Mastering Cancer Reconstructive Surgery with Free Flaps Prabha Yadav, Vinay K Shankhdhar, Dushyant Jaiswal
Page numbers followed by f refer to figure.
Abdominal closure 86f
Abdominal skin mobilized 85f
Abdominal wall transplantation 147
Acrylic nasal prosthesis retained with spectacles 140f
Adductor compartment 115f
Adductor longus retracted to dissect pedicle 117f
Adductor muscle 116
Adhesive retained nasal prosthesis 141f
Allen's test, modified 63
ALT See Anterolateral thigh
ALT plus AMT flap, planning of 28f
AMT See Anteromedial thigh
Analgesia 14
completed end-to-end 6f
creating venotomy for end-to-side 7f
and free flaps 12
and position 82
conduct of 13
considerations 11
critical care and pain 12
management 12
preoperative assessment 12
principle of 12
Angiosarcoma, excision of 34f
Anterior noncommittal incision permitting flexibility in flap design 21f
Anterior superior iliac spine 20, 20f, 83
Anterior tibial vessels, visualization of 42f
Anterolateral thigh 28f, 127f
2 perforators 27f, 28f
flap 11, 20, 29, 31f
for lower lip 31f
plan 27f, 38f
for chest wall 36f
for lip defect 31f
for orbital exentration 33f
for patch pharynx 35f
for scalp 34f
for UL 37f, 38f
pedicle with 3 septocutaneous perforators 127f
perforator flap 23f
Anteromedial thigh 21, 22f, 28f, 29f
harvested 25f
in absence of ALT perforators 24f, 25f
pedicle 23
perforator medial to rectus muscle 22f
Anti T cell agents 147
Arterial blood pressure 13
Arterial complications 155
forceps, grasping glove with pair of 68f
to serratus anterior 88f
Aspirin 17, 18
ATF See Anterolateral thigh flap
Azathioprine 146
Balanced general anesthesia 13
Basic microvascular instrument set 4f
Bipennate muscle 42
defect 60f
well united 60f
Brachioradialis, belly of 66, 66f
Breast 163
conservation surgery 112
microsurgery for 121
reconstruction 118
primary 153
secondary 153
Buccal mucosa 24f, 30f, 31f, 67, 156
composite resection 154
defect of 100, 100f
post-tumor resection 68f
partially de-epithelized 113f
right 27f
with commisure and skin defect 100f
Calcineurin inhibitors 147
Cancer defects, allotransplants in 148
Cancer reconstruction, tissue regeneration in 150
Capanna's technique 49f, 61f
Cartilage grafts 67
Cephalic vein 64
anastomosis of 86f
axis of 64f
dissected with cuff of fat 64f
dissection of 86f
expose 64f
Cervical esophagus, lower inset to 96f
Chest complications 18
Chest wall cover 36
Chimera–Greeek mythological creature 124f
Chimeric ALT
flap 124f
on descending and oblique branch 125f
plus AMT 125f
Chimeric flap 26, 101, 111, 124, 125f
planned 35f
with serratus muscle 107f
Chimeric gastrocnemius 99f
Chimeric latissimus dorsi myocutaneous 106
Chimeric radial artery forearm flap 125f
Chimeric skin islands 29f
Chimerism 124
Complex maxillary defect 106
Composite buccal mucosa 100
Composite tissue allotransplantation 146
Contour deformity of left thigh 120f
Contoured fibula 49f, 52f
with skin flap sutured 54f
Contoured flap 55f
Cortical radial bone, wedge of 67
Cosmetically unfavorable split thickness skin graft scar 98
Coupling devices 130
Cranial bone and implant, exposed 107f
Cubital crease 63
Cyclophosphamide 146
Cyclosporine 147
Deep inferior epigastric artery perforator flap 1, 82, 87, 118, 153
vascular basis of 82
Deep vein thrombosis 2
prevention of 15
paddle 52f, 53f
skin paddle 53f
Deltopectoral flap 96
for neck skin defect 95f
Dental compound for contouring 57f
Dental implant placement 133
Denture-guided epithelial regeneration, subperiosteal dissection with 139f
Dextran 17, 18
Diabetes 147
DIEP See Deep inferior epigastric perforators
Discarding non-viable free fibula osteocutaneous flap skin paddle 74
Dissect radial artery and venae comitantes 65f
Dissecting perforators 98, 109
Distal transplants 147
Dobutamine 14
Donor closure 99
Donor site
after harvest 111f
assessment 10, 63
closed in layers 100f
complications 155
management 26, 67
primary closure of 97, 129f
scar 100f
Dopamine 14
Double free flap 127f
for mandible reconstruction 62f
Duodenojejunal flexure 91
Elbow after excision, defect at 77f
Elliptical skin paddle 98
End stoma with monitoring paddle 76f
End tracheostoma 75f
pedicle, dissection of deep inferior 84f
flap, deep inferior 82, 122f, 129f, 130
vessels, distal end of deep inferior 87f
dissection of superficial inferior 83f
superficial inferior 86f
Exploratory lazy S incision 64f
facial prosthesis 138
prosthesis 138, 142, 143
types of 138
prosthesis, late postoperative with 77f
socket reconstruction 74
Eyeball position after fixation of orbital segment, comparing 48f
cutaneous defect over left side of 107f
transplantation 147
Facial nerve intact, defect with 32f
FALT See Free anterolateral thigh flap
Fascia plane with magnification, superficial 112f
Fasciocutaneous flap 101
Fat, cuff of 64
Femoral artery, lateral circumflex 21f, 22f
Fibual osteocutaneous 127f
Fibula 49
blood supply of 39f
contouring, wedge osteotomy for 46f
cross-section of 40f
de-epithelized paddle 47f
divided paddle 47f
flap, advantages of 40
for lower limb
defect 60f
with allograft 61f
for mandible reconstruction
with outer skin defect 51f, 52f
with ramus 50f, 51f
without outer skin defect 49f, 50f
for mandible with outer skin defect 52f54f
for mandibular
and maxillary defect 55f
reconstruction 54f
for orbital floor reconstruction with outer skin defect 59f
for palatal defect 56f
with outer skin 57f
for upper limb defect 60f
harvest, leg position for 41f
holder 43f
osteotomy 43f
skin paddle, well-settled 51f
Fistula closure, magnet retained 142f
at completion 25f
completed inset 73f
contoured 86f
covered with STSG 107f
designs 79
dissection complete 110f
excess 86f
extended indications for 123
harvest 40, 103, 116
donor site after 117f
donor site complications 117
incisions for 103f
marking 40
muscle flap 116
patient position and draping 103
postoperative course 117
postoperative management 104
ready for pedicle division, completed 99f
without any muscle harvest 88f
inset 67, 88f
after 107f
and anastomosis done 86f
defect post excision with partial 70f
into defect with multiple cavities filled 107f
of patch FRAFF completed, intraoperative 75f
inset completed 71f, 74f, 76f
intraoperative 71f, 78f
islanded 85f
marking 69f, 70f, 74f, 75f, 89f, 109
based on site, size and shape of defect 64f
for proximally based RAF flap 77f
of distally-based RAF flap 78f
with skin island 106f
monitoring 2, 15
on perforators, large ALT 24f
perforators 29f
planning 116
surface landmarks 116
prefabrication, application of 150
proximal end of 66f
raised 65f
radial border of flexor carpi radialis 65f
ready for transfer 80f
site assessment 10
split, proximal part of 28f
surgically thinned 32f
survival, stage of 121
venous drainage of 63, 100
volume of 123
well settled 105f, 107f
with right and left DIEP vessels 88f
Flap-wise distribution, chart of 153
Flexor carpi radialis muscle 63, 65, 66
Flexor hallucis longus muscle 39
Flipping clamp 6f
Fluid management 13
defect over plantar aspect of 120f
dorsum of 79
Forearm muscles, deep branches supplying 65f
Fracture fibula to unnatural loading 139f
FRAFF See Free radial artery forearm flap
Free anterolateral thigh flap 1, 98
Free deep inferior epigastric artery perforator flap 1
Free fibula
flap 10, 39, 67
osteocutaneous flap 1, 39
morbidities 154
Free fibular reconstruction 135
Free flap 100, 153
from abdomen 10
irrespective 2
monitoring 151
surgery, refinements in 121
Free jejunum flap 1, 91, 96
Free latissimus dorsi flap 2
advantages of 102
anatomy 102
contraindications 104
indications 104
Free latissimus dorsi muscle flap 107
for knee defect 105
Free radial artery forearm flap 10, 63, 97, 150
disadvantages of 97
harvested 66f, 73f
inset to reconstruct eye socket 76f
intraoperative steps for harvest of 64
marking 72f
morbidities 154
skin marking 68f
Free style perforator flap 98
Free tissue transfer 112
Free Transverse rectus abdominis muscle flap 122f
Fungating lip lesion 31f
entering medial belly of 97f
muscle 101
Gentle traction 65f
Gently withdrawn through tunnel 68f
Glycemic control 15
Gracilis fibers 116
Gracilis flap 115
Gracilis muscle 115, 115f, 116
and STSG, reconstruction with 120f
Grafted donor site, extensive area of 79
Hagen-Poiseuille equation 12
Hand sarcoma 37f
Hand transplants 147
safety and efficacy of 147
Hand-held audio Doppler 20
Hand-held audio Doppler, use of 98, 108
Harvested ALT flap 32f, 34f
with 3 perforators 127f
Harvested flap 79f, 111f, 129f
and specimen 118f
with small skin island 104f
Harvested gracilis muscle flap 120f
Harvested jejunal segment 93f
Harvested MSAP flap 99f
Harvested muscle only flap 104f
Harvesting anterolateral thigh flap 20
Harvesting jejunum flap 91
Harvesting medial sural artery perforator flaps 98
Harvesting thoracodorsal artery perforator flap 109
advantages 111
disadvantages 112
donor closure 111
Head and neck 5, 120, 153
cancer 124
defects 1
microsurgery for 121
reconstruction 67
region 112
Healed donor site STSG 79f
Hematoma 18, 155
Hemiglossectomy 27f, 100
defect reconstructed with MSAP 101f
Hemimandiblectomy 31f
defect 27f
with large skin 28f
Heparin 17, 18
Human leucocyte antigens 146
Hypertension 147
Hypothermia 14
number of 133
primary 133, 137f
secondary 134
timing of 133
retained fixed prosthesis 134f, 136f
in maxillary arch 135f
retained removable over denture 133f
supported nasal prosthesis 143f
with nail cement spacer 106f
Incision 109
Infrafascial dissection septum to reveal perforators 41f
Insertion of conformer after enucleation 139f
Intercanine distance 46f
Intermuscular septum cut to facilitate pedicle dissection 66f
Internal jugular vein 91
Interosseous membrane
cutting 42f
dissection to reveal 42f
Interosseous septum 39
Interstitial edema 12
Intramuscular course provides long pedicle, long 99f
Intraoral prosthetic rehabilitation 132
Jejunal and ileal vascular arcades 92f
Jejunal segment isolated for harvest 93f
flap necrosed 96f
selected for harvest 92f
Jeweler's forceps 7
Jugular vein 7
K wire template 46f
with angle measurements 45f
Knee with exposed bone, large defect over 105f
Larger armamentarium, alternate free flaps for 128
Latissimus dorsi 103, 121
flap 102
muscle flap 121
components 107f
flap 122f
LCFA See Lateral circumflex femoral artery
LD See Latissimus dorsi
Left mastectomy for secondary reconstruction 119f
Left maxilla planned, advanced carcinoma of 106f
Limb 5
exsanguination of 98
reconstruction 112, 118
Lip 69, 157
height maintained 72f
long-term follow-up with 72f
Long bone defects 153
Long pedicle length 98
Low molecular weight heparin 18
Luminal discrepancy, managing large 8f
Lymphedema 117
Major flaps, re-explorations for 154
Major upper limb artery, sacrifice of 98
Mammary vessels exposed, internal 86f
and orbital floor, reconstructed 55f
reconstruction 45
Mandiblectomy defect, marginal 25f, 30f, 113f
Mathes and Nahai classification 115
Maxilla 159
reconstruction 47
without reconstruction, retrusion of 56f
Medial knee joint 116
Medial malleolus, center of 97
Medial sural artery
originating 97f
perforator flap 1, 97, 97f
advantages of 98
harvested on perforator with pedicle 128f
planning and marking 128f
perforator with chimeric gastrocnemius muscle harvested 101f
Melanoma of left foot 120f
Meticulous dissection 98
Microbots, development of 151
Microsurgery instruments 4
Microvascular anastomoses 80f, 124
art and technique of 4
devices 5
of artery 80f
of nerves done 80f
of veins 80f
standardization of 130
Microvascular surgery, achieving specific goals of 14
Monitoring paddle discoloration indicating jejunal flap necrosis 96f
Mosaic arrangement 89
MSAP See Medial sural artery perforator flaps
Mucosalized flap, late postoperative with 30f
Multiple free flaps 126
Multiple organ failure 15
and incision, surface marking of 103
harvest, no 24f
preservation 22
Muscular components and skin island 107f
Musculocutaneous flap 116
Musculocutaneous perforator 22f, 23f, 31f, 97, 98, 110f
deroofing and dissecting 22f
visualized, strong 98f
Mycophenolate mofetil 146
Myocutaneous latissimus dorsi flap 102
Nanotechnology 151
and auricular prosthesis 140
and tracheal defects, reconstruction of 67
lining 74
Nasogastric tube 3
Nasojejunal tube 94
Neck complications 154, 155
and muscle, preserved 22f
from anterior division 115f
obturator 115f
preservation 22
to rectus muscle preserved 88f
Non-circumferential pharyngeal defect reconstruction 101
Ocular defects, rehabilitation of 138
Ocular prosthesis 139, 140f
Old healed scar of TUG flap 119f
One way up technique 6
Oral and oropharyngeal reconstruction 100
Oral competence maintained, long-term follow-up with 72f
exentration 33f
floor reconstruction, fibula used for 58f
prosthesis 139, 140f, 144f
Orocutaneous fistula 155
closure of 141f
Osseointegrated implants 133
supported prosthesis 133, 135
Osteocutaneous flap 67
Osteotomy planning 44, 45f
Paddle TDAP, marking for vertical 109f
Palatal defects 74, 101
Palmaris longus sling 71f
Parotidectomy with skin excision 32f
Partial breast reconstruction 112
Partial buccal mucosa defects 67
Patch prosthesis 140
Pectoralis major muscle flap 96
inset for patching of leak 96f
covered in cut piece of glove 67f
dissection 99, 109
before ligating of pedicle, completed 93f
complete 117f
joining 29f
ligation, ready for 117f
safe passage of 67
Penile reconstruction 79
concept 121
consistent presence of 98
dissection 44f, 84f, 128f
completed 89f
to source vessel 99f
flap 97
from medial and lateral branches of thoracodorsal vessels 108f
lateral row 83f
multiple 122f
reached from opposite side 85f
to pedicle dissection 22
visualized and intramuscular dissection commenced 99f
Peri-implant inflammation 138
Peronea magna 42, 42f
Pharyngeal reconstruction 74
Pharynx 160
Planning surgery, models for 130
Plastic surgery 156
PMMF See Pectoralis major muscle flap
Popliteal fossa 101
to medial malleolus, line joining midpoint of 98f
midpoint of 97
Popliteal vessels 97f
Post-craniofacial resection 74
Postosteotomy and fixation 59f
Post-radiation follow-up 74f
Post-skin suturing 59f
Prefabrication 150
Preoperative lower lip lesion 71f
choice of 133
types of 133
reconstruction 132
rehabilitation 132
Proximal perforators, preservation of 66f
Pudendal vessels, superficial external 87f
Radial artery
axis of 64f
course in forearm 63f
Radial forearm flap 63
Radial nerve
identification of superficial 65f
preservation of superficial 65f
Radical mastectomy specimen 36f
RAFF, planning of 79f
Rapid recovery protocols 3
Recipient artery, selection of 5
femoris 20, 20f
muscle identification 21f
closure done 85f
incision 84f
Red cell transfusions 15
Reexploration 161
Regional anesthesia, role of 13
Reliable fasciocutaneous flap 69
Renal failure, chronic 147
Replacing cervical esophagus, humans of 91
Retro-orbital tumor, preoperative right 76f
Right forearm dorsal aspect defect with
brachytherapy tubes in situ 78f
Right knee bony reconstruction 106f
Right lateral tongue 74f
Right lower lip lesion 69f
Right MRM defect 119f
Right orbital exenteration defect with eyelids preserved 76f
Right upper lip lesion with outer skin induration 70f
Robotic surgery 151
Room temperature vulcanizing silicone 140, 141f
Rotation, circular arc of 101
RTV See Room temperature vulcanizing
Ryle's tube 94
Safeguarding nerve 98, 109
Scalp defect, bilateral 34f
Scapular-parascapular conjoint flap 129f
Selecting recipient vein 5
Sensate flap 67
Septocutaneous AMT perforartors in absence of ALT perforators 24f
Septocutaneous perforator 21f23f
arising anterior to free border of LD muscle 110f
dissection 22f
Serratus branch, intraoperative large 106f
Short saphenous vein 99, 99f
Silicone ear prosthesis 141f
Single perforator 122f
Site-wise distribution, charts of 153
Skin 31f
closure, final appearance at 94f
cover 74
defect 24f, 100
external 51f
in neck not amenable for primary closure 94f
large 106f
marking of external 52f
excision 31f
grafting of exposed surface, final flap inset with 105f
incision, opposite side 85f
malignancy 32f
marking 83f
designs 116
for buccal mucosa and palate, proximal 28f
for pharynx 35f
marking of 41f
sizing of 44f
surface forming inner lining, tubed FRAFF with 76f
Sodium nitroprusside 14
Soft palate 27f
Soft tissue
complication 138
defect in heel with exposed bone, large 104f
reconstruction of upper extremity 77
sarcoma, recurrent 77f
Split thickness skin graft 65
over FRAFF donor area 67f
SSV See Short saphenous vein
Steep learning curve 100
Stereolithography 131
Stretched healed scar of
horizontal paddle 111f
vertical paddle 111f
Stretching of vessel 7f
STSG See Split thickness skin graft
Subscapular artery
branches of 108f
originates 102
Subscapular vessels, retraction and pedicle dissection to reach 110f
Superficial circumflex iliac perforator flap 121
Superficial external pudendal artery 82
Superficial inferior epigastric artery 82
Superior mesenteric artery 91
Suprafascial harvest 41f
Supramicrosurgery 4
Sural arteries, medial and lateral 97f
and exploration, cost counseling of 11
flap harvest steps of 103
Surgical techniques, standardization of 2
Suturing technique
end-to-side 7f
in special situations 7
Swallowing function maintained post-radiation 75f
Tacrolimus 147
TDAP See Thoracodorsal artery perforator flap
Telemedicine 151
Template of plan–Biemer pattern 79f
Tensor fascia lata 21, 127f
flap 21
in absence of both ALT and AMT perforators 26f
intramuscular perforator dissected 26f
pedicle 23
perforator flap 26f
Thinned ALT flap 123f
Thinned DIEP flap 123f
Thoracodorsal artery 102
descending branch of 102
perforator flap 1, 67, 108, 112, 113f, 122f, 128f
indications 112
marking 128f
Thoracodorsal nerve and branches 110f
Thoracodorsal pedicle 103
Thoracolumbar fascia 102
Thromboprophylactic drugs, comparison of 18
Thromboprophylaxis 2
drug 18
for free flaps 17
for microvascular anastomosis 2
Thrombosis 18
Tibia, shin of 79
Tibialis posterior 43f
Tibioperoneal trunk into peroneal and posterior tibial, division of 43f
Tissue supported prosthesis 132
advantages 132
disadvantages 133
Tongue 160
and neck skin defect 54f
defect, distal skin paddle for 28f
lesion over right lateral border of 72f
mandible and buccal mucosa, lesion involving 73f
mound, create 54f
reconstruction 100, 120
with floor of mouth defect 64f
Total glossectomy 100
Total laryngectomy with partial pharyngectomy 35f
Total laryngopharyngectomy requiring free jejunal flap, defect of 91f
Total maxillectomy with orbital exentration 106f
Total penectomy, stump of 79f
Total pharyngectomy defect with end tracheostoma 75f
Tracheal transplant 147
TRAM See Transverse rectus abdominis muscle
Transillumination vascular arcade 92f
Transverse paddle upper gracilis, marking for 116f
Transverse rectus abdominis muscle 82
flap 82
Transverse upper gracilis 116
Tubed free radial artery forearm flap 74
TUG See Transverse upper gracilis
TUG flap, late postoperative result of 119f
Turbocharging 87f, 124, 126
Ulnar border of brachioradialis 65f
Umbilicoplasty 86f
Upper abdominal incision 91
Upper alveolectomy 31f
Upper extremity 77
Upper limb, lower limb 36
Upper oropharynx to jejunal suture line 95f
Uterine transplant 148
Vascular anatomy 91
of small bowel 92f
Vascular loop technique 8, 8f
Vascular network 82f
Vascular pedicle from medial circumflex femoral vessels 115f
Vascularized composite allotransplant 146
current applications of 147
Vastus lateralis 20f
harvest 23f
Veins of forearm, superficial 63f
Vertical paddle gracilis flap, donor site scar of 117f
Vertical skin paddle design 109
arcade of 63
preparation of 6
selection 2
size mismatch 7
Xeroderma pigmentosa 143f
Chapter Notes

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Philosophy and Current Practice of Cancer Reconstruction at Tata Memorial HospitalCHAPTER 1

Dushyant Jaiswal,
Prabha Yadav,
Vinay K Shankhdhar
The current gold standard, for head neck and breast reconstruction world over, is Free tissue transfer or free flaps, as commonly called. We have performed over 5000 free flaps over the last 12 years. Currently, every year we perform around 600 free tissue transfers for reconstruction of cancer defects. Tata Memorial Centre receives 65000 patients every year. 11000 are Head Neck cancer of which 2100 undergo surgery and 500 receive a free tissue transfer. 5000 are breast cancer cases of which 1800 are operated and only 50 receive a free tissue transfer. 50 more free tissue transfers are done for limbs and trunk.
We believe that every patient should receive the best possible reconstruction.
If resection adds years to life, Reconstruction add life to those years.
Reconstructive surgeons pushing boundaries of reconstruction, to handle more and more complex and large defects, has enabled the resecting surgeons to push the limits of surgically possible resections.
We use a Reconstructive Tool Box approach for decision-making. The option which provides the best possible outcome with least donor morbidity, irrespective of difficulty level or time for surgery, is chosen over simpler options which will only heal the wound.
The option usually exercised is of microvascular free tissue transfer or free flaps.
Free tissue transfer is the ‘gold standard’, ‘bedrock’ or default option for most Head Neck reconstruction in our Plastic and Reconstructive Surgery Department.
We believe that most, up to 95%, of all defects after HN cancer excision, can be managed with the three free flaps.
Free Fibula Osteocutaneous Flap (FFOCF)
Wherever bone is needed fibula is used. The skin paddle, based on the perforators from peroneal vessels, can be used with great liberty to address the associated mucosal, skin and soft tissue defect.
Free Radial Artery Forearm Flap (FRAFF)
Provides the thin, pliable option for small defects of buccal mucosa and tongue defects.
Free Anterolateral Thigh Flap (FALT)
It is our default option whenever the flap needs more volume or surface area.
The remaining only 5% defects need a flap beyond these three. The defect might be large, complex, odd shaped or all of them needing an alternative flap. Sometimes an unfavorable donor profile, too thin or thick as compared to the defect or violated by chemotherapy might necessitate this. Very rarely an alternative choice could be made solely to reduce the donor area skin graft or muscle function loss morbidity.
The alternative flaps could be from anywhere in the body. We generally use thoracodorsal artery perforator flap (TDAP), medial sural artery perforator flap (MSAP) and deep inferior epigastric artery perforator flap (DIEP) as our options when needed.
Other few specialized free flaps needed in arsenal are:
Free DIEP Flap
For whole breast reconstruction after mastectomy
Free Jejunum Flap
For pharyngeal reconstruction after total laryngopharyngectomy2
Free Latissimus Dorsi Flap
For occasional large, irregular defect on limbs with exposed implants, bone cement or vital structures.
Generally, a lot of fear and timidity is associated with free flaps, especially for a beginner. This is often projected, especially in an event of thrombosis to age, comorbidities, previous surgery and radiation. Often they end up becoming a reason for not doing a free flap in a given patient, when it might be the best solution.
We routinely perform free flaps irrespective of all these factors, age, routine controlled comorbidities like diabetes mellitus/Hypertension/IHD, previous surgery and neck dissection, radiation, recurrence, size or complexity of defect, presumed short survival of the patient.
Generally, if the defect demands a free flap it gets a free flap!
Sometimes the surgery might be a little challenging technically or needs to be completed in relatively short duration. This should not be a deterrent or contraindication to free tissue transfer, all it needs an experienced surgeon as in any other case.
We would think twice before executing a free flap, only if the anesthetist expresses concern over the long duration of surgery or we are worried about the risk of exploration.
The surgical technique of harvest of the ‘three’ flaps has been almost standardized in the department. Individual harvest techniques are discussed with each chapter. This enables the beginners to scale the learning curve rapidly. It also enables easy communication about details. The deviations and tricks are also easy to understand as a basic set template exists.
The perforator philosophy is now firmly established in almost all flaps we do. Any flap, ALT, DIEP or the skin island with fibula is only as good as the perforator it possesses. Perforators are visualized and dissected. There is no provision for blind muscle harvest for perforator presumption or protection.
Our default option is to harvest free flaps simultaneously. Only times we harvest flaps after defect creation is, when there is uncertainty, about the size, shape and components of the final defect resulting in an altered flap choice. Sometimes it is logistically not possible to do so due to lack of space or change of position is required for flap Harvest.
Choice of vessel in Head Neck and limbs should be made based on their quality, size, patency and blood flow. Name of vessel should not dictate its selection, its character should.
Generally, end-to-end microvascular anastomosis are done. End-to-side is considered when, tributary is unavailable or mismatch is severe. End to side anastomosis is a must in armamentarium of every microvascular surgeon doing reconstruction, especially for Head Neck. It takes away the question of vessel availability and gives a choice of doing microvascular anastomosis (MVA) on side where the flap would contour/fit better.
We monitor our free flaps only clinically. No mechanical monitoring real time devices are used. This is mainly due to cost constraints. With the low exploration rates, high salvage rates and overall high rates of free flap survival it might not be cost effective to use these devices.
Clinical monitoring includes visual inspection for color and turgor and needle prick/scratch for assessing the resultant bleed.
We do not use thromboprophylaxis for microvascular anastomosis (MVA) patency as a routine. Only in case of a thrombotic event is therapeutic anticoagulation started.
We do however use LMWH (Low molecular weight heparin) for deep vein thrombosis (DVT) prophylaxis at once daily dose in cases requiring immobilization.
Clinical photography is practiced for each patient. Pre, intra and post-operative and follow-up image documentation is done.3
Currently we do not use imaging or any sort of modeling as a routine for our reconstruction planning mostly for logistic reasons. Cost if a deterrent.
Recently we have started using CT angiograms for DIEP flap planning for breast reconstruction and found them to be useful. But we intend to use imaging more liberally especially for complex, complicated defects which required customized, personalized solutions.
Very occasionally we do use stereolithography for 3D models, mostly for benign cases where primary osteointegration is done.
The aim is to keep the hospital stay minimum, return to function rapid and radiation in time when needed.
Nasogastric tube feeds are started on POD 1 and oral feeds on day 4, urinary catheter removal at 24–48 hrs, tracheostomy decannulation by 5–7 days, Suture removal by 10–14 days. Speech and swallowing therapy, shoulder exercises are started before discharge. Patients are generally discharged by postoperative day 6–10.
Radiation has to be started by 4–6 weeks. Low threshold is kept for surgical intervention in marginal or partial necrosis of flaps.
Tata Memorial Centre receives a huge influx of patients from the all over the country. Theatre space is limited, leading to a waiting time for surgery of 4–6 weeks.
We perform around 600 free tissue transfers a year and another 300 pedicle flaps and major surgical procedures. The number of free flaps might appear large, but it is only a third of patients who get operated at TMC and need a free flap for an ideal outcome. The denominator is yet unaddressed.