Optimal Management of Vascular Pedicle Is an Important Concern in Facial Free Flap Reconstruction

by Linda Kossoff •

How frequently are alternative pedicle maneuvers required for mid and upper face free flap reconstructions, and is there any association between these maneuvers and flap survival or postoperative complications?

BOTTOM LINE

In mid and upper face reconstruction, vascular grafting, targeting more distal branches of the facial system, or additional maneuvers to optimize pedicle orientation is often required to secure revascularization, and vein grafting is associated with a higher flap failure rate.

BACKGROUND: One challenge to using free flaps for mid and upper face reconstruction is managing the vascular pedicle; however, this critical element has received little attention. Understanding the likelihood of requiring vascular grafting, atypical target vessels, or alternative maneuvers in advance could aid operative planning, and save time and stress.

STUDY DESIGN: Retrospective review.

SETTING: Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Penn.

SYNOPSIS: Researchers gathered data from three institutions and identified 295 patients who underwent partial/ total maxillectomy or periorbital tumor resection and received free flap reconstruction between 2004 and 2019. Location of defect, free flap selection, and vessels selected for anastomsosis were reviewed, as were any additional maneuvers required, such as vascular grafting, alternate target vessels, parotidectomy, flow-through flap, or bone repositioning; data on postoperative complications were reviewed. Fifty-two cases (18%) were revision surgery. Most of the flaps used were soft tissue (63%). Vascular grafting of the artery, vein, or both was required in 7% of patients; anastomosing the distal facial vessels was performed in 6%. Few patients received removal of flap bone, coronoidectomy, or parotidectomy. Ipsilateral anastomosis to the neck was achieved without grafting in 82% of patients. Most cases that required venous grafting were osteocuteanous reconstructions and were also correlated with higher flap failure rates. The complication rate among all patients was 19%; complications were more likely to occur with osteocutaneous flaps. Study limitations included variation in surgeon experiences and temporal trends, and small numbers within each management category.

CITATION: Swendseid B, Stewart M, Mastrolonardo E, et al. Technical considerations in pedicle management in upper and midfacial free flap reconstruction. Laryngoscope. 2021;131:2465-2470.