Abstract
Microsurgical free tissue transfer represents the mainstay of care in both ablative
locoregional management and the simultaneous reconstruction of a defect. Advances
in microsurgical techniques have helped balance the restoration of both form and function—decreasing
the significant morbidity once associated with large ablative, traumatic, or congenital
defects—while providing immediate reconstruction enabling early aesthetic and functional
rehabilitation. There are a multitude of perioperative measures and considerations
that aim to maximize the success of free tissue transfer. These include nutritional
support, tight glycemic control, acknowledgment of psychological and psychiatric factors,
intraoperative surgical technique, and close postoperative monitoring of the patients'
hemodynamic physiology. While the success rates of free tissue transfer in experienced
hands are comparable to alternative options, the consequences of flap failure are
catastrophic—with the potential for significant patient morbidity, prolonged hospital
stay (and associated increased financial implications), and increasingly limited options
for further reconstruction. Success is entirely dependent on a continuous arterial
inflow and venous outflow until neovascularization occurs. Flap failure is multifactorial
and represents a dynamic process from the potentially reversible failing flap to the
necrotic irreversibly failed flap—necessitating debridement, prolonged wound care,
and ultimately decisions concerned with future reconstruction. The overriding goal
of free flap monitoring is therefore the detection of microvascular complications
prior to permanent injury occurring—identifying and intervening within that critical
period between the failing flap and the failed flap—maximizing the potential for salvage.
With continued technique refinement, microvascular free flap reconstruction offers
patients the chance for both reliable functional and aesthetic restoration in the
face of significant ablative defects. The caveat to this optimism is the requirement
for considered perioperative care and the optimization of those factors that may offer
the difference between success and failure.
Keywords
microvascular - free tissue transfer - perioperative care - surgical optimization
- head and neck
