Head and Neck Cancer Free Flap Surgery: Strategies for Success

[Dr. Gopi Shah]
Intra-op, tell me the sequence of, and may vary, maybe case to case or what your day is like, but in terms of the harvest, and then when you come back to put the flap in. Tell me about that. How do you harvest or prepare the donor site and are you able to do it at the same time that ablation is happening or do you wait until they're done, or?

[Dr. Eli Gordin]
Depends on the case. If it's thigh flap cases, generally you can do the vast majority of the harvest without committing to the size of the actual skin paddle. That's more difficult to do with forearm and fibula cases. Usually, we want to make the reconstruction no larger than it has to be because they end up having a skin graft in those donor site locations when it comes to forearm and fibula. Usually, for those two locations, I'll wait until the resection is done, but then they still usually have a neck or two to do and we can get the harvest done while we're waiting for frozens and waiting for them to complete the neck dissections.

For thigh reconstructions, I'll just start pretty much immediately unless I have something else going on in a different room. For scapula, it's challenging to simultaneously work, any of the subscapular system like lat or serratus or scapula, because the arm has to be up and extended. You can do it, but everybody is uncomfortable. I usually just wait until they're completely done to start doing any of those subscapular system flaps.

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[Dr. Eli Gordin]
For the entire case, we try to stay below 5 liters of crystalloid for the entire case. Not specific to the harvest but part of our time out when we're discussing antibiotics. Usually, we're doing just Ancef for cutaneous cases and we're doing Unasyn for mucosal cases. Then if it's some sort of chronic wound situation, we might be doing something different based on cultures. As far as pressors, some people are pretty adamant that they don't want to use pressors on any free flap cases.

From my perspective, I think there's sufficient evidence. There's not that much evidence for most things in microvascular reconstruction, but for pressors, it seems like there are a decent number of studies at this point, including meta-analyses that show that using pressors at normal, reasonable doses do not adversely affect the flap outcomes. I just tell anesthesia, "Look, we need to use pressors." If the patient is euvolemic and they're still not maintaining adequate blood pressure, then I'd rather that they give them some pressors as opposed to start flooding them with fluids.

For blood transfusions, we usually use around eight as a cutoff. There is a little bit of a upper limit to what you want the hemoglobin to be, just theoretically speaking in terms of blood viscosity. If you're going to be transfusing, it's not like we would intentionally blood-let a patient to get them below nine. Unless there's some sort of medical reason to transfuse them, we certainly wouldn't do it for anything that's above nine just because of viscosity issue and therefore flow.

[Dr. Eli Gordin]
We're trying to create a document that's both tells people what happens on each day, post-operative day, and things to look out for when preparing for a case and pre-op preparations and things like that. Then also filling in the rationale behind different things and all kinds of stuff like who might be appropriate to decannulate and how you decide if somebody is maybe ready to start PO intake or capping their trach or whatever. There's just a lot of background information in there too. It's not all just day-to-day do this at this point in time.

As far as flap checks, we do Q1 hours for almost 72 hours. We have them go to the ICU. We don't have an intermediate or a step-down unit, unfortunately. Q1 hour checks can't be done on the floor. They can do Q4 hour, I believe is the most frequent checks that they can do…

[Dr. Ashley Agan]
What does that entail, Eli? Is that just them Dopplering the stitch, or what are you asking?

[Dr. Gopi Shah]
They document the color, the warmth?

[Dr. Eli Gordin]
Everything. As long as it's visible, then flap check entails looking at the flap. Does the color look normal? It should just look like normal, healthy skin. Unfortunately, a lot of times the flap is more pale than the surrounding tissue, especially when it's coming from the leg and it's going to the face or the thigh. It's pretty pale relative to the face. It's always going to look pale relative to the surrounding tissue, but it's really more of a change than anything else. Whether it looks pale, extra pale, whether it starts looking purple, which might be a sign of congestion—

Edema, like I mentioned, is pretty normal and flaps, especially perforator-based flaps, they tend to get pretty edematous slowly over the course of the first three days. That's the peak I think is around day three. Then it starts slowly tapering off again, but a sudden change in flap edema or swelling that might signify hematoma under the flap or hematoma in the neck or wherever else.

The temperature is not the easiest thing to assess. A lot of time the flap does feel more cool relative to the surrounding skin, but you palpate it. You feel the temperature, you feel the general turgor or just how tight it feels. It again should feel pretty normal, but it does get swollen. Then the Doppler check. Usually, we have some degree of donor site extremity checks too. Just doing the same thing with the hand. If it's a forearm, just look at the hand, and especially thumb and forefinger, which are the distal most in the circulation.

If you're getting your circulation from your ulnar artery now and you have no radial artery, making sure that the cap refill and sensation and motor are all intact on the donor site, and there's no evidence of compartment syndrome developing. Then if there's any concern, then they call our resident team, and then the residents would assess. If they agree that there's something questionable on the flap check, then the next step is to scratch it or stick it with a needle, depending on your preference.

Usually I take a scalpel and just make a tiny little, paper cut depth thing, just through the epidermis and barely into the dermis. Not anything that needs to be sutured up, but just a little-- Literally, it looks like a paper cut. I just find that easier to ascertain whether or not there's blood return than if you stick it with a little needle, then you look at the blood, and if it's not bleeding, then obviously that's concerning for ischemia. If it's bleeding real dark red blood that comes out extremely quickly, then that's concerning for venous congestion because you have backflow of blood into the flap. Then there's everything in between, which is usually where it is. Then you're trying to figure out what you should do at that point.