsur-gery, and to Danny Enepekides and Kevin M. Higgins, who constantly encouraged me to identify my limits and expand them further.To Jafar-Sasan Hamzavi and Christian A. Mueller for their friendship and loyalty.With sincere appreciation and special thanks to Wolfgang Gstöttner for his unlimited trust and continued support.

Boban M. Erovic

I thank my children Claudio and Leonardo, who are the sunshine of my life.Many thanks to my family and closest friends, who helped me to fulfill my various commitments as well as supported and motivated me throughout.My special thanks to those patients who contributed to the creation of this book by revealing their personal medical history. By doing so, they made a valuable contribution to the medical care and quality of life of those with similar diseases.

Piero Lercher

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Preface

Ablative tumor surgery of the head and neck frequently results in substantial cosmetic and functional deformities. Microvascular free-tissue transfer permits three- dimensional reconstruction of defects of the head and neck. The selection of adequate donor tissue and profound knowledge of human anatomy and various har-vesting techniques are paramount in ensuring successful reconstruction.

Reflecting on current surgical approaches, this book presents the most frequently used flaps in head and neck surgery, including detailed elucidations of the flaps, their advantages, and pitfalls. Each section contains a preoperative checklist and a step-by-step description of flap harvesting. Algorithms for reconstructing defects, subsequent flap selection, and flap surveillance are also presented.

The overlay technique, along with high-quality photographs and drawings, helps the reader to acquire skills. Stepwise descriptions of various techniques make this book a useful reference work for doctors in training as well as specialists in the fields of otolaryngology, head and neck surgery, plastic, maxillofacial and skull base surgery.

Vienna, Austria Boban M. Erovic Piero Lercher

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Acknowledgments

We greatfully acknowledge the significant contributions of Christian Schopper and Wolfgang Paul Pöschl.

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Contents

Part I Introduction

1 History of Microvascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Selection of Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3 Classification of Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

4 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Clinical Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Reconstructive Ladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Allen Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Contraindications for Free Flap Reconstruction . . . . . . . . . . . . . . . . . . . 16 Educating the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

5 Intraoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Intraoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

6 Arterial Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

7 Venous Anastomosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 End-to-Side Anastomosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

8 Patency of Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

9 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

10 Timetable of Homeostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

11 No Patency and Flap Salvage Options . . . . . . . . . . . . . . . . . . . . . . . . . 49

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12 Skin Graft Harvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Split-Thickness Skin Graft (STSG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Full-Thickness Skin Graft (FTSG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Disadvantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Preoperative Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Surgical Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Pitfalls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

13 Harvesting a Vein Graft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

14 Sural Nerve Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Epineurial Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Epiperineurial Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

15 Harvesting Rib Cartilage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Part II Regional Flaps

16 Paramedian Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

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17 Buccal Fat Pad Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

18 Palatal Island Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Blood Supply and Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

19 The Facial Artery Musculomucosal Flap. . . . . . . . . . . . . . . . . . . . . . . 97Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

20 Sternocleidomastoid Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Contents

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Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

21 Supraclavicular Artery Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

22 Deltopectoral Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

23 Pectoralis Major Muscle Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

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Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Part III Free Flaps

24 Temporoparietal Fascia Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

25 Scapular and Parascapular Free Flap . . . . . . . . . . . . . . . . . . . . . . . . . 153Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Preoperative Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Scapula/Parascapular Flap for Cheek Reconstruction . . . . . . . . . . . . . . . 164 Osteocutaneous Scapula/Parascapular Flap for Mandibular and Cheek Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Tip of Scapula and Latissimus Dorsi Muscle Flap Harvest. . . . . . . . . . . 169 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

26 Latissimus Dorsi Muscle Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

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Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

27 Radial Forearm Free Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Radial Forearm Free Flap for Total Pharyngeal Defects . . . . . . . . . . . . . 194 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

28 Anterolateral Thigh Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

29 Tensor Fasciae Latae Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Anatomy, Blood Supply, and Innervation . . . . . . . . . . . . . . . . . . . . . . . . 216 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

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Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

30 Fibula Free Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

Motor Innervation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Sensory Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Surgical Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

Curriculum Vitae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Contents

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Contributors

Wolfgang Paul Pöschl MD, DDS, PhD, Department of Maxillofacial Surgery, Klinikum Wels- Grieskirchen, Wels, Austria. (Figs. 23.7a, 23.11, 30.2–30.12, 30.13b–30.16)

Christian Schopper MD, DDS, PhD, Department of Maxillofacial Surgery, Medical University of Vienna, Vienna, Austria. (Figs. 25.21–25.29)

Part I

Introduction

3B.M. Erovic, P. Lercher, Manual of Head and Neck Reconstruction Using Regional and Free Flaps, DOI 10.1007/978-3-7091-1172-7_1, © Springer-Verlag Wien 2015

Reconstruction of defects of the face using pedicle flaps is, apart from tooth extraction and skull trepanation, one of the oldest surgical procedures in human history.

The first nose reconstruction was performed approximately 1500 BC in India, at a time when amputation of the nose was used as a punishment. One of the most famous illustrations of such humiliation shows Prince Lakshmana amputating the nose of Lady Surpanakha (Fig. 1.1). However, King Ravana ordered her nose to be reconstructed with a pedicle forehead flap.

1History of Microvascular Surgery

1.1

4

Many centuries later, the pedicle flap for nose reconstruction was described in the Sushruta Samhita, a Sanskrit text on surgery attributed to Sushruta, a physician from the sixth century BC. The principles of plastic surgery known at that time, and also the importance of proper physiotherapy before the operation, have been described in this manuscript. Specifically, techniques to release the skin for cover-ing small defects, rotation flaps, and the use of pedicle flaps for covering complete skin loss from certain areas of the human body have been described in detail.

Although the secrets of reconstruction were most closely guarded by Indian physi-cians, the knowledge reached Greece and was adopted by Greek as well as Roman doctors. As the Arabs occupied Sicily between the ninth and twelfth century, the knowledge spread all over Europe. However, the advancement of medical sciences was severely restricted in the Middle Ages because the church condemned surgical proce-dures. A rediscovery took place in the Renaissance, particularly in Italy, where a delayed forearm flap for rhinoplasty was introduced in 1400. This type of reconstruction is attributed to Gustavo and Antonio Branca, who lived in Catania, Italy.

Gaspare Tagliacozzi (1545–1599), an Italian surgeon and a pioneer of plastic and reconstructive surgery, improved the procedures used by Gustavo and Antonio Branca. In his groundbreaking book entitled On the Surgery of Mutilation by Grafting, he described the surgical procedures comprehensibly and in great detail (Fig. 1.2).

1.2

1 History of Microvascular Surgery

5

Human knowledge is apt to be lost over time; the same was true for the know-ledge and skills of flap surgery. In the nineteenth century, Karl Ferdinand von Graefe (1787–1840), a German surgeon, rediscovered Tagliacozzi’s technique of recon-structing defects in the face. Based on Tagliacozzi’s procedure, von Graefe devel-oped his own technique of rhinoplasty and performed one of the first operations for the treatment of a congenital cleft palate.

A contemporary physician who was also involved in the resurgence of skin grafts and flaps in Europe was Joseph Carpue (1764–1846). He is known for having per-formed the first rhinoplastic surgery in England. In 1816 Carpue published his paper entitled Account of Two Successful Operations for Restoring a Lost Nose from the Integument of the Forehead. From this time on, medical interest in reconstructive surgery experienced a revival in Europe.

Further significant developments in reconstructive surgery were made after the introduction of general anesthesia. Specifically, in 1869 the Swiss surgeon Jacques- Louis Reverdin (1842–1929) performed a “fresh skin” allograft. This procedure, which became known later as the “Reverdin graft,” helped significantly in wound healing.

Carl Manchot (1866–1932), also a Swiss surgeon, worked intensively on cuta-neous vascularization. In 1889 he published his anatomical studies in German enti-tled Die Hautarterien des menschlichen Körpers (Skin Arteries of the Human Body). Manchot was convinced that only flaps with an appropriate length-to-width ratio would survive: the length of the flap should be no greater than 1.5 times its width. In the 1930s, William D. Morain edited Manchot’s manuscripts, which were largely unknown until this time, and published them in English.

Pietro Sabattini lived from 1810 to 1864 and worked as a surgeon at the University of Bologna. He was another pioneer of reconstructive surgery, but did not achieve widespread recognition because he published all of his work in Italian (1838). In one manuscript he described the reconstruction of a posttraumatic upper lip defect by using a composite flap from the lower lip. Robert Abbé (1851–1928), an American surgeon, reported on the same musculocutaneous labial flap in a widely read English-language medical journal 60 years after Sabattini. Subsequently it became known as the Abbé flap.

Several advancements in flaps were made over time, including extensive facial flaps and the first cross-leg flap. However, the first recorded muscle flap was the pectoralis minor muscle flap used by the French surgeon Louis Ombrédanne (1871–1956) in 1906. In the same year, the Italian Iginio Tansini (1855–1943) introduced the latissimus dorsi muscle flap. Six years later, in 1912, the first myocutaneous flap was also introduced in Italy at the University of Pavia by Stefano d’Este.

Finally, the appalling injuries of modern warfare in World War I and II served as an impetus for the advancement and establishment of plastic and reconstructive surgery.

Gino Pieri (1881–1952), an Italian military surgeon in World War I, addressed the paucity of information regarding the vascularization of the skin. He created a skin perforator map of the human body. Six decades later, in 1971, Stuart Milton showed that the viability of any flap is determined by its blood supply and, conse-quently, its vascular pedicle.

History of Microvascular Surgery

6

The introduction of new technology and medications for anesthesia, new antibi-otics, and advances in wound healing led to significantly better postoperative results. Further improvements in surgical techniques resulted in harvesting of more com-plex flaps, such as composite and compound pedicle and muscle flaps.

One of the most impressive facial reconstruction, and the first flap reconstruction to be documented on photographs, was performed in 1917 by the New Zealand-born and later London-based Sir Harold Gillies (1882–1960). The procedure was per-formed on Walter Ernest O’Neil Yeo (1890–1960) at Queen Mary’s Hospital in Sidcup, Kent. The sailor Yeo sustained terrible facial injuries, including the loss of his upper and lower eyelids in World War I, and was one of the first patients to benefit from the new technique of tubed pedicle skin grafting (Fig. 1.3). The left and right pictures of Walter Ernest O’Neil Yeo (1890–1960) are classical before- and- after views of the medical procedure.

In 1921 the Swedish surgeon Carl-Olof Siggesson Nylén (1892–1978) was the first to operate with a surgical microscope. This marked the birth of the era of micro-surgery. Pedicle flaps were commonly used during World War I and II. The next period of development was marked by the use of axial flaps—also known as pattern flaps—in the 1950s and 1960s.

The old Russian proverb holds true for the history of microvascular surgery as well: “Something new is something old that has been forgotten.” Stuart Milton (1971) and Ian A. McGregor (1972) described “axial pattern skin flaps” and “groin flaps,” which came very close to the perforator flaps described later.

1.3

1 History of Microvascular Surgery

7

Developments in microvascular surgery signified a major step forward in patient care, but were also linked with certain drawbacks, such as flap ischemia, necrosis, infection, and significant donor site morbidity.

In 1981 Bengt Pontén of Sweden was the first to harvest lower-limb flaps. These so-called fasciocutaneous flaps enhanced flap survival because of their generous prefascial and subfascial blood supply. The Japanese plastic and reconstructive surgeons Isao Koshima and Shugo Soeda published a landmark report about perforating arteries in 1989. These arteries course along intermuscular and inter-compartmental fascial septa and reach the superficial fascia, and finally, the skin. Several studies were then performed to determine all perforator vessels in the human body to create more potential flaps. This led to a large number of flaps, which caused significant confusion because of the absence of a consistent international nomencla-ture. The nomenclature of different flap types will be addressed in detail in the fol-lowing chapters.

The newest flaps are the so-called freestyle free flaps, which can be dissected from any region of the body as long as a perforator vessel from the skin is detectable by Doppler ultrasound. Future research on chimeric and local perforator flaps, perforator- to-perforator free flaps, as well as the development of finer instruments, is expected to introduce further advancements in microvascular reconstructive surgery.

History of Microvascular Surgery

9B.M. Erovic, P. Lercher, Manual of Head and Neck Reconstruction Using Regional and Free Flaps, DOI 10.1007/978-3-7091-1172-7_2, © Springer-Verlag Wien 2015

Restoration of defects after tumor resection in the head and neck is a major challenge for the reconstructive surgeon. Prior to flap selection, the defect should be analyzed carefully. The goal of reconstruction, the critical parts, and the technical feasibility of the intended procedures should be determined.

Flaps used to reconstruct functional units must include the skin, muscle, bone, cartilage, or tendon (Fig. 2.1). To achieve an acceptable cosmetic result, flap

2Selection of Flaps

Defect

Yes

Yes

Pedicled Flap

Free Flap

+Advancement+Bilobed flap

+STSG/FTSG+Tendon+Cartilage+Fascia

+PML+LAT+SCAF+DP+Paramedian

Yes

Yes

No

No

Grafting

No

No

Rotation flap

Healing by primary intention

ALT/Scapula/LAT/TFL/RFFF/TPF

ALT/Scapula/LAT+STSG

ALT/Scapula/LATTFL

Contour

Color match

Thickness

Bone

Tendon

Size of flap

Fibula/Scapula/RFFF+bone

RFFF+Palmaris

LAT

ALTTFL

RFFFTPF

Scapula

2.1