Free flap

The terms free flap, free autologous tissue transfer and microvascular free tissue transfer are synonymous terms used to describe the "transplantation" of tissue from one site of the body to another, in order to reconstruct an existing defect. "Free" implies that the tissue is completely detached from its blood supply at the original location ("donor site") and then transferred to another location ("recipient site") and the circulation in the tissue re-established by anastomosis of artery(s) and vein(s). This is in contrast to a "pedicled" flap in which the tissue is left partly attached to the donor site ("pedicle") and simply transposed to a new location; keeping the "pedicle" intact as a conduit to supply the tissue with blood.

Various types of tissue may be transferred as a "free flap" including skin and fat, muscle, nerve, bone, cartilage (or any combination of these), lymph nodes and intestinal segments. An example of "free flap" could be a "free toe transfer" in which the great toe or the second toe is transferred to the hand to reconstruct a thumb.

For all "free flaps", the blood supply is reconstituted using microsurgical techniques to reconnect the artery (brings blood into the flap) and vein (allows blood to flow out of the flap).

Indications

Free flaps may be done for a number of reasons, including:

• Aesthetic (cosmetic) reconstruction: Most commonly creating a breast after a mastectomy. This may happen at the time of mastectomy or at a later date. Free flaps are usually only done if a TRAM flap is not possible. Plastic surgeons usually perform these surgeries. Patients with Bell's palsy can have their face re-animated using "free functioning muscle flaps".
• Functional reconstruction:

- Reconstruction of post-traumatic defects: Some area of the body has missing tissue either from a trauma or from some existing wound. This may include areas on the leg where bone is exposed or any other area on the body that needs soft tissue coverage.

- Reconstruction of a defect following removal of a tumor in the mouth or elsewhere: Some Head and Neck, Otolaryngologists, and Oral and Maxillofacial surgeons will excise a tumor from the head and neck leaving a large tissue defect, and then use one of a variety of techniques to reconstruct the wound--often free flaps are needed. If the cancer involves a part of the lower jaw (mandible) then often the fibula will be transplanted as a free flap for reconstruction of the jaw (replacement of the removed mandible)--although other options including bone grafts exist.

- Reconstruction of esophageal (food-pipe) continuity using segments of intestine

- Reconstruction of paralyzed face or hand using functioning free muscle flaps

Surgical Steps during "free autologous tissue transfer"

1. A defect is created surgically (either following removal of a tumor or following cleansing of a wound)
2. An incision is made over the area from where the flap will be taken.
3. The flap is dissected and freed from the surrounding tissue.
4. At least one vein and one artery (which constitutes the vascular pedicle) are dissected.
5. The vein and artery (vascular pedicle) are divided, separating the flap from the rest of the body.
6. Before the pedicle is divided, the area the flap will be re-attached to is prepared by identifying a recipient artery and vein.
7. The free flap is brought up to the defect area, and the vein and artery from the flap (vascular pedicle) are anastomosed (re-connected) to the vein and artery identified in the wound. The anastomosis is done using a microscope or a "loupe", hence it is termed "microsurgery"
8. The free flap is sutured to the defect, while it is monitored to ensure the blood vessels remain patent (i.e. the vessels have good blood flow).
9. The donor site area is closed primarily. Sometimes a Split Thickness Skin graft (STSG) may be performed and placed on top of the defect site and/or the donor site.

Postoperative Complications/Sequalae

The most common serious complication of a free flap is loss of the venous outflow (e.g. a clot forms in the vein that drains the blood from the flap). Loss of arterial supply is serious too and both will cause necrosis (death) of the flap. Close monitoring of the flap both by nurses and by the surgeon is mandatory following the completion of the operation.^[1][2] If detected early, loss of either the venous or arterial blood supply may be corrected by operative intervention. Many times an implantable Doppler probe or other devices can be installed during surgery to provide better monitoring in the post-operative period. The Doppler probe can be removed before discharge from the hospital.

Usually the harvest of a "free flap" is performed in such a fashion to cause the least amount of disability. Despite this some disability may occur following removal of this tissue from the "donor site".

Other complications/sequalae which may occur with any surgery are also possible, including infection and pain.

See also

• Flap (surgery)
• Rotation flap
• TRAM flap
• Microsurgery
• List of plastic surgery flaps
• Perforator flaps

Bibliography

• Dolan, Robert (2003). Facial, Plastic, Reconstructive, and Trauma Surgery. Informa Healthcare. ISBN 0-8247-4595-7.
• Ip, David (2008). Orthopedic Traumatology - A Resident's Guide. Springer. ISBN 3-540-75860-7.
• Myers, Eugene N.; Michael R. Smith; Jeffrey Myers; Ehab Hanna (2003). Cancer of the Head and Neck. Saunders. ISBN 0-7216-9480-2.
• Baker, Shan R. (2007). Local Flaps in Facial Reconstruction:. Mosby. ISBN 0-323-03684-8.
• Wolff, K.-D.; Hölzle, R. (2005). Raising of Microvascular Flaps: A Systematic Approach. Springer. ISBN 3-540-21849-1.

References

1. F. Hölzle, D. Löffelbein, D. Nolte, K.-D. Wolff: Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg. (2006) 34: 25-33.
2. F. Hölzle, A. Rau, D. J. Loeffelbein, M. R. Kesting, T. Mücke, K.-D. Wolff: Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases. Int J Oral Maxillofac Surg. (2010) 37: 21-28.