Regional Flap vs. Free Flap Reconstruction: Point–Counterpoint

From the size and location of the defect that’s being corrected to patient preference in terms of function and appearance, many factors go into choosing between a local or regional flap and a free flap reconstruction. Experts at the Triological Society Combined Sections Meeting gathered to offer tips on several kinds of head and neck defects.

Posterior Maxillary Defects

Samir Khariwala, MD, chief of the division of otolaryngology-head and neck surgery at the University of Minnesota in Minneapolis, said that tumors in the posterior maxillary region, as well as the resulting defects, are often small, and a local or regional flap—such as a facial artery myomucosal (FAMM) flap, a palatal island flap, or submental flap—will often be a reasonable choice.

“When we’re talking about a small posterior maxillary defect, I would really argue to prefer local tissue, basically to minimize unfavorable scarring,” he said. “We want to prevent things like trismus or VPI (velopharyngeal insufficiency), and really free tissue is probably not necessary in some of these small defects, especially if we’re not going to be opening the neck anyway.”

Matthew Hanasono, MD, professor and reconstructive microsurgery fellowship program director at The University of Texas MD Anderson Cancer Center in Houston, pointed to studies showing that patients receiving free flaps for these defects were typically able to be fitted for a conventional dental prosthesis or didn’t want one because they were happy with their results. Dentition is often not a concern (Plast Reconstr Surg. 2013;131:47-60). “Just because you get a free flap doesn’t mean you can’t get teeth,” he said, although larger defects generally require osseointegrated implants.

At most centers, he said, morbidity is low, more often sealing off foods and liquids and avoiding nasal escape during speech, he said. “I think reliability is an advantage certainly over some pedicle flaps, which may have a lower reliability or partial necrosis rate,” he said. “Soft tissue free flaps really are, at least in our practice, the standard of care for posterior maxillary defects.”

Parotid Defects

Daniel Deschler, MD, vice chair of academic affairs at Massachusetts Eye and Ear in Boston, said a pectoralis major flap can be a good option for some patients, even though they can be bulky. “You can debulk these later on,” he said.

Another option is the supraclavicular flap. For one of his patients, who had a recurrent extensive lesion that involved part of the mandible and a wide surface defect, he said he opted against a pectoralis flap—due to concerns about coverage and bulk—and used a supraclavicular flap instead. It folded over a bit on itself, but eventually that folding faded, and in the end was a minimally morbid operation with good coverage.

For the total parotidectomy patient, the defect “remains a challenge…. We all know that contour defect that occurs in this patient population.”

“The go-to for us right now for this type of reconstruction is the submental flap,” he said. But he cautioned that it “doesn’t work for everything.” He recalled one patient with an aggressive parotid malignancy, for whom a submental flap was planned, but he ended up using an anterior lateral thigh flap because of the man’s extensive disease.

He advised against a rigid, either-or approach and emphasized choosing wisely on a patient-by-patient basis. “It’s all about doing the right thing for the patient,” Dr. Deschler said. “It’s not ‘pedicle or free.’”

Dr. Hanasono said that free flaps are a good option in parotidectomy cases, even for aesthetic reasons. “To me, it didn’t make sense when I was in training that we would do eight-hour free flap surgery for breast reconstruction, but we wouldn’t do it for facial reconstruction for what’s essentially an aesthetic defect,” he said.

In the case of a man with a parotid tumor, a flap wasn’t necessary for closure, but, after the procedure, the patient requested a revision because of his appearance. So, the next day, Dr. Hanasono used an adipofascial perforator flap for a better aesthetic result. “Free flaps are certainly warranted in the head and neck, this most visible part of the body for all of us,” Dr. Hanasono said. “For small contour deformities, you can use local pedicle flaps or fat grafting.” But he said that for more significant defects such as total parotidectomy involving the temporal bone, “I like using adipofascial flaps. And in particular I like the ALT (anterior lateral thigh) flap when you need nerve grafts and fascial grafts that can be harvested from the same donor site.”

Lateral Mandibular Defects

Dr. Khariwala pointed to a study of 59 patients with these defects who were reconstructed with soft tissue flaps and bridging plates (Otolaryngol Head Neck Surg. 2003;129:48-54). There were delayed failures in just five of the cases. “That would suggest you can use a bridging plate with soft tissue,” he said. “There is a risk of plate failure or exposure that’s present but low.” Evidence also suggests that a free tissue transfer might be a better option in patients who are dentate, but in those without teeth, a bridging plate in the soft tissue is fairly safe (Head Neck. 2008;30:709-717). This approach can also save time, he said, noting, “If you really want to focus on getting the patient off the table, maybe this is something you want to think about.”

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.”

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Tom Collins is a freelance medical writer based in Florida.