Regional Flap vs. Free Flap Reconstruction: Point–Counterpoint

Mark Wax, MD, director of microvascular reconstruction at Oregon Health Sciences University, said that, for most patients, bony free tissue transfer is better in almost all aspects of lateral mandibular defects.

Another study compared functional outcomes in 32 patients who had these defects reconstructed with vascularized bone flaps to 26 whose defects were reconstructed with soft tissue free flaps (J Reconstr Microsurg. 2002;18:365-371). Those in the bone flap group had a higher rate of return to a normal diet, better oral competence, better speech, more comfort dining in public, and better midline symmetry. “Everything is much better if you rehabilitate the mandible and put it back into its normal shape,” he said.

Reconstruction of Laryngectomy or Pharyngectomy Defects

Dr. Deschler said that pedicled flaps—including those using the pectoralis major, supraclavicular, or submental flaps—are options in some cases requiring reconstruction of laryngectomy or pharyngectomy defects.

The bulk can be an issue when using the pectoralis, he said, but the muscle tissue tends to settle over time, and it can yield a good result. It can even be a good thing, he said. “In some aspects, we like that bulk because when we do the closure of the skin we can reinforce that with the muscle and, especially in the chemoradiation era, having all that good vascularized muscle can be a benefit.”

With standard chemoradiation therapy laryngectomy defects, he said, “I find that the supraclavicular flap is really a nice option,” Adding that while pedicled flaps won’t be the right choice in every case, “it’s nice to have them in the toolbox.”

Dr. Wax said the duration of supplemental feeding is decreased for patients undergoing the free flap procedure compared to those with pedicled flaps. He also said the contour differences created using pedicled flaps with the pectoralis were important and shouldn’t be glossed over. “There are indications for it, but it is a large bulky muscle,” he said. “That bulk—it does degenerate, and it does atrophy, and it goes away, but oftentimes leaves you with some strictures and some scarring. And it requires secondary reconstruction. In our hands, we end up having to revise a number of these.”

He emphasized the amount of control offered by the free flap. The key, he said, is that it “allows you to better reconstruct in the three-dimensional modality with replacing the tissues that you’ve taken out. And your scar formation and your external contours can oftentimes be better.”