Oral Presentation NZAPS and ANZSOPS Joint Scientific Meeting

“A novel technique for clinical examination of buried head and neck free flaps ” (570)

Joseph J Overland 1 , Damien Grinsell 1
  1. St Vincent's Hospital, Melbourne, Collingwood, VIC, Australia

BACKGROUND

 

Since the advent of microsurgery, free-tissue transfer (FTT) has become the goldstandard reconstructive option for bony, soft tissue and combined defects of the head and neck. (1,2,3,4) Even with success rates of 92% and above  (1,2,3,4,5,6), there remains a small percentage of cases in which circulatory compromise develops. Early identification of compromise and prompt return to theatre is associated with higher rates of salvage (7,8,9). Here we present a new technique of clinical examination for a particular subset of buried head and neck flaps.

 

METHODS

We conducted an independent review of the literature using Medline, PubMed and Q Read performed up to February 2017 using combinations and variations of search terms including “buried free flap”, “free flap clinical monitoring”, “free tissue transfer monitoring” and “salvage free flap”. We also manually searched reference lists of articles, and used institutional access to the University of Melbourne Library.

 

DISCUSSION

Monitoring buried flaps within the head and neck presents a unique challenge to the microsurgeon. In this paper, we present a variation of the Acland’s empty-and-refill test (10) which may be used to monitor buried flaps that have venous anastomosis in an end-to-end fashion to the external jugular vein. The EJV can be occluded externally using the clinician’s fingers, and emptied in a inferior direction. Refilling of the vein on releasing the superior occlusion indicates adequate flow from the flap. As is the case when venous doppler monitoring is used, this can be extrapolated to conclude that the arterial supply is also adequate.

 

We believe that our technique meets nearly all of the criteria for an ideal free flap monitoring technique, as outlined by Creech and Miller (11), and would be a valuable tool in the clinical assessment of this particular subset of free flaps.

  1. 1. Gerressen M, Pastaschek CI, Riediger D, Hilgers RD, Holzle F, Noroozi N, et al. Microsurgical free flap reconstructions of head and neck region in 406 cases: a 13-year experience. J Oral Maxillofac Surg. 2013;71(3):628-35.
  2. 2. Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck. 2010;32(9):1236-45.
  3. 3. Podrecca S, Salvatori P, Saraceno MS, Fallahdar D, Calabrese L, Cantù G, et al. Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2006;59(2):122-9.
  4. 4. O'Brien CJ, Lee KK, Stern HS, Traynor SJ, Bron L, Tew PJ, Haghighi KS. Evaluation of 250 free-flap reconstructions after resection of tumours of the head and neck. Aust N Z J Surg. 1998 Oct;68(10):698-701.
  5. 5. Singh B CP, Santamaria E, Shaha A, Pfister D, Shah J. Factors associated with complications in microvascular reconstruction of head and neck defects. Plast Reconstr Surg. 1999;103(2):403-411.
  6. 6. Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. Journal of Cranio-Maxillofacial Surgery. 2003;31(4):197-201.
  7. 7. Chen KT, Mardini S, Chuang DC, Lin CH, Cheng MH, Lin YT, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007;120(1):187-95.
  8. 8. Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. Head Neck Oncol. 2009;1:33.
  9. 9. Reiter M, Harreus U, Kisser U, Betz CS, Baumeister P. Buried free flaps in head and neck reconstruction: higher risk of free flap failure? Eur Arch Otorhinolaryngol. 2017;274(1):427-30.
  10. 10. Acland RD. Technical prerequisites and training in micro-surgery; technique of small vessel anastomosis. In: Acland RD,editor. Microsurgery practice manual. CV Mosby Company;1980.
  11. 11. Creech B, Miller S. Evaluation of circulation in skin flaps. In: Grabb WC, Myers MB, eds. Skin flaps. Boston, MA: Little, Brown; 1975.