Written by Michael Fritz, MD

Free tissue transfer is among the most complex procedures performed in head and neck surgery, and it is typically associated with high morbidity treatment and protracted hospital stays. Advances in flap harvest and design, vessel isolation and postoperative patient management—all initiated here in  Cleveland Clinic’s Head & Neck Institute—have dramatically changed this landscape.^1-3 By combining the minimal morbidity of anterolateral thigh (ALT) perforator flap harvest technique with minimal access approaches for vessel procurement, a low morbidity free flap subset has been created. Patients undergoing these surgeries are commonly discharged within 72 hours and as early as the first postoperative day after surgery. This policy does not compromise flap success or increase postoperative complications or hospital readmissions.^4,5  As a result, we have dramatically decreased the physical and financial “cost” of free flap surgery. Thus, indications for free tissue transfer have expanded both with regard to primary defect reconstruction and also for secondary procedures to improve quality of life, correct deformities or counter complications from previous oncologic treatment. Examples are as follows:

Palatal fistula reconstruction

Defects in the palate may persist for a variety of reasons. These could be the result of unsuccessfully repaired congenital clefts, previous cancer or tumor removal, ischemic events (e.g., Wegener’s granulomatosis or cocaine use), trauma or infection. When locoregional tissue is compromised, or when primary reconstructive attempts fail, patients with fistulas have typically been relegated to management with long-term obturators. While these devices often provide tremendous relief to the speech and swallowing compromises created by palatal insufficiency, they require chronic maintenance, are prone to leakage and require manual dexterity for placement. As an alternative, using free vascularized fascia lata and vessels obtained through a 3 cm incision under the mandible, these defects can be repaired with near 100% reliability. Patients undergo a three- to four-hour operation and are typically discharged within two days after surgery.⁶

Rescue flaps to halt osteoradionecrosis

Osteoradionecrosis of the mandible, maxilla, skull base or cranium poses a frequent challenge for reconstructive surgeons. Typical management following bone debridement has included hyperbaric oxygen (HBO) therapy, despite controversy about the effectiveness of this costly and time-consuming treatment. However, if this initial course of action fails, there have been few options to stop disease progression. Using heavily vascularized fascia lata free flaps layered into oral bone defects, obliterating and covering areas of cranial exposure and draped onto debrided skull base bone, progression of bone destruction can be permanently halted. This method carries the advantage of a relatively short procedure with low morbidity, minimal edema, no risk of airway compromise and a 95% success rate in appropriate candidates. In a comparison study, the combined cost of rescue flap surgery and hospitalization was less than one-third the cost of HBO therapy. More importantly, this method does not compromise the ability to perform larger scale reconstruction, such as segmental mandibular repair, if necessary.⁷

Effective reconstruction of smaller, complex facial defects or longstanding deformities

Low morbidity fascia lata flaps can be applied to repair complex facial wounds following cancer resection. For example, one of the more challenging subsets of nasal reconstruction is large columellar and caudal septal defects. In the past, free tissue transfer was an infrequent consideration because of bulk, complexity and high morbidity. However, given the malleability and reliability of vascularized fascia lata, this flap can be applied to support new structural grafts and provide a foundation for skin grafts—using this method, rapid restoration of facial form and function can be achieved.⁸ Furthermore, when applied beneath the skin, these free flaps impart lasting and reliable correction of facial contour deformities, even in a previously irradiated or scarred milieu.⁹

A new opportunity to improve lives

Using low morbidity free flaps and vessel isolation techniques, the overall “cost” of free tissue transfer has decreased dramatically. This opens the opportunity for innovation to improve short- and long-term functional and aesthetic outcomes for our patients. Our ability to permanently transfer vascularity to compromised tissue with rapidity and high reliability suggests that early surgical intervention for osteoradionecrosis has merit to arrest this process and avoid long-term sequelae.

References

1. Revenaugh PC, Haffey TM, Seth R, Fritz MA. Anterolateral thigh adipofascial flap in mucosal reconstruction. JAMA Facial Plast Surg. 2014;16:395–399.
2. Revenaugh PC, Fritz MA, Haffey TM, Seth R, Markey J, Knott D. Minimizing morbidity in microvascular surgery: small-caliber anastomotic vessels and minimal access approaches. JAMA Facial Plast Surg. 2015;17:44–48.
3. Hanick A, Ciolek P, Fritz M.  Angular vessels for free-tissue transfer in head and neck reconstruction: clinical outcomes.  Laryngoscope. 2020 Feb. Online ahead of print.
4. Hanick A, Meleca JB, Fritz MA. Early discharge after free-tissue transfer does not increase adverse events. Am J Otolaryngol. Mar-Apr 2020;41(2):102374.
5. Devine CM, Haffey TM, Trosman S, Fritz MA. Short-stay hospital admission after free tissue transfer for head and neck reconstruction. Laryngoscope. 2016 Dec;126(12):2679-2683.
6. Kerr RP, Hanick A, Fritz MA. Fascia Lata Free Flap Reconstruction of Limited Hard Palate  Cureus. 2018 Mar 21;10(3):e2356.
7. Haffey T, Winters R, Kerr R, Fritz M. Mandibular rescue: Application of the ALT fascia free flap to arrest osteoradionecrosis of the mandible.  Am J Otolaryngol. 2019 Nov-Dec;40(6):102262
8. Seth R, Revenaugh PC, Scharpf J, Shipchandler TZ, Fritz MA. Free anterolateral thigh fascia lata flap for complex nasal lining defects. JAMA Facial Plast Surg. 2013;15:21–28
9. Ciolek PJ, Prendes BL, Fritz MA.Comprehensive approach to reestablishing form and function after radical parotidectomy. Am J Otolaryngol. 2018 Sep-Oct;39(5):542-547.