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BackTable / ENT / Article
Planning Free Flap Surgery: Patient Counseling, History-Taking & Imaging
Julia Casazza • Feb 21, 2024 • 38 hits
During free tissue transfer, also called “free flap surgery,” tissue is detached from its native blood supply, then re-attached to a new blood supply where it fills a surgical wound. Due to the complexity of these operations, particularly in the context of head and neck cancer reconstruction, rigorous planning is a must. Microvascular reconstructive surgeon Dr. Eli Gordin of UT Southwestern Medical Center recently spoke on BackTable ENT to share his tips on how he prepares patients and team members for these intense operations.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Reconstructive options following head and neck cancer range from primary wound closure to free tissue transfer.
• Due to the relative rarity of these conditions, patients recently diagnosed with head and neck cancer often lack context on treatment. Preoperative functional status is the most important factor to consider when discussing the length of recovery, though radiation treatment will lengthen recovery time.
• Clotting disorders, malnutrition, and current smoking all increase the risk of poor surgical outcomes following free flap surgery. Though all patients should receive evidence-based smoking cessation treatment, this is not a reason to delay surgery.
• Virtual surgical planning (VSP) assists the reconstructive surgeon by enabling advanced planning to fix the defect.
Table of Contents
(1) Determining the Optimal Reconstructive Option in Head & Neck Cancer
(2) Managing Patient Expectations Regarding the Hospital Course
(3) Increasing the Odds of Free Flap Surgery Success
(4) Pre-Surgical Imaging & Virtual Surgical Planning
Determining the Optimal Reconstructive Option in Head & Neck Cancer
The reconstructive strategy depends on wound characteristics (e.g. size and location) plus the function of the affected tissue. Non-load-bearing structures (e.g. the orbital rim) can be managed with bone grafts. Locoregional flaps are appropriate for Mohs repairs and smaller cutaneous defects. Surgeries to the mouth, throat, bony mandible, or upper maxillary alveolus typically require free flaps. In certain cases, both locoregional flaps and free flaps may be necessary for reconstruction.
[Dr. Gopi Shah]
When patients are referred to you for reconstruction, how do you decide which patients are going to get the free flap versus something local? How do you start thinking about it?
[Dr. Eli Gordin]
Do they have arms or legs? If so, then free flap. If not, then local. It really just depends on the defect size and where it is. I was talking about the Mohs reconstruction, most of that ends up being local flaps nasal reconstruction, unless it's a total nasal reconstruction. The color match for tissue that comes from the face is better than the color match and texture match of tissue that's going to come from elsewhere in the body. If it's possible to get away with something that's locally sourced tissue from the head and neck region for external defects, that's always a little bit nicer cosmetically, but then sometimes the defect is just a little bit too big or too deep, too thick.
You can do free flaps in combination with local flaps. It's not like it's either/or. Usually, there's some sort of hybrid approach for these more external facial defects. It really just depends on where it is. Anything that's for the most part inside the mouth, inside the throat, bony defects of the mandible or the upper maxillary alveolus, then those are generally going to get a free flap, whether it's a fibula or scapula for the bony requirement there, but some smaller bone reconstructions like the orbital rim or things that aren't load-bearing structures, those might get bone grafts. Those may or may not be wrapped in free fascia flaps or fasciocutaneous free flaps or just standalone.
It really just depends on the type of defect.
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Managing Patient Expectations Regarding the Hospital Course
Due to the relative rarity of head and neck cancer (which accounts for 4% of all cancer diagnosed in the United States), most patients don’t know what to expect from treatment. When counseling patients at their pre-operative appointment, Dr. Gordin meets fears with compassion and underscores the experience of his clinical team. The most common question he fields at this visit is “How long will I be in the hospital?” He explains that most patients stay about one week; he then uses this as a launching-off point to discuss recovery more broadly. Pre-operative functional status influences the length of recovery, but most patients take a year to return to their baseline following surgery. Most free flap patients require radiation or chemoradiation therapy to reduce the risk of recurrence, which further lengthens recovery.
[Dr. Eli Gordin]
They like to know how long they're going to be in the hospital. People are always asking what's the recovery time. That's a complicated question. It's not really like you wait a couple of weeks and then all of a sudden you are recovered. It's a long process. That's what I tell them. I tell them it takes-- the majority of the healing occurs after the first several weeks to month, but then it's really going to be an ongoing process for really a year until they're really not noticing, not thinking about the fact that they had this surgery every day. Especially when it comes to donor site issues like fibula, they have ankle swelling, they have sore ankle issues. I tell them it's going to be like a terrible ankle sprain for potentially months. That depends on how big of a segment of bone you have to take and how low you go into the ankle, but I just prepare them that they may need, especially elderly patients who are already or not as spry as some of the younger patients, they might need assistance, they might need a walker or a cane. Some of them temporarily need a wheelchair or just can't walk. It really depends on their pre-op functional status.
Again, this conversation is tailored to the patient, depending on where they're at in their current life in terms of age. Age is not really the indicator for expecting there to be problems or complications or difficulties with their recovery, it's more their overall functional status. Sometimes we operate on 86-year-olds, 90-year-olds who do better than 60-year-olds, depending on just their other medical problems and their overall conditioning. Yes, the most common question is definitely just, "How long is it going to take for me to get back to my normal life?"
The other thing that complicates that, of course, is if they're getting radiation post-op. For the oncologic patients, most of them, if their tumor is large enough that they're going to need a free flap, most of these patients are going to end up getting radiation. Right at the point where they start to feel like they're recovering from the surgery, about a month after the surgery, then they have to start radiation, and then it sets them back. People inevitably get frustrated by that.
By the time they've started recovering after they've been in the hospital for a week and after those several weeks of additional time past post-op, the last thing they want to do is subject themselves to another treatment with pain and with losing their energy and all the side effects that come along with radiation or chemoradiation. Then the conversation shifts to trying to make sure that they do go through with it and reiterating the fact that they've already undergone all this stuff and all this surgery and all this recovery, and the purpose of the next step with the adjuvant therapy is to prevent this from recurring so that we don’t have to go through this all over again.
Increasing the Odds of Free Flap Surgery Success
The pre-operative interview assesses the risk of flap failure. Clotting disorders, poor nutrition, and cigarette smoking all increase the risk of poor surgical outcomes. Inquiring about diagnosed hypercoagulable states (e.g. Factor V Leiden) identifies cases that require heparin intra- and post-operatively. Nutritional status should be appraised, and nasogastric or gastric tube placement considered for the most malnourished patients. Most cancer patients manifest malnutrition to some degree, so surgery should only be deferred if nutritional status is severe enough to inhibit wound healing. Current smoking also impairs wound healing, but should not delay cancer surgery.
[Dr. Gopi Shah]
Are there certain questions in your history in that initial visit that help you determine whether the patient is a good candidate for a free flap? What are some red flags where put them at higher risk for a flap failure or where you wouldn't necessarily-- that might disqualify them in your mind for a free flap?
[Dr. Eli Gordin]
The main thing is whether they have some hypercoagulable state or a family history thereof. I ask everybody if they've had a prior blood clot in their legs or their lungs, DVT/PE, or are aware of any clotting disorders that they have or that might run in their family. That's pretty rare to see that, at least in our patient population. The other thing would be peripheral vascular disease. I ask them if they've ever been told they have poor circulation in their legs or in general at all. A lot of people start saying that they had a blood clot in their coronary artery and they had a stent, that kind of thing. That's different than having some unexplained DVT/PE situation…
[Dr. Gopi Shah]
Does nutrition play a role? Are y'all checking labs for nutrition status?
[Dr. Eli Gordin]
We do, but a lot of times there's nothing you can do about that, because they oftentimes have the malnutrition from their disease, from their tumor. Then sometimes we'll try and place a pre-op feeding tube, either NG tube or G tube, and try to boost their nutrition a little bit. You also don't want to wait too long to do the surgery. It's a balancing act between trying to optimize them in terms of nutrition and trying to expeditiously get them to the OR.
Some people, their nutrition is so poor that you know that they're going to have a major wound healing problem and it could be a life-threatening issue. Then it's worthwhile to delay for maybe several weeks to try and optimize them a little bit. That’s not common.
Pre-Surgical Imaging & Virtual Surgical Planning
Pre-surgical studies needed vary based on the flap planned. For fibular flaps, a CT angiogram abdomen/pelvis assesses the lower extremity vessel perfusion. For scapular flaps, a non-contrast CT chest is needed only if using virtual surgical planning. For forearm flaps, a positive Allen Test indicates sufficient perfusion for surgical use [1]. Though it comes with a learning curve, Dr. Gordin advises that surgeons consider virtual surgical planning (VSP) for reconstructive cases. In his experience, VSP shifts planning decisions from the OR to the preoperative stage, saving valuable anesthesia time while providing custom cutting guides that assist with the reconstruction itself.
[Dr. Gopi Shah]
For your pre-op workup for the donor site, do you get MRAs of the legs or are you getting any ultrasounds or anything specific on your exam to help you know that the perfusion is good or the artery is good? Is that routine or how do you—
[Dr. Eli Gordin]
For fibula, CTA ends up being a CT angiogram abdomen pelvis, and then we're just writing in the comments that we're trying to evaluate the three vessel runoff to the lower extremity bilaterally. We get CTA for fibula patients. Forearm, we don't do any imaging. We just clinically do Allen tests, and then scapula, no imaging. Unless we're doing virtual surgical planning, then we'll get imaging just of the scapula itself, but not of any angiography. It's a non-contrast CT chest. Thigh flaps don't require any imaging. It's really just fibula.
[Dr. Ashley Agan]
You mentioned the virtual surgical planning. I feel like that's a lot more common than when I was a resident. Are you doing that a lot more than you used to and what does that entail?
[Dr. Eli Gordin]
Yes, I did not train with virtual surgical planning. It's something that I slowly adopted over time. I tried it out a little bit when I first completed my training because one of my partners was interested in using it and I didn't like it that much, but then it's improved over the years. There is a certain amount of learning curve that is required in terms of learning how to design the cutting guides and design the plates and just the way you're going to position bone segments. It's a little bit different. You get on this session with an engineer, depending on the vendor that you're using. Usually, it's Stryker or KLS Martin or Synthes are the main three that we use. You get on a call with an engineer and they're controlling the computer-assisted design software and manipulating things and you're trying to direct them what you want exactly. They do this with many other surgeons. They don't really suggest stuff, which I wish they would early on because sometimes you're just not sure how most people would do X, Y, or Z defect.
There's a little bit of a learning curve that was required as far as designing the shape of the cutting guides because they have a lot of different options and sometimes it's hard to physically fit the cutting guide into the space that you're working in. You have to know what works and what doesn't. After I got the hang of it, I realized it did just help-- It does save some time in the OR, granted you're using that time elsewhere. A simple case is about 10 minutes to plan, but sometimes they can take 30 minutes or even 40 minutes if it's something complex. You still are spending that time, but at least you're saving the patient a little bit of anesthetic time.
The main reason why I like it is just because it forces you to think about what you're going to do ahead of time. You have a definitive plan and you pin down the person that's doing the resection and you communicate more thoroughly than you otherwise would. Think of contingency plans and plan A and plan B, which of course you should normally, but it just requires it to be more precise because you have to know exactly what tooth on the mandible you're going to make your osteotomy.
Then you can see it in three dimensions. You can see how the different segments are going to fit together and what degree of asymmetry. Because you're taking straight bone segments, it's never going to be perfectly the same shape as a native mandible, which is curved. You can play with things and see what works better, especially with very long fibula segments. If you're reconstructing more than half a mandible, you want to see how much fibula is available, and you might be pushing the boundary of how much fibula you can resect. Then that might affect the resecting surgeon's margins.
Sometimes they just want to take an extra centimeter or two because it doesn't really affect the patient at all. If you can't reconstruct that as well, then that might influence that decision. That's something you wouldn't really know ahead of time unless you were really, really good at just looking at the images and being able to tell those small distances in your mind. The fact that it forces you to plan the case out in your mind ahead of time is really why I like it. Because then you're just executing on the day of surgery. You're not really thinking about how you're going to solve the problem. You're just doing the technical things. Unless the plan changes, and occasionally, it does.
Podcast Contributors
Dr. Eli Gordin
Dr. Eli Gordin is an otolaryngologist, head and neck surgeon, facial plastic surgeon, and assistant professor with the department of otolaryngology at UT Southwestern in Dallas, Texas.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 12). Ep. 128 – Free Flaps 101 [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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