Free Flap Surgery (Microvascular Reconstruction)

Overview

Free flap surgery, also called microvascular reconstruction, is a specialized head and neck surgery technique for reconstructing defects from trauma, head and neck cancer removal, or other conditions. It involves transferring or transplanting skin, muscle, bone, or other tissues from one part of the body to another to restore function and aesthetics. Head and neck surgeons connect the blood vessels in the transplanted tissue to the blood vessels in the neck, sewing them together under a microscope to keep the tissue alive and healthy. These reconstructions provide excellent long-term results and can help you regain function, appearance, and quality of life after head and neck cancer surgery.

The success of flap surgery depends on your health, meticulous planning on the part of your surgeon, careful selection of donor site, and precise microvascular techniques. Vigilant, expert postoperative care is essential in monitoring for complications such as blockages or clots forming in the newly joined blood vessels, infection, or failure of the incision to heal properly. Advances in microsurgical techniques and tissue engineering continue to enhance the outcomes of flap surgery in otolaryngology, improving quality of life by optimizing functional and aesthetic results. 

What is free flap surgery used to treat?

Otolaryngologists commonly use free flap microvascular reconstruction after removal of head and neck cancers, including:

• Oral Cavity Cancer: Cancer that affects the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips, the bottom (floor) of the mouth under the tongue, the hard palate (the front part of the roof of the mouth), and the small area of the gum behind the wisdom teeth
• Oropharyngeal (Throat) Cancer: Cancer of the soft palate (the back part of the roof of the mouth), uvula, back of the tongue, and tonsils
• Laryngeal Cancer: Cancer that involves the voice box or vocal cords and the nearby anatomy
• Nasal Cavity and Paranasal Sinus Cancers: Cancer that affects the inside of the nose and the sinuses (air-filled cavities inside the bones of the nose and cheeks)
• Salivary Gland Cancer: Cancers of the parotid, sublingual, and submandibular glands, which produce saliva in your mouth and throat
• Advanced Skin Cancers of the Head and Neck: Skin cancers that have grown to involve large areas of the head and neck
• Other Head and Neck Tumors or Cancers

Noncancerous Tumors and Diseases of the Head and Neck

While cancerous tumors pose a more significant threat to your health, benign tumors that are fast growing or prone to invade nearby structures may also require surgical removal and subsequent reconstruction. Complex wound issues due to other diseases and their treatments may also require free flap reconstructive surgery.

Treatment of these tumors or cancers often will impact a person’s breathing, speech, swallowing, and appearance. The goal of these surgeries is to remove the tumor and optimize your ability to breathe, speak, and swallow after cancer treatment. 

Radial Forearm Free Flap

One common type is the radial forearm free flap, where surgeons use skin and soft tissue from the forearm to rebuild areas inside the mouth or throat. This flexible, thin flap makes it ideal for restoring speech and swallowing function after surgery for smaller cancers. It can also be designed with a portion of bone (osteocutaneous radial forearm flap) if the jaw bone (mandible) or cheek bone (maxilla) needs reconstruction. 

Fibula Free Flap

Another option is the fibula free flap. In this procedure, surgeons take a portion of the lower leg bone (fibula) along with some skin and soft tissue. Otolaryngologists commonly rely on the fibula free flap approach when reconstructing the jaw bone (mandible or maxilla) after part of it has been removed due to cancer or trauma. The fibula is strong enough to support dental implants, which can help restore chewing ability.

Anterolateral Thigh Free Flap

The anterolateral thigh (ALT) free flap takes skin, fat, and sometimes muscle from the outer thigh. This flap is useful when more significant amounts of soft tissue are needed, such as for reconstructing parts of the mouth, throat, or face. Because it includes extra soft tissue, it can provide good coverage for large wounds.

Scapula Free Flap

The scapula free flap uses a portion of the shoulder blade to reconstruct the jaw, palate, or cheekbone. It can be combined with nearby muscles, such as the latissimus or serratus, to help reconstruct more significant defects.  

Latissimus Free Flap

This flap uses a large back muscle and can also include skin. Similar to the ALT flap, it can provide a large amount of soft tissue if needed. Head and neck surgeons frequently use this flap to reconstruct the scalp.

Rectus Abdominis Free Flap

Surgeons use the rectus abdominis free flap for cases requiring soft tissue and muscle. It relocates muscle and skin from the lower abdomen and is sometimes used for complex reconstructions in the head and neck region.

Other Flaps

Other flaps can be used depending on your needs and unique anatomy.

Steps of Free Flap Surgery

While each person is different, free flap microvascular reconstruction generally follows the following steps or phases.

Step 1: Preparing for Surgery

Before the procedure, your surgical team will assess your condition and choose the best donor site for your free flap. Depending on the type of tissue needed, common donor sites include the forearm, leg, or thigh. You may need imaging tests to check your blood vessels and ensure a good blood supply for the transplant.

Step 2: Removing the Tumor

The first part of the surgery involves removing the tumor. If you have mouth, throat, or jaw cancer, the surgeon will remove the affected tissue, extracting all cancer cells while sparing as much normal tissue as possible. This step may also involve removing part of the jawbone, tongue, or other structures.

Step 3: Removing the Tissue Flap

Next, the surgeon carefully removes the donor tissue (the flap) and its small blood vessels and prepares it for transfer. If the surgery involves bone reconstruction (such as jaw repair), the surgeon will also include a portion of bone

Step 4: Preparing the Recipient Site

After removing the tumor, the surgeon prepares the area for flap placement, creating a healthy surface for the new tissue to join with.

Step 5: Connecting Blood Vessels

This is the most delicate part of the surgery. Using a high-powered microscope, the surgeon carefully reconnects the tiny blood vessels from the flap to blood vessels in the neck or face. This step, called anastomosis, provides a blood supply to the tissue, keeping it alive and functional.

Step 6: Securing the Flap in Place

Once the blood flow is confirmed, the flap is carefully shaped and sutured into position. If bone is transferred, the surgeon may use small plates or screws to secure it in place. The donor site is also closed; sometimes, a skin graft is used if needed.

Step 7: Recovery and Monitoring

After surgery, you’ll be closely monitored in the hospital to ensure the flap is healthy and receiving adequate blood flow. In the first few days, your care team will frequently check the flap’s color, temperature, and blood supply. You may have drains, bandages, or support devices to help you heal.

Step 8: Healing and Rehabilitation

Recovery takes time, and depending on the surgery, you may need physical therapy, speech therapy, or other rehabilitation. Swelling and temporary numbness are normal, but most people regain function and appearance over the following months.

Free flap surgery is a major procedure, but it provides an excellent way to restore lost tissue, improve function, and enhance your quality of life.

Many people temporarily need a feeding tube after surgery, especially if the reconstruction involves the mouth, throat, or jaw. Since swallowing may be difficult right after surgery, a feeding tube gives you enough nutrition while your body recovers and your incisions heal.

There are two types of feeding tubes:

• Nasogastric Tube (NG Tube): A thin tube that goes through your nose into your stomach. This is usually used short-term and removed once you can swallow safely.
• Gastrostomy Tube (G Tube): A small tube placed directly into your stomach through the abdomen. Your doctors may recommend a G tube if they expect long-term swallowing issues, but it can often be removed once you can eat again.

Your medical team will assess your swallowing function and help you transition back to eating when it’s safe.

A tracheostomy (or trach) is a small breathing tube placed in the neck to help with breathing if the airway is swollen after surgery. Not every person needs a trach, but it is common if the reconstruction involves the tongue, throat, or jaw. It will help you breathe safely while you are healing from surgery. 

If you need a trach, it is usually temporary and removed once the swelling goes down and you can breathe independently. The hole (stoma) typically heals within a few days to weeks after removal.

Some additional things you may experience include:

• Swelling and Bruising: This is normal and gradually improves over a few weeks.
• Speech and Swallowing Therapy: If your surgery affects your mouth or throat, a speech therapist will work with you to help restore swallowing and speaking abilities.
• Physical Therapy for the Donor Site: If your flap came from your arm, leg, or thigh, you may need physical therapy to regain strength and mobility.
• Scarring and Sensation Changes: Scars will fade over time, but you may have numbness or tightness in the surgical areas for several months.

Complete healing from free flap surgery can take several months. Most people regain function and appearance, but some may need additional procedures, such as dental implants, if part of the jaw is reconstructed. Your medical team will guide you through follow-up care and any necessary rehabilitation to help you return to daily life.