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Review | Journal Club

Free Tissue Transfer for Head and Neck Reconstruction A Contemporary Review

Steven B. Cannady, MD1; Eben L. Rosenthal, MD2; P. Daniel Knott, MD3; Michael Fritz, MD4; Mark K. Wax, MD5
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia
2Division of Otolaryngology–Head and Neck Surgery, University of Alabama, Birmingham
3Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco
4Department of Otolaryngology–Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio
5Microvascular Reconstruction Program, Departments of Otolaryngology–Head and Neck Surgery and Oral Maxillofacial Surgery, Oregon Health and Sciences University, Portland
JAMA Facial Plast Surg. 2014;16(5):367-373. doi:10.1001/jamafacial.2014.323.
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Microvascular free tissue transfer is used for complex composite tissue defects in previously treated fields, in particular after treatment of malignant disease. The increasing incidence of skin cancer in the general population has increased the number of patients with massive tumors that require the expertise of the free flap reconstructive surgeon. We herein examine a number of the recent advances in the field that use free tissue transfer for orbitomaxillary and scalp reconstruction, including maxillary reconstruction, virtual surgical planning in head and neck reconstruction, and scalp reconstruction. Advanced computer algorithms allow planning of these procedures at a savings of time and cost. Free tissue transfer is a reconstructive modality that is often at the top of the reconstructive ladder and, in some instances, is the reconstructive method of choice. The ability to harvest composite tissue that matches the tissue defect in composition, surface area, and volume makes free tissue transfer a versatile modality.

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Figure 1.
Maxillectomy That Involves the Inferior Orbital Rim and Floor

The rim is reconstructed with a fibula free flap to restore periorbital integrity and contour. The zygoma provides a stable platform for dental rehabilitation.

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Figure 2.
Fibula Free Flap Used to Reconstruct a Lower Maxillectomy

Implants have been placed and matured and the prosthesis allows for normal chewing.

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Figure 3.
Patient Missing the Lower Part of the Maxilla

The fibula flap has been osteotomized to reconstruct the anterior face of the maxilla and the inferior alveolar buttress.

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Figure 4.
Possible Computer-Generated Surgical Scenarios

Three-dimensional surgical planning allows for the development and placement of the osteotomies that take into account contour, future implant placement, and size of bony segments. A, Preoperative computed tomographic (CT) image of the mandible. B, A CT scan shows the resected mandible and a fibula used to reconstruct from the glenoid fossa to the parasymphyseal area. C, An alternative example preserves the condyle and coronoid process.

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Figure 5.
Custom Cutting Guide

Cutting jigs are fashioned in collaboration with the ablative surgeon to determine where bony cuts will be made, allowing for planning of the reconstruction. Metal mandible guides use 35-mm metal slot inserts. The circled slot illustrates the cutting slot for plan B (Figure 4C).

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Figure 6.
Surgical Planning and Prebending of the Reconstruction Plate

Extra plate (6 holes in the straight portion of the reconstruction plate [green]) can be removed or saved if the size of the defect to be created is of concern. The circled portion shows the excess amount of the plate that can be trimmed or used depending on circumstances.

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Figure 7.
Latissimus Dorsi Flap in Scalp Reconstruction

The latissimus dorsi is the most popular choice for scalp reconstruction. In this patient, the latissimus dorsi flap provides complete coverage of the calvarial bone. Vessel anastomosis in the left neck has been performed.

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Figure 8.
Postoperative Result in a Patient With Hemi-scalp Reconstruction and Meshed Split-Thickness Skin Graft

This flap has a large surface area and allows complete coverage of the defect and the bony reconstruction. The muscle atrophies over time and thus matches the scalp in thickness.

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