Reconstructive Techniques in Head and Neck Surgery

Recon Principles & Ladder - Building Blocks

• Goals & Principles:
  • Restore form & function.
  • Replace "like with like" (e.g., mucosa for mucosa).
  • Minimize donor site morbidity.
  • Simple to complex approach.
• Reconstructive Ladder: Guides choice of technique. Ascend if simpler options are inadequate.
  • Healing by secondary intention
  • Direct/Primary closure
  • Skin grafts (Split/Full Thickness)
  • Local flaps (e.g., rotation, transposition)
  • Regional flaps (e.g., PMMC, Deltopectoral)
  • Free tissue transfer (microvascular anastomosis)

⭐ The choice of reconstructive technique is guided by the "reconstructive ladder," starting with the simplest effective method for the defect presented.

Skin Grafts & Local Flaps - Covering Ground

• Skin Grafts: Transfer of epidermis & variable dermis; rely on recipient bed vascularity.

  • Split-Thickness Skin Graft (STSG): Epidermis & part of dermis. Higher take, can contract. Donor site heals by re-epithelialization.
  • Full-Thickness Skin Graft (FTSG): Epidermis & entire dermis. Better cosmesis, less contraction. Donor site needs primary closure or grafting.
  • Meshing: Expands STSG, allows drainage.
  • Indications: Superficial defects, burns, lining cavities.

• Local Flaps: Tissue moved from adjacent area with intact blood supply.

  • Types: Advancement, rotation, transposition, interpolation.
  • Examples: Rhomboid flap, Z-plasty, nasolabial flap.
  • Advantages: Good color/texture match, robust vascularity.

⭐ McGregor (Z-plasty) Flap: Angles of 60° theoretically lengthen the scar by 75%. Used for scar revision and contracture release.

📌 Mnemonic for flap survival: Plan, Perfusion, no Pressure, no Pull (tension).

Pedicled Regional Flaps - Workhorse Wonders

• Maintain own blood supply; rotated/transposed from nearby/distant areas.
• Pectoralis Major Myocutaneous (PMMC) Flap:
  • Artery: Thoracoacromial (pectoral branch).
  • Uses: Oral cavity, oropharynx, hypopharynx, neck.
  • Reliable, versatile; can be bulky.
• Deltopectoral (DP) Flap:
  • Artery: Internal mammary perforators.
  • Uses: Pharyngoesophageal, neck resurfacing. Thinner.
• Latissimus Dorsi (LD) Flap:
  • Artery: Thoracodorsal.
  • Uses: Large defects (scalp, skull base).
• Trapezius Flap: (Upper, Lateral, Lower based on pedicle)
  • Arteries: Occipital, transverse cervical, dorsal scapular.
  • Uses: Posterior scalp, lateral face, neck.

⭐ The PMMC flap is a workhorse for intraoral reconstruction due to its robust thoracoacromial artery pedicle and versatility.

Microvascular Free Flaps - Advanced Arsenal

• Tissue (skin, muscle, bone, or composite) transferred with its own artery & vein; anastomosed to recipient site vessels.
• Indications: Large, complex defects; composite tissue requirements (e.g., bone and soft tissue).
• Advantages: Superior vascularity, versatility, single-stage reconstruction, allows like-for-like tissue replacement.
• Key Flaps & Pedicles:
  • Radial Forearm Free Flap (RFFF): Radial a. (Thin, pliable; excellent for oral lining).
  • Anterolateral Thigh (ALT) Flap: Descending branch of Lat. circumflex femoral a. (Versatile; skin/fascia/muscle).
  • Fibula Free Flap (FFF): Peroneal a. (Osseous/osteocutaneous; gold standard for mandibular reconstruction).
• Monitoring: Crucial. Clinical (color, temperature, capillary refill, turgor, bleeding on pinprick), handheld Doppler. Flap checks q1h for first 24h, then progressively less frequent.
• Complications: Thrombosis (venous > arterial), hematoma, infection, partial/total flap loss.

⭐ Venous thrombosis is the most common cause of free flap failure, typically occurring within the first 48-72 hours post-operatively. Early detection and intervention are key to salvage.

High‑Yield Points - ⚡ Biggest Takeaways

• PMMC flap: Workhorse for intraoral defects, pedicled on thoracoacromial artery.
• Radial Forearm Free Flap (RFFF): Thin, pliable for tongue/FOM reconstruction, pedicled on radial artery.
• Anterolateral Thigh (ALT) flap: Versatile for large soft tissue defects, pedicled on descending branch of LCFA.
• Fibula free flap: Gold standard for mandibular reconstruction, pedicled on peroneal artery.
• Latissimus Dorsi flap: For extensive defects, pedicled on thoracodorsal artery.
• Local flaps (e.g., nasolabial, forehead): Key for smaller facial defects reconstruction.