Microsurgical Free Flaps
The arrival of microsurgical techniques which uses special operating microscopes and instruments, has allowed the possibility of performing intricate operations on tiny blood vessels in our body. This, in turn, has made tissue transfer from a distant site to reconstruct defects in the head and neck region after surgical resection feasible.
The tissue that is harvested from the patient’s own distant body site for reconstruction is known as a free flap. This includes the skin and often with its surrounding tissue, together with its supplying blood vessels. This free flap is then detached from its donor site and transplanted to the head and neck area where the blood vessels are reconnected under microscopic magnification, and the skin is used to resurface the defect.
Microsurgical reconstruction has allowed surgeons to adopt a more aggressive approach in resecting tumours that would have resulted in defects that were previously deemed too extensive for reconstruction.
Besides allowing for a larger volume of tissue to be transferred to these defects, the use of free flaps has also resulted in a more precise reconstruction of head and neck defects. Reconstruction of complex defects involving bone, muscle and soft tissue can also be reliably achieved.
The common free flaps that are used for the construction of head and neck defects are the anterolateral thigh flap (outer border of thigh), fibula free flap (lower leg) and radial forearm flap (lower arm).
Each patient is unique, and the expertise of the reconstructive surgeon is harnessed to plan the most suitable method of reconstruction to achieve both functionally and aesthetically acceptable outcomes.
1. Anterolateral Thigh (ALT) Flap
An anterolateral thigh (ALP) flap is obtained from the outer border of the thigh. This is often used in reconstruction in the mouth and throat after the removal of the tumour. The flap is connected to the blood vessels in the neck to ensure that its blood supply is restored.
The doctors and nurses will ensure that the flap is healthy by monitoring the reconstructed area and donor site (where the flap is obtained) closely. It is important for you to start exercising (as indicated by the doctors) your hip and knee to ensure that you regain full movement. There may be some restriction in movement after surgery due to swelling, bandaging or drains in your leg. Gentle lower limb exercises can also help to reduce any swelling. Complete recovery of the leg can be expected within 3 months.
2. Radial Forearm Flap
A radial forearm flap is an area of skin and subcutaneous tissue obtained from the lower arm. It is a commonly used flap for reconstruction of the tongue following head and neck surgery. It is considered one of the most reliable flaps for reconstructive surgery.
The area where the flap is taken from the forearm is usually covered with a skin graft. The doctors and nurses will ensure that the transplanted flap is healthy by monitoring the reconstructed area and donor site (the area where the flap is obtained) closely.
It is important to exercise your elbow, wrist and fingers (as indicated by the doctors) in order to regain full movement. You will need to wear a splint to stabilise the forearm after the bandages are removed. Gentle exercises will help to reduce any swelling and prevent stiffness at the elbow and wrist joints. Complete recovery of the arm can be expected within 3 months.
3. Fibula Free Flap
A fibula free flap is obtained from the lower leg where skin and bone (fibula) are taken for reconstruction. The area commonly reconstructed using this flap is the jaw where bone replacement is needed following the surgery. The doctors and nurses will ensure that the flap is healthy by monitoring the reconstructed area and donor site (where the flap is obtained) closely.
You will need to avoid bearing any weight on the leg where the flap is obtained as it may be sore after the surgery. To help reduce the pain and improve the movement in the leg, gentle exercise can be done while on the bed or chair.
Your leg will be bandaged and placed on a cast to stabilise the area for about 2 weeks. You may start mobilising with a walking frame or crutches initially and progress to a walking stick when the leg can take more weight as it recovers. Complete recovery of the lower leg can be expected in 3 to 6 months.