2.5.

7 Free Flaps
•Locoregional flaps are unavailable either due to prior surgery, radiation
therapy, or patient anatomy → in some circumtances

•At this institution, the radial forearm and ALT flaps are the two most
commonly selected free flaps for tongue defects, and remain the
reconstructive options of choice for hemiglossectomy or larger defects.
2.5.8 Radial Forearm Free Flap

• First described by Yang et al 1981 and popularized for head and neck reconstruction by Soutar and
McGregor.
• It is the workhorse for oral cavity reconstruction → thin, pliable skin paddle, and long vascular
pedicle.
• Allows for a two-team approach, shortening the duration of surgery.
• Based on the radial artery and its venae comitantes as well as the cephalic vein.
• A communicating vein is found between the superficial and deep systems that allows for a single
venous anastomosis.
• The lateral antebrachial cutaneous nerve can be harvested along with the flap to create a sensate flap.
 Patient Selection
• An ideal flap for reconstruction of tongue and floor of mouth
• Suited for defects that do not require much bulk

• Vascular anatomy of the forearm and hand is also critical to successful harvest
• In patients who both have an incomplete superficial arch and lack communications
between the two arches, sacrifice of the radial artery may lead to critical hand
ischemia of the thumb and index finger.
 Surgical Technique and Considerations
1. oral defect measurement
2. skin paddle over the radial artery is designed
• If an oral tongue and floor of mouth are involved → bilobed design to separately
reconstruct each subsite may help maintain mobility (Fig. 2.7 → Fig. 2.8)
• template-based technique, as described by Chepeha et al, is also
commonly employed (Fig. 2.9 → Fig. 2.10)
• The cephalic vein is identified and ideally also captured by the skin
paddle.
3. Under tourniquet control, a lazy “S” incision is carried from the flap
up to the antecubital fossa.
4. Subcutaneous flaps elevated just beneath the dermis to facilitate
flap harvest. (following the length of the cephalic vein
5. Beginning on the ulnar side, the skin is raised in a suprafascial plane
until the edge of the flexor
6. Dissection → over tendon, preserving the paratenon (carpi radialis
tendon is identified)
7. The fascia is then incised from distal to proximal, ligating branches
of the pedicle that enter into the muscle
8. On the radial side, the cephalic vein is identified and raised with the
flap.
9. Suprafascial dissection is continued until the brachioradialis tendon
is reached.
10. The fascia is incised from distal to proximal and any branches into
the brachioradialis are ligated.
11. The pedicle can then be ligated distally and flap elevated from distal
to proximal.
12. The communicating vein → a continuation of the radial venae
comitantes into the cephalic system.
13. The flap is then reperfused for
at least 15 minutes and
hemostasis is achieved prior to
harvest.
14. The flap pedicle is tunneled into
the neck most commonly medial
to the mandible and posterior to
the mylohy
15. Partial flap inset → horizontal
mattress absorbable sutures to
achieve a watertight closure oid
16. A microvascular anastomosis is
performed (under microscope
or loupe magnification using 8–0
or 9–0 nylon) -Fig. 2.11
 Perioperative Management
• All patients undergoing complex head and neck reconstruction → 24
to 48 hours of perioperative antibiotics, with ampicillin Sulbactam)
• nasogastric feeding tube (at least 7 days)
• volar splint and bolster are removed within 5 to 7 days.
 Pearls
• Suprafascial harvest is recommended because it results in reduced donor
site morbidity.
• Fasciocutaneous flaps tolerate ischemia well. The majority of the inset can
be completed prior to revascularization, after which edema and bleeding
can make suturing more difficult.
• Insetting the posterior portion of the flap first is most efficient, although
one or two insetting sutures at the anterior tongue or floor of mouth
placed early in the process can allow an assistant to protrude the tongue
and make the posterior inset easier.
• The donor site for small flaps can sometimes be managed with an ulnar-
based rotation flap of volar forearm skin.28
2.5.9 Anterolateral Thigh Free Flap
• a versatile flap (fasciocutaneous or musculocutaneous flap)
• can be tailored to include added bulk as required by the defect
• subtotal or total glossectomy defects
• The flap has a long vascular pedicle with a single artery and two
venae → lateral circumflex femoral artery (LCFA).
• Based on perforating vessels that most often run through the vastus
lateralis muscle before piercing the fascia lata and entering the skin
 Patient Selection
• Medium-to-large defects of the oral tongue
and floor of mouth that require addition
bulk.
• For larger defect → it can be raised in
conjunction with vastus lateral is muscle to
fill in soft tissue deficits in the deep floor of
mouth.
• Can be harvested with the lateral femoral
cutaneous nerve as a sensate flap
• Patients with a history of severe peripheral
vascular disease should be avoided
 Surgical Technique and Considerations
1. The flap is centered over a line drawn between the anterior
superior iliac spine and the superolateral patella
2. Measurement of the oral cavity defect
3. Flap is designed about the dominant perforators in an elliptical
fashion to facilitate primary closure.
4. The medial incision is then carried down through fascia lata and the
rectus femoris muscle
5. Fascia is then elevated off of the rectus femoris muscle and the
search for perforators begin
6. Meticulous dissection is carried from
distal to proximal through the vastus
lateralis, unroofing the perforator until
the pedicle is reach.
• 7. A small cuff of muscle may be left
surrounding the perforators to
protect it during dissection
• 8. The nerve to vastus lateralis is
identified and preserved. The limit of
pedicle dissection is the branch to the
rectus femoralis, which should be
preserved to avois necrosis of the
muscle.
• 9. the lateral insicion can then be made through fascia lata and the
decision can be made to raise the flap as a fasciocutaneous flap or
include variable amounts of vastus lateralis.
• 10. Immobilization and weightbearing restriction are not required
• 11. free flap inset is then performed as described for radial forearm
free flap and microvascular anastomosis is completed.
• 12. laryngeal suspension should be seriously considered in patients
undergoing total glossectomy to help protect the airway and help
protect the airway and optimize swallowing outcomes.
 Perioperative Management
• All patients undergoing complex head and neck reconstruction → 24
to 48 hours of perioperative antibiotic, ampicillin sulbactam.
• Nasogastric feeding tube → at least 7 days
• Salvage surgery → Radiation therapy at least 14 days
 Pearls
• Meticulous dissection is required with myocutaneous perforators.
• If only one perforator is taken with the flap, some muscle left
adherent to it can alert the surgeon to twisting during the inset.
• Aggressive thinning of ALT flaps has been described in order to
optimize the reconstructed volume. Alternatively, an overly thick flap
can be thinned secondarily, even after adjuvant therapy and often
under local anesthesia.
• During closure, the facia lata is not reapproximated. The skin is
undermined in the suprafascial plane to achieve a minimaltension
closure.
2.6 Adjuncts to Surgery
• Rehabilitation after oncologic surgery for tongue cancer begins with
appropriate reconstructive surgery.
• When reconstructive aim of good palatal contact is not achieved, due
to a combination of poor residual tongue mobility and inadequate
volume, function might be improved by modification of the position
of the palatal.
• Speech function, particularly production of alveolar and palatal
consonants and swallowing.
• Outcomes may improve even futher with a combination of prosthesis
and speech therapy