INTRODUCTION
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.
MOST HEAD NECK DEFECTS CAN BE MANAGED BY THE ‘THREE’ FLAPS
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
Free Latissimus Dorsi Flap
For occasional large, irregular defect on limbs with exposed implants, bone cement or vital structures.
FREE FLAPS IRRESPECTIVE
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.
STANDARDIZATION OF SURGICAL TECHNIQUES
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.
EMBRACING THE PERFORATOR CONCEPT
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.
SIMULTANEOUS HARVEST
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.
VESSEL SELECTION
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.
END-TO-END OR END-TO-SIDE
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.
FLAP MONITORING
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.
THROMBOPROPHYLAXIS
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.
PHOTOGRAPHY
Clinical photography is practiced for each patient. Pre, intra and post-operative and follow-up image documentation is done.3
IMAGING
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.
RAPID RECOVERY PROTOCOLS
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.
THE UNADDRESSED DENOMINATOR
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.